Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies

Abstract

Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%–60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.

Letter: Potential Predictors of Saphenous Vein Graft Disease After Coronary Artery Bypass Operations

“…In conclusion, the development of SVG disease is multifactorial. 10 Therefore, the surgical procedure, SVG harvesting technique and storage conditions, structure of the target coronary vessel and saphenous vein, and the quality and quantity of previous percutaneous coronary interventions applied to this vessel should be considered when analyzing the factors affecting SVG disease.…”

A New Clue on Chest Radiography for Late Saphenous Vein Graft Failure Saphenous Vein Graft Failure

“…Coronary artery bypass graft surgery (CABG) remains an important treatment option for multi-vessel coronary artery disease, left main coronary lesions, and diabetic patients, despite the latest developments in percutaneous coronary interventions (PCI) and current medical therapy. Left internal mammary artery (LIMA) and saphenous vein graft(SVG)s, the most commonly used grafts in this type of treatment and native coronary arteries are all susceptible to the atherosclerotic process in the long-term (1,2). The LIMA has been shown to have excellent long-term patency rates, but it is not generally suitable to use as multiple grafts because of limited length.…”

“…The LIMA has been shown to have excellent long-term patency rates, but it is not generally suitable to use as multiple grafts because of limited length. Improvement in surgical venous graft harvesting techniques and the chemical solvents used afterwards, optimal medical treatment, and the use of arterial grafts have resulted in lower instances of graft failure (1)(2)(3). SVGs are also widely used due to their easy accessibility, ability to be harvested at the same time as LIMA grafts, and viability for multiple bypasses.…”

The “curious graft”: when LIMA’s fate depends on SVG PCI

“…The LIMA is then anastomosed with the LAD and the SVG sequentially to other coronary branches. This technique holds the advantage of minimal ascending aorta manipulation, continuous SVG exposure to endothelium-protective substances released from the IMA, and the need for shorter SVGs than if those were originated from the aorta [1]. Proximal anastomosis of LIMA on an SVG can put the LIMA at risk, but sometimes this technique is applied because of inadequate LIMA length or LIMA injury during harvesting.…”