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• W3204994377 abstract "Central MessageAs vein grafts are widely used, measures to enhance their patency are paramount, and some hold promise. Multiarterial grafting including the use of the radial artery is a readily available solution.See Article page 102. As vein grafts are widely used, measures to enhance their patency are paramount, and some hold promise. Multiarterial grafting including the use of the radial artery is a readily available solution. See Article page 102. Despite mounting evidence for the prognostic benefit of multiarterial grafting (MAG) including use of the radial artery over the past 20 years, left internal thoracic artery (LITA) plus saphenous vein grafts (SVG) remains the dominant operation for coronary artery bypass grafting (CABG) worldwide, accounting for more than 90% of CABG.1Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: a systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (50) Google Scholar Consequently, SVGs comprise more than 80% of individual coronary artery bypass conduits.2Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (230) Google Scholar LITA + SVG has remained essentially unchanged for more than 30 years. Concurrently, percutaneous revascularization has progressed significantly with advances in stent technology and associated antithrombotic therapeutics. Adopting MAG will take time. Consequently, SVG will remain the majority conduit even though SVG patency is compromised, with 10-year failure rates of up to 50%.3Sabik III, J.F. Understanding saphenous vein graft patency.Circulation. 2011; 124: 273-275Crossref PubMed Scopus (75) Google Scholar There is a need to improve SVG patency in parallel with developments in MAG. Vervoort and colleagues4Vervoort D. Malik A. Fremes S.E. The evolving evidence base for coronary artery bypass grafting and arterial grafting in 2021: how to improve vein graft patency.J Thorac Cardiovasc Surg Tech. 2021; 10: 102-109Scopus (2) Google Scholar recognized this, providing an excellent and timely overview, that evaluates the current status of SVG, methods under investigation, and future opportunities to improve SVG patency. They focus on 6 areas, and several will have possible traction. The no-touch SVG technique, usually through long open incisions, although promising, is based on results predominantly from one center. It is severely compromised by unacceptably high rates of leg wound infections, probably even worse in patients with diabetes and obesity. Endoscopic SVG harvest with low infection rates is now standard, and it is unlikely that this will change. The excellent results for LITA-SVG Y grafts also emanate from only one center. Many would be uncomfortable anastomosing a 4 to 5 mm diameter SVG to a 2 to 3 mm LITA, with concerns over distortion and vascular steal. Most would consider this only as a bail-out strategy. External support of the SVG to reduce intimal hyperplasia and to enhance patency is elegant and attractive via its simplicity and has potential if the current large study results are favorable and it is not costly. Endoscopic SVG harvesting has been repeatedly associated with high SVG failure rates.5Lopes R.D. Hafley G.E. Allen K.B. Ferguson T.B. Peterson E.D. Harrington R.A. et al.Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery.N Engl J Med. 2009; 361: 235-244Crossref PubMed Scopus (273) Google Scholar The authors have not suggested improvements nor potential advances—dedicated harvesters? Improved endoscopic technology? Storage solutions to preserve endothelial integrity have not provided convincing results. The “DuraGraft” studies may contribute, but answers will be some years away. Pharmacotherapy advances have the greatest potential to improve SVG patency. Newer antiplatelet drugs or combinations thereof, have had marginal benefit—more so in off-pump CABG. They appear to predominantly influence perioperative SVG patency but are worth further exploration. Incidentally, there is little information re their efficacy on arterial grafts. Statins and antilipid immunoglobulins6Gao J. Wang H.-B. Xiao J.-Y. Ren M. Reilly K.H. Li Y.-M. et al.Association between proprotein convertase subtilisin/kexin type 9 and late saphenous vein graft disease after coronary artery bypass grafting: a cross-sectional study.BMJ Open. 2018; 8: e021951Crossref PubMed Scopus (3) Google Scholar hold the most promise, especially in combating long-term atherothrombotic changes in SVG, and they are simple to administer. One would predict substantial activity in this domain. Potential problems include multi-medication fatigue, nonadherence (hopefully countered by regular patient review), and cost. It is extremely important that this modality is vigorously pursued. The “elephant in the room” remains the (non)use of multiple arterial grafts. Reasons for MAG hesitancy are not clear. MAG is supported in revascularization guidelines,2Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (230) Google Scholar including the radial artery, which is readily available, and can be harvested and used identically to SVG, but with greater impact—better patencies and long-term outcomes.1Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: a systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (50) Google Scholar,7Tatoulis J. The radial artery: an important component of multi-arterial coronary surgery. considerations for its optimal harvest.J Thorac Cardiovasc Surg Tech. 2021; 5: 46-55Google Scholar Although every endeavor to improve SVG patency is important and to be encouraged, the solution “is on our doorstep,” ie, greater use of MAG. It is essential to focus on ways to enhance graft patency and prognosis in CABG by encouraging both the use of MAG while simultaneously implementing means to enhance SVG patency, succinctly presented in this important contribution. The evolving evidence base for coronary artery bypass grafting and arterial grafting in 2021: How to improve vein graft patencyJTCVS TechniquesVol. 10PreviewCoronary artery bypass grafting (CABG) is foundational to managing multivessel coronary artery disease. The internal thoracic artery (ITA) remains the gold standard for left anterior descending artery (LAD) grafting. Although saphenous vein grafts (SVGs) may be considered for non-LAD targets, the right ITA (RITA) and radial artery (RA) are associated with improved outcomes1 and thus are more commonly used for CABG. A recent systematic review and a network meta-analysis of 150,000 patients2,3 highlighted that the use of RA was associated with a lower risk of major adverse cardiovascular events (MACE) at 5 and 10 years and with a higher rate of patency at 5 years. Full-Text PDF Open Access" @default.
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• W3204994377 date "2021-10-01" @default.
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• W3204994377 title "Commentary: Vein Grafts in Coronary Surgery: Time for an Upgrade!" @default.
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