No-touch vein grafts and the destiny of venous revascularization in coronary artery bypass grafting—a 25th anniversary perspective

Abstract

Ischemic heart disease is currently the leading cause of death globally, with coronary artery bypass grafting among the most common operations performed worldwide. More extensive use of arterial grafts has been advocated because of their high long-term patency, long-term survival benefit, and freedom from reinterventions. Despite this, the saphenous vein is the most frequently used conduit in patients undergoing coronary artery bypass surgery since its introduction over 50 years ago. Consequently, the saphenous vein remains an indispensable conduit in coronary artery bypass grafting and maintaining its long-term patency is one of the most crucial challenges in cardiovascular surgery. This situation led to the development of the no-touch saphenous vein harvesting technique, where the vein is harvested completely with its pedicle of surrounding tissue. Several studies report a superior long-term patency rate, slower progression of atherosclerosis, and better clinical outcomes whilst employing no-touch harvesting technique. The success of the technique is multifactorial, including the decreased risk for graft spasm-and the need for manual distension-preservation of the vaso vasorum and an intact endothelium, reducing neointimal hyperplasia and subsequent atherosclerosis. Furthermore, the intact perivascular tissue, including the surrounding cushion of fat, may act as a "natural external stent", providing mechanical support preventing the graft from kinking. We are convinced that the use of arterial grafts, in combination with the no-touch saphenous vein graft, will significantly improve the results of coronary artery bypass grafting. This is important for achieving a comprehensive and evidence-based balance between the major treatment strategies of ischemic heart disease, explicitly coronary artery bypass grafting and percutaneous coronary intervention. The no-touch technique is becoming increasingly popular among surgeons, with further studies to be initiated worldwide.

SUPERIOR SVG: no touch saphenous harvesting to improve patency following coronary bypass grafting (a multi-Centre randomized control trial, NCT01047449)

“…No Touch SVG harvesting has been shown to have favorable biochemical and histological findings in vein specimens [5–8] – furthermore, the fatty pedicle may provide some external support, and also reduces the risk of kinking of the SVG in the pericardium [7, 22]. Using an artificial external support device such as a Venous External Stent (VEST) has also shown to reduce diffuse intimal hyperplasia 1 year after CABG [23].…”

Percutaneous coronary intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis

“…No results have yet been reported regarding PCI of a saphenous vein harvested with the no-touch technique or treated in any other way during the primary CAGB operation. The no-touch technique differs from the conventional technique in that it causes less endothelium damage during the harvesting procedure [42,43] and leads to reduced neo-intimal hyperplasia and subsequent atherosclerosis in the long term [44].Our future intention is to evaluate whether PCI of a no-touch SVG results in better outcome compared to PCI in conventional SVGs.…”

Preserving the endothelium in saphenous vein graft with both conventional and no-touch preparation

“…Coronary artery bypass grafting (CABG) is a standard therapy for ischemic heart disease. Despite the inferior patency compared to arterial grafts, saphenous vein grafts (SVGs) are still widely transplanted for CABG due to their ease of manipulation [ 1 – 4 ]. Consequently, the long-term patency of SVG has been thoroughly investigated.…”