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  • Review Article
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Saphenous vein grafts in contemporary coronary artery bypass graft surgery

Nature Reviews Cardiology volume 17, pages 155–169 (2020)Cite this article

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Abstract

Myocardial ischaemia resulting from obstructive coronary artery disease is a major cause of morbidity and mortality in the developed world. Coronary artery bypass graft (CABG) surgery is the gold-standard treatment in many patients with complex multivessel coronary artery disease or left main disease. Despite substantial improvements in the outcome of patients undergoing CABG surgery in the past decade, graft patency remains the ‘Achilles’ heel’ of this procedure. Whereas the use of the left internal mammary artery as a conduit is associated with the highest 10-year patency rate (>90%), saphenous vein grafts — the most commonly used conduit in CABG surgery — fail in 40−50% of treated patients by 10 years after surgery. Vein graft disease (VGD) and failure result from complex pathophysiological processes that can lead to complete occlusion of the graft, affecting long-term clinical outcomes. Optimal harvesting techniques, intraoperative preservation strategies and intraoperative patency control have important roles in the prevention of VGD. In addition, several studies published in the past decade have reported similar mid-term patency rates between vein grafts and arterial grafts when veins are used as a composite graft based on the internal mammary artery. In this Review, we present the latest evidence on the utilization of saphenous vein grafts for CABG surgery and provide an overview of the current practices for the prevention of VGD and vein graft failure.

Key points

  • Saphenous vein grafts (SVGs) are the most frequently used conduits for coronary artery bypass graft (CABG) surgery but are associated with 10-year vein graft failure (VGF) rates of 40−50%.

  • Endothelial damage attributable to mechanical harm and ischaemia–reperfusion injury contribute to the development of vein graft damage (VGD) and VGF, which are mediated by thrombosis, intimal hyperplasia and atherosclerosis in the early, intermediate and late phases, respectively.

  • Prevention of VGD and VGF requires a meticulous harvesting strategy (either open, no-touch or endoscopic) to reduce surgical trauma and avoid excessive handling and distension.

  • Optimized intraoperative preservation of SVGs to maintain normal endothelial function and integrity of the SVG during harvest can reduce the occurrence of VGD and VGF.

  • Traditional intraoperative preservation solutions, such as saline or autologous whole blood, cannot sufficiently preserve the endothelium and might even be harmful to SVGs.

  • Intraoperative graft flow assessment is important in identifying grafts that have initial low flow and can provide an opportunity to correct the issue intraoperatively.

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Fig. 1: Milestones in the evolution of CABG surgery.
Fig. 2: Different configurations of SVGs with a LIMA graft.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany

    Etem Caliskan & Maximilian Y. Emmert

  2. Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany

    Etem Caliskan & Maximilian Y. Emmert

  3. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden

    Domingos Ramos de Souza

  4. Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany

    Andreas Böning

  5. Department of Cardiac and Thoracic Surgery, Heart Center of the University of Cologne, Cologne, Germany

    Oliver J. Liakopoulos & Yeong-Hoon Choi

  6. Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK

    John Pepper

  7. Boston Clinical Research Institute, Boston, MA, USA

    C. Michael Gibson

  8. Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada

    Louis P. Perrault

  9. DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA

    Randall K. Wolf

  10. Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea

    Ki-Bong Kim

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Contributions

E.C. and M.Y.E. researched the data for the article and wrote the manuscript. All the authors made substantial contributions to discussion of content and reviewed/edited the manuscript before submission.

Corresponding author

Correspondence to Maximilian Y. Emmert.

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Competing interests

E.C., A.B. and Y.-H.C. are investigators in the European VASC registry and members of the registry scientific advisory board. C.M.G. has received consultancy fees from Somahlution. L.P.P. is a member of the VASC registry scientific advisory board and has received consultancy fees from Somahlution. M.Y.E. is the principal investigator of the VASC registry and the chair of the registry scientific advisory board, and has received consulting fees from Maquet and Somahlution. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks T. Kieser, S. Raja and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Vineberg procedure

Direct implantation of the left internal mammary artery on the anterior myocardial wall for treatment of angina.

Payr’s ring

A device of two interlocking rings facilitating non-sutured anastomosis of vessels.

Cardiopulmonary bypass

(CPB). An extracorporeal circuit in which venous blood is drained, oxygenated and pumped back to the circulatory system to provide circulatory and respiratory function.

Off-pump CABG surgery

Performing coronary artery bypass graft surgery without the aid of cardiopulmonary bypass on a non-arrested, beating heart.

Octopus stabilizer

Local tissue stabilizer to facilitate off-pump coronary artery bypass graft procedures.

Totally endoscopic coronary bypass surgery

Procedure performed through four to five fingertip-sized portholes as a closed-chest procedure with the aid of robotic telemanipulation systems.

Vein graft failure

(VGF). Complete occlusion of a saphenous vein graft as a result of complex pathophysiological processes.

Autologous whole blood

(AWB). Blood with all components obtained from the patient during surgery.

Scanning electron microscopy

(SEM). Focused beam of high-energy electrons generating signals at the surface of a solid specimen.

PlasmaLyte

A family of balanced crystalloid solutions with multiple different formulations closely mimicking human plasma in pH, osmolality and electrolyte content.

Bretschneider’s cardioplegic solution

Also known as HTK or Custodiol solution. A cardioplegic solution with the main ingredients of histidine, tryptophan and ketoglutarate.

Ringer’s crystalloid solution

A crystalloid solution containing Na+, K+, Ca2+ and Cl− with a pH of 6.5.

University of Wisconsin solution

(UWS). A preservation solution that mimics the ionic composition of intracellular fluids and contains antioxidants and high-molecular-weight molecules; the gold-standard solution for preservation of abdominal organs.

TiProtec

A dedicated storage solution enriched in potassium chloride and N-acetylhistidine.

GALA solution

A dedicated preservation, storage and flushing solution for vascular conduits; works as an endothelium-damage inhibitor and contains reduced glutathione, l-ascorbic acid and l-arginine.

Multidetector computed tomography (MDCT) angiography

Angiography based on CT technology with a 2D array of detector elements.

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Caliskan, E., de Souza, D.R., Böning, A. et al. Saphenous vein grafts in contemporary coronary artery bypass graft surgery. Nat Rev Cardiol 17, 155–169 (2020). https://doi.org/10.1038/s41569-019-0249-3

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