[HSF] be kind to SVG

Thu May 22 05:12:59 EDT 2008

Don/David

Have a patient I plan do do CABG - end-stage renal vasculopath (CAD, renal artery stenosis, severe peripheral vascular disease, moderate carotid stenosis). Obviously perfect indication for anaortic OPCAB. Has 70% LMS stenosis and high grade stenosis of proximal LAD, ramus and circumflex. ALso occluded RCA. Prior inferior infarct with moderately depressed LV function. What conduits would you use here and in what configuration? Would you base it all one IMA in this instance?

Ani

> From: donross at bigpond.com> Subject: Re: [HSF] be kind to SVG> Date: Thu, 22 May 2008 10:07:06 +1000> To: OpenHeart-L at lists.hsforum.com> CC: > > Yes of course dear boy!> But a lot of unenlightened surgeons still use regularly use the SVG > ( remember the stuff about belief-holders? ) and just occasionally > both you and I need to use them as well.> Don> On 22/05/2008, at 8:45 AM, David Harris wrote:> > > I have a very good suggestion: do`nt use the SVG as a first option, > > ise the right IMA as a y-graft off the LIMA> >> > Dr. David G. Harris, FCS, MMED,> > Cardiothoracic Surgeon> > Suite 207> > Kuils River Private Hospital,> > PO Box 1200, Kuils River, 7579, Cape Town, South Africa.> > Tel +27-21-9006411> > Fax +27-21-9006412 Mobile +27-83-3309587> >> >> > --- On Tue, 20/5/08, Donald Ross <donross at bigpond.com> wrote:> >> >> From: Donald Ross <donross at bigpond.com>> >> Subject: Re: [HSF] be kind to SVG> >> To: OpenHeart-L at lists.hsforum.com> >> Date: Tuesday, 20 May, 2008, 3:51 AM> >> Gustavo,> >> Try a simple flush and soak with Verapamil as soon as the> >> vein is> >> harvested.> >> On 20/05/2008, at 7:21 AM, gustavo abuin wrote:> >>> >>> Ok, Today I perform a mammary to lad and SVG to OM.> >>> I dissect the saphenous vein.> >>> I don`t distended the graft.> >>> when I connected the vein to the cardioplegia line,> >> that was at the> >>> same time connected to the ascending aorta (90mm Hg of> >> systolic> >>> pressure), NO BLOOD EXIT FROM THE OTHER SIDE OF THE> >> VEIN.> >>> So, I have to distend the vein "gently".with> >> a siringe.> >>> The vein distended and a new attempt was performed.> >>> BLOOD EXIT FROM THE OTHER SIDE OF THE VEIN.> >>> So.> >>> The next " with saphenous" surgery I will> >> try to distend the vein> >>> controlling the pressure of the graft no trespassing> >> 100mm of Hg.> >>> Any comments, tips?> >>> gustavo.> >>> ----- Original Message ----- From: "Dan> >> Waters" <DWATERS at mcclinic.com>> >>> To: <OpenHeart-L at lists.hsforum.com>> >>> Sent: Monday, May 19, 2008 9:54 AM> >>> Subject: Re: [HSF] be kind to SVG> >>>> >>>> >>> For preparing a SV conduit using heparinized blood at> >> physiologic> >>> pressure, see Annals of Thoracic Surgery 56:385-6,> >> 1993. Although> >>> described at the time for on-pump cases, this> >> technique works just> >>> as well for off-pump.> >>>> >>> DJW> >>>> >>>>>> Donald Ross <donross at bigpond.com>> >> 5/19/2008 12:22:16 am >>>> >>> Ani,> >>> You are correct regarding my fear of single ima inflow> >> for tight LM> >>> especially if it is dominant.> >>> I am not sure I would have baulked at bilateral ima> >> unless she was> >>> diabetic and obese as well as on steroids.> >>> If you used a vein as I did today ( radial not> >> available ) I hope you> >>> used a no-clamp proximal technique.> >>> Incidentally, my case was a little old lady with a> >> rapidly tapering> >>> SVG from her thigh and I lysed it's valves to> >> enable it to be non-> >>> reversed because the distal vein was too small for a> >> proximal> >>> anastomosis.> >>> Furthermore, for those who don't want to distend> >> the SVG> >>> hydrostatically ( which should be all of you ) a> >> simple flush with> >>> verapamil followed by a soak in the same stuff> >> releases spasm as it> >>> does for the radial artery.> >>> Don> >>> On 18/05/2008, at 11:26 PM, Ani Anyanwu wrote:> >>>> >>>> Don, Hal, Michael et al> >>>>> >>>> We are influenced by preconceptions - that is the> >> essence of> >>>> decision making. What differs is what that> >> preconception is and how> >>>> much weight we add to it. I must agree that my> >> preconception here> >>>> is that all veins are bad so that is my bias.> >>>>> >>>> My suggestion of low vein graft patency is not> >> however a> >>>> preconception but based on fact. If you were to> >> study data from the> >>>> 1980s and 1990s, most studies you will come across> >> found a vein> >>>> graft patency of 85 to 90%. However, if you look> >> at contemporary> >>>> multicentre US studies published in last 5 years> >> that included> >>>> graft patency as an outcome, the story is> >> different with patency of> >>>> 70%.