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{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; Jason C. Choi, M.D.; Xin Yang, M.D.


'''Associate Editor-In-Chief:''' {{CZ}}
==[[Overview]]==


{{Editor Join}}
==[[Saphenous vein graft anatomy|Anatomy]]==


==Overview==
==[[Saphenous Vein Graft Harvesting|Harvesting]]==


Since Rene Favaloro first described it in 1967, coronary artery revascularization with [[saphenous vein]]s (saphenous vein grafts or SVGs) has become a surgical standard for treatment of [[coronary artery disease]]. When a native [[coronary artery]] is obstructed, the sutured graft provides a connection between the [[aorta]] and the [[coronary artery]] beyond the area of obstruction. The procedure is repeated on all the [[coronary artery]] segments that are significantly diseased.
==[[Saphenous Vein Graft Nomenclature|Nomenclature]]==


The vein is often removed by [[cardiac surgeon]]s and used for [[autotransplantation]] in [[Coronary artery bypass surgery|coronary artery bypass operation]]s, when arterial grafts are not available or many grafts are required, such as in a [[triple bypass]] or [[quadruple bypass]].
==[[Pathophysiology of Saphenous Vein Graft Disease|Pathophysiology]]==


The [[great saphenous vein]] is the conduit of choice for [[vascular surgeon]]s,<ref>Muhs BE, Gagne P, Sheehan P. Peripheral arterial disease: clinical assessment and indications for revascularization in the patient with diabetes. Curr Diab Rep. 2005 Feb;5(1):24-9. PMID 15663913.</ref> <ref>Mamode N, Scott RN. Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev. 2000;(2):CD001487. PMID 10796649.</ref> when available, for doing peripheral arterial bypass operations because it has superior long-term patency compared to synthetic grafts ([[PTFE]], [[PETE]] (Dacron)), [[human umbilical vein graft]]s or biosynthetic grafts [Omniflow]. Often, it is used ''[[in situ]]'' (in place), after tying off smaller tributaries and stripping the [[valves]] with a device called LeMaitre's valvulotome.
==[[Assessment of Target Vessels for Saphenous Vein Grafting]]==


The [[saphenous nerve]] is a branch of the [[femoral nerve]] that runs with the [[great saphenous vein]] and is often damaged in surgeries that make use of the similarly named vein.
==Diagnosis and Evaluation of SVG Disease==


==Normal Anatomy==
=====[[Symptoms of SVG Occlusion|Symptoms]]=====


The [[great saphenous vein]] ([[GSV]]) originates from where the dorsal vein of the [[first digit]] (the large [[toe]]) merges with the [[dorsal venous arch of the foot]].
=====[[Chest X-Ray in the Patient with Saphenous Vein Grafts|Chest X-Ray]]=====


After passing anterior to the [[medial malleolus]] (where it often can be visualized and [[Palpation|palpated]]), it runs up the [[medial]] side of the leg. At the [[knee]], it runs over the posterior border of the [[medial epicondyle]] of the [[femur]] bone.
=====[[CT Angiography in the Assessment of Saphenous Vein Graft Disease|CT]]=====


The [[great saphenous vein]] then courses laterally to lie on the anterior surface of the thigh before entering an opening in the [[fascia lata]] called the [[saphenous opening]]. It joins with the [[femoral vein]] in the region of the [[femoral triangle]] at the saphenofemoral junction.
=====[[Cardiac Catheterization]]=====


The '''small saphenous vein''' (also '''lesser saphenous vein''') is originated where the dorsal vein from the [[fifth digit]] (smallest toe) merges with the [[dorsal venous arch of the foot]], which attaches to the [[great saphenous vein]]. It is considered a [[superficial vein]] and is [[subcutaneous]] (just under the skin). From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the [[lateral malleolus]]) and runs along the posterior aspect of the leg (with the [[sural nerve]]), passes between the heads of the [[gastrocnemius muscle]], and drains into the [[popliteal vein]], approximately at or above the level of the [[knee]] joint.
=====[[Saphenous Vein Graft Pathology|Pathology]]=====


