[HSF] be kind to SVG

Thu May 22 18:23:59 EDT 2008

Clearly the added clinical information might reshuffle the list of goals, but probably only adds to the uncertainty of the calculus. 
I, perhaps like you, do not seek to defend a particular position only to criticise the elevation of one to clear immanence.  In this case by the admisssion of all parties I believe, it would be impossible to construct a trial of all comers to CABG all arterial multigrafting which is in itself a mushy concept, so scientific testing of such a position is, if fact, a null concept.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, May 22, 2008 6:11:02 PM
Subject: RE: [HSF] be kind to SVG

Tea

While not necessarily my opinions on the matter I will address some issues you raised.

Patient has ESRD and is scheduled for a living donor renal transplant from a family member. Coronary disease was picked up as part of transplant work up and the aim of surgery is to allow him have his transplant. We get a lot of such patients because of our large renal and liver transplant program. Indeed only this morning I saw another patient with left main stenosis - this one has Hep C, liver carcinoma and liver cirrhosis and is being worked up for liver transplant and the coronary stenosis was picked up on work-up. ALso today I saw a lady with Budd-Chiari who is listed for liver transplant who has a clot in the RA prolapsing through the tricuspid and embolizing. That is the nature of the patient population that get to me, and I suspect is a primer for things to come for surgeons in practice by the next decade. I rarely would see a CABG being referred for surgery on its own merit. In my center last year we did just over 200 CABGs compared to 6,000 PCI
 - that is a ratio of 30 PCI for every CABG. Elective CABG is all but dead in our practice. I suspect Michael can relate more to this. 

As regards arterial grafts in this or any other patient, the idea that arterial grafts are more complex, increase risk or should be avoided in high risk cases is not borne out by data or evidence. Indeed all contemporary evidence suggests that the early results or arterial grafting are better and not worse than venous grafting (of course issues like selection are in operation). In a patient with peripheral vascular disease even there are arguments against venous grafting  - when i was an intern in vascular surgery we were banned from even cannulating leg veins in such patients. If there is no subclavian disease, it is possible, indeed likely, that BIMA grafting will be superior to venous grafting.

As regards the numbers of grafts, I do not think 4 grafts - arterial or venous - are necessary in such circumstances if the goal is to get the patient safely through a non-cardiac operation rather than to improve cardiac related quality or quality of life. Indeed whether anybody *needs* four grafts can be a valid subject of debate.

And finally as regards off-pump, there are valid reasons why this should be expected to yield better outcomes in such a patient - whether these transform to reality in practice I don't know.

Ani

> Date: Thu, 22 May 2008 10:09:30 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] be kind to SVG> To: OpenHeart-L at lists.hsforum.com> CC: > > Let me just say for the record having followed this thread up to now in silence, I am very un-enlightened. For those who bother to read my posts , this may be an unnecessarily redundent declaration. > It seems to me that we have moved to the point of the theoretical absurb in this case. We are now considering doing a free LIMA all arterial CABG X 4 with occluded RCA in a vasculopath with ESRD. Oh yeh, off pump. If this is one's standard then it makes a good deal of sense to continue one's stand approach varying as required. However, if not, what exactly is the logic of this surgical exercise? Long term mortality, long term patency, short term patency, short term survival, smoothly completed and least morbid operation for a chronically ill patient? Every one of the othese goals are highly debatable based on any
 kind of evidence and some perhaps highly irrelevant to this particular patients situation. Are we in love with the so called superiority of our technical maneuvers or the so called needs of our patients?> tea> > > ----- Original Message ----> From: Donald Ross <donross at bigpond.com>> To: OpenHeart-L at lists.hsforum.com> Sent: Wednesday, May 21, 2008 11:53:26 PM> Subject: Re: [HSF] be kind to SVG> > Ani,> I would use both imas, R to lad, L to ramus with a T from L to Cx and  > pda using a radial if available or SVG.> In a patient like this I check back flow from a large intercostal  > prior to taking ima incase intercostals are blocked and the sternum  > is dependant on  the ima. ( tip from Mark who uses a small doppler on  > the intercoastal )> It would also be nice to exclude subclavian stenosis. My rule of  > thumb for adequacy of ima  is to make sure it is pulsatile distally  > after division and Veraparmil soak. If it is not I inject
 verapamil  > retrogradely and reassess, if still not pulsatile I use as free  > graft. ( very rare)> Don> On 22/05/2008, at 2:12 PM, Ani Anyanwu wrote:> > > 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> >> >>>>>  > >> ----------------------------------------->> >>>> >>>>>> >>  > >>
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