> >>>>> >>>> Hal - you may *think* your vein graft patency has> >> remained constant> >>>> over the years, but I seriously doubt that is the> >> case and that if> >>>> you performed angiograms you would surprised at> >> how many of your> >>>> patients are walking around, many asymptomatic,> >> with blocked> >>>> grafts. Before I go into any data, think back Hal> >> on those patients> >>>> you operate on (done elsewhere or by you) for> >> ischemic MR following> >>>> previous CABG - have you not come across several> >> with grafts down> >>>> to circumflex or RCA within a year or two of> >> surgery? We certainly> >>>> have.> >>>>> >>>> For anyone who wants data, a good starting point> >> is the recent> >>>> analysis from Prevent IV trial published recently> >> in annals. Magee> >>>> et al Annals of Thoracic SurgeryVolume 85, Issue> >> 2, February 2008,> >>>> Pages 494-500. This included data from over 3000> >> CABGs done 2002-3> >>>> in 107 US centers so I find it hard to believe> >> this will not be> >>>> generalizable to the most of the US. About 2,000> >> (over 4,000) had> >>>> one-year angiograms as per study protocol. The> >> results? A stunning> >>>> 46% of patients on-pump and 45% off-pump had at> >> least one vein> >>>> graft stenosed within a year of surgery. Analysis> >> by graft, rather> >>>> than patient, showed 25% of veins, both on or> >> off-pump, were> >>>> stenosed within a year of surgery (IMA failure> >> rate 8%). The> >>>> authors looked for predictors of vein graft> >> stenosis and guess> >>>> what? Endoscopic harvest was a predictor of early> >> failure of vein> >>>> graft, more so with off-pump (odds-ratio 1.8) than> >> on-pump (odss> >>>> ratio 1.3). This is very believable and I suspect> >> is the case in> >>>> all our centers.> >>>>> >>>> Michael - while quality of targets may have a> >> role, do not for one> >>>> second think US patients have the worst quality in> >> terms of conduit> >>>> or distals. Speak to Prasanna and he might give> >> you a different> >>>> perspective. Indeed one of the things that struck> >> me on moving from> >>>> the UK to the US was the abundance of good quality> >> distals to graft> >>>> here, as opposed to the tiny indian vessels> >> typical of west london.> >>>> I doubt one could explain decreasing vein graft> >> patency on quality> >>>> of conduits and targets alone.> >>>>> >>>> Biologically too there are reasons to believe> >> endoscopic harvest is> >>>> inferior and that initial intimal disruption does> >> predispose to> >>>> vein graft thrombosis. Unfortunately the early> >> trials of endoscopic> >>>> harvest were introduced without trials that> >> included the true> >>>> outcome (angio patency) so we may never know for> >> sure.> >>>>> >>>> Don I hear you regarding anaortic grafts. I> >> operated 2 days ago> >>>> OBCAB*3 on an 80 year old with 90% Left main> >> stenosis on> >>>> corticosteroids for rheumatoid arthritis - would> >> you do bilateral> >>>> IMA OPCAB in him? Odd I placed a vein graft and> >> quoted you as> >>>> justification because I thought you taught me not> >> to rely on a> >>>> single IMA inflow for a tight left main? Or have> >> you ditched the> >>>> vein entirely> >>>>> >>>> Ani> >>>>> >>>>> >>>>> >>>>> >>>>> >>>>> >>>>> From: donross at bigpond.com> Subject: Re:> >> [HSF] AATS> Date: Sun, 18> >>>>> May 2008 14:15:12 +1000> To:> >> OpenHeart-L at lists.hsforum.com> CC: >> >>>>>> I agree, Hal.> Ani has shown himself> >> to be influenced by> >>>>> preconceived ideas like the > rest of> >> us.> Just because he has> >>>>> seen an odd SVG acutely occluded the cause> >> must > be traumatic> >>>>> harvest. Ani, welcome to anecdote land!>> >> SVGs start to fall off> >>>>> the perch at ten years so why is a good eight> >>> year patency so> >>>>> special?> I can't understand why anyone> >> would want to use them for> >>>>> a > significant stenosis anyway, but that> >> is just my> >>>>> unsubstantiated view.> So, if you need a> >> CABG Ani, Martin Misfeld> >>>>> can now fix you up with an > anaortic> >> arterial opcab.> Don> > On> >>>>> 18/05/2008, at 8:24 AM, Hgrmd at aol.com> >> wrote:> > > Ani,> > For such> >>>>> an analytical fellow, I'm surprised at the> >> conclusions > > you've>> >>>>>> drawn about endoscopically harvested> >> veins. As far as I know, >> >>>>>> there's never> > been a head to> >> head study comparing open versus> >>>>> closed harvesting > > of the veins>> >>> in regards to patency. I> >>>>> have the clinical experience of having >> >>> done CABG's> > for at> >>>>> least 10 to 12 years of open veins and around> >> 6-8 years of > >> >>>>> endoveins.