<gallery perRow="3">
==Saphenous Vein Graft Failure and Patency==
Image:Gray432 color.png|Cross-section through the middle of the thigh.
Image:Gray440_color.png|Cross-section through middle of leg.
Image:Great_saphenous_vein.png|The great saphenous vein and landmarks along its course
Image:Gray580.png|The great saphenous vein and its tributaries at the [[Saphenous opening|fossa ovalis]] in the [[groin]].
Image:Gray582.png|Small saphenous vein and its tributaries.
</gallery>


==Preparation (Saphenous vein harvesting)==
=====[[Definition of Saphenous Vein Graft Failure]]=====


===Saphenous Vein Stripping===
=====[[Historical Rates of Saphenous Vein Graft Failure]]=====


===Minimal Invasive Technique===
=====[[Determinants of Sapheous Vein Graft Patency]]=====


===Side Effects of Saphenous Vein Stripping===
=====[[Saphenous vein graft failure as a Surrogate Endpoint in Clinical Trials]]=====


* [[Saphenous nerve]] injury
==[[Saphenous vein graft disease treatment|Treatment]]==
* [[Infection]] at incision sites or [[sepsis]].
* [[Deep vein thrombosis]] ([[DVT]])
* [[Keloid]] scarring
* [[Chronic pain]] at incision sites


==Graft Patency==
====[[Saphenous vein graft disease treatment#2011 ACCF/AHA/SCAI Guideline Recommendations: Saphenous vein grafts|2011 ACCF/AHA/SCAI Guideline Recommendations]]====
 
===Definitions===
Saphenous vein graft occlusion is defined as a complete, 100% occlusion of a saphenous vein graft. <ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
 
Saphenous vein failure is defined as an occlusion of the vein graft or a 75% or greater stenosis.
 
The rate of occlusion or failure of saphenous vein grafts is calculated on a per graft basis and a per patient basis. The per patient basis is higher, because only one vein graft out of several must fail for the patient to be characterized as a failure.
 
Current rates of graft occlusion and failure are as follows:<ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
The rate of '''per patient vein graft occlusion''' at 12-18 months is about 42%
 
The rate of '''per patient vein graft failure''' at 12-18 months is about 46%
 
The rate of '''per graft vein graft occlusion''' at 12-18 months is about 26%
 
The rate of '''per graft vein graft failure''' at 12-18 months is about 29%
 
As a comparison, the rate of [[internal mammary artery]] failure at 12-18 months was only 8%.
 
===Determinants of Vein Graft Patency===
Graft patency is dependent on a number of factors, including the type of graft used ([[internal thoracic artery]], [[radial artery]], or [[great saphenous vein]]), the size or the [[coronary artery]] that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. left internal mammary (LIMA), radial) are far more sensitive to rough handling than the [[saphenous vein]]s and may go into spasm if handled improperly.
 
Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the [[subclavian artery]]) left [[internal thoracic artery]] with the distal end being anastomosed with the [[coronary artery]] (typically the [[left anterior descending artery]] or a diagonal branch artery). Lesser patency rates can be expected with [[radial artery]] grafts and "free" [[internal thoracic artery]] grafts (where the proximal end of the thoracic artery is excised from its origin from the [[subclavian artery]] and re-anastomosed with the [[ascending aorta]]). [[Saphenous vein graft]]s have worse patency rates, but are more available, as the patients can have multiple segments of the [[saphenous vein]] used to bypass different arteries.
 
Veins that are used either have their [[valve]]s removed or are turned around so that the valves in them do not occlude blood flow in the graft.
 
LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the [[left anterior descending coronary artery]] ([[LAD]]) because of its superior long-term patency when compared to [[saphenous vein graft]]s.<ref>Kitamura S, Kawachi K, Kawata T, Kobayashi S, Mizuguchi K, Kameda Y, Nishioka H, Hamada Y, Yoshida Y. [Ten-year survival and cardiac event-free rates in Japanese patients with the left anterior descending artery revascularized with internal thoracic artery or saphenous vein graft: a comparative study] Nippon Geka Gakkai Zasshi. 1996 Mar;97(3):202-9. PMID 8649330.</ref><ref>Arima M, Kanoh T, Suzuki T, Kuremoto K, Tanimoto K, Oigawa T, Matsuda S. Serial Angiographic Follow-up Beyond 10 Years After Coronary Artery Bypass Grafting. Circ J. 2005 Aug;69(8):896-902. PMID 16041156. [http://www.jstage.jst.go.jp/article/circj/69/8/896/_pdf].</ref>
 