> > I certainly haven't> >> perceived a difference in> >>>>> patency. In other > > words, I> >> >> can't tell that a lot more cases> >>>>> are coming to cath with closed > >> >> grafts as> > compared to open> >>>>> harvested veins. Indeed, there may be a >> >>> difference, but it> >>>>> has> > been imperceptible to us.>> >>> Our P.A.'s are extremely> >>>>> skilled at rapidly delivering an > >> >> endoscopic vein> > through a> >>>>> 2 cm stab wound (usually no incision in groin> >> at all) > > that> >>>>> rarely> > has avulsed branches requiring> >> repair with 7-0. Quite> >>>>> frankly, I > > can't tell> >> >> the difference in appearance between> >>>>> open and closed harvested > > veins.> >> Your> > point about dilating> >>>>> with blood and papaverine is well taken. >> >>> That preparation> >> >>>>> may be less stressful to the vein's> >> endothelium. However, in the >> >>>>>> end, no> > matter how you prep> >> them, the veins die no matter> >>>>> what you do to > > them. That's>> >>> why it is imperative that we> >>>>> spend more time harvesting arterial > >> >> conduits and> > not> >>>>> letting concerns about time supervene.>> >>>>> Hal> >> >> >> >> >>>>> **************Wondering what's for Dinner> >> Tonight? Get new twists> >>>>>>> on family> > favorites at AOL> >> Food.> > (http://food.aol.com/> >>>>> dinner-tonight?NCID=aolfod00030000000001)>> >>>> >>>>>> >> _______________________________________________> >> >> OpenHeart-L> >>>>> mailing list> >> > Send postings> >> to:> > OpenHeart-> >>>>> L at lists.hsforum.com> >> > To> >> UNSUBSCRIBE, to CHANGE email address,> >>>>> or to view archives:> >> >> http://mmp.cjp.com/mailman/listinfo/> >>>>> openheart-l> >> > All messages> >> transmitted by the OpenHeart-L are> >>>>> subject to the > > policies and> >> >> disclaimers posted at:> >> >>>>> http://www.hsforum.com/listdisclaim> >> >>>>> ----------------------------------------->> >>>> >>>>>> >> _______________________________________________>> >> OpenHeart-L> >>>>> mailing list> > Send postings to:>> >> OpenHeart-L at lists.hsforum.com>> >>>>>> To UNSUBSCRIBE, to CHANGE email address,> >> or to view archives:>> >>>>>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> All messages> >>>>> transmitted by the OpenHeart-L are subject to> >> the policies and >> >>>>> disclaimers posted at:>> >> http://www.hsforum.com/listdisclaim>> >>>>> -----------------------------------------> >>>>> >> _________________________________________________________________> >>>>> >>>>> >> http://clk.atdmt.com/UKM/go/msnnkmgl0010000002ukm/direct/01/> >>>> _______________________________________________> >>>> OpenHeart-L mailing list> >>>>> >>>> Send postings to:> >>>> OpenHeart-L at lists.hsforum.com> >>>>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to> >> view archives:> >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>>> >>>> All messages transmitted by the OpenHeart-L are> >> subject to the> >>>> policies and> >>>> disclaimers posted at:> >>>> http://www.hsforum.com/listdisclaim> >>>> -----------------------------------------> >>>> >>> _______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view> >> archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are> >> subject to the> >>> policies and> >>> disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>> _______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view> >> archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are> >> subject to the> >>> policies and> >>> disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>>> >>>> >>> -- > >>> No virus found in this incoming message.> >>> Checked by AVG.> >>> Version: 7.5.524 / Virus Database: 269.23.21/1454 -> >> Release Date:> >>> 5/19/2008 7:44 AM> >>>> >>>> >>> _______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view> >> archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are> >> subject to the> >>> policies and disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>> >> _______________________________________________> >> OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To UNSUBSCRIBE, to CHANGE email address, or to view> >> archives:> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted by the OpenHeart-L are subject to> >> the policies and> >> disclaimers posted at:> >> http://www.hsforum.com/listdisclaim> >> -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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