==Saphenous Vein Graft Diseases==
 
===Venospastic Phenomena of Saphenous Vein Bypass Grafts===
 
===Saphenous Vein Graft Aneurysms===
 
It is also known as SVGA, aortocoronary saphenous vein graft aneurysms, saphenous vein graft aneurysm disease and saphenous vein graft aneurysmal dilatation.
 
=====Causes of Saphenous Vein Graft Aneurysms=====
 
* [[Atherosclerosis]]
* [[Hypertension]]
* Mycotic 
* Postoperative [[mediastinitis]]
* Previous aneurysms
* Torn sutures
 
===Saphenous Vein Graft Degeneration===
 
===Saphenous Vein Graft Failure and Occlusion===
 
 
===Amyloidosis of Saphenous Coronary Bypass Grafts <small> <ref>Marti MC, Bouchardy B, Cox JN. Aortocoronary bypass with autogenous saphenous vein grafts: histopathological aspects. Virchows Arch Abt A Path Anat 1971; 352: 255–66.</ref> <ref>Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft. JAMA 1973; 223: 792–4.</ref> <ref>Zemva A, Ferluga D, Zorc M, Popovic M, Porenta OV, Radovanovic N. Amyloidosis in saphenous vein aortocoronary bypass grafts. J Cardiovasc Surg 1990; 31: 441–4.</ref> <ref>Salerno TA, Wasan SM, Charrette EJ. Prospective analysis of heart biopsies in coronary artery surgery. Ann Thorac Surg 1979; 28: 436–9.</ref> <ref>Pelosi F, Capehart J, Roberts WC. Effectiveness of cardiac transplantation for primary (AL) cardiac amyloidosis. Am J Cardiol 1997; 79: 532–5.</ref> </small>===
 
===Rupture of the Saphenous Vein Coronary Artery Bypass Grafts===
 
Aspergillus species causing a necrotizing [[vasculitis]] have been associated with rupture of a saphenous vein graft.
 
==Diagnostic & Evaluation Findings==
 
===Chest X-Ray===
 
[http://www.radswiki.net Images courtesy of RadsWiki]
 
<gallery>
Image:CABG-clips-001.jpg|Median sternotomy wires and CABG clips
Image:CABG-clips-002.jpg|Lateral graphy: Median sternotomy wires and CABG clips
</gallery>
 
===Coronary Angiography===
 
===CT Angiography===
 
===MR Angiography===
 
===Postmortem Angiography===
 
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
 
<gallery>
Image:Postmortem angiography saphenous vein graft 001.jpg
Image:Postmortem angiography saphenous vein graft 002.jpg
</gallery>
 
===Pathological Findings===
 
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
 
<gallery perRow="3">
Image:Saphenous vein graft 001.jpg|Saphenous vein coronary bypass graft: Gross, natural color, external view of heart with thrombosed veins
Image:Saphenous vein graft 002.jpg|Saphenous vein coronary bypass graft: Thrombosis, Acute: Gross, fixed tissue but well shown cross sections of bypass graft and anastomotic site with thrombosis. 61 yo male, with and acute infarct treated with streptokinase and two days later had bypass. Died 5 days post op. Two veins are thrombosed
Image:Saphenous vein graft 003.jpg|Myocardial Infarct Acute Reflow Type: Gross, fixed tissue but good color. A very enlarged heart with moderate LV dilation and high anterior wall hemorrhagic infarct. Initially treated with streptokinase and two days later had saphenous vein grafts. Both grafts are thrombosed. He died after 5 days
Image:Saphenous vein graft 004.jpg|
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Image:Saphenous vein graft 031.jpg|
Image:Saphenous vein graft 032.jpg|
</gallery>
 
==Treatment==
 
===Thrombolysis===
 
===PCI===
 
=====Plain Old Balloon Angioplasty (POBA)=====
 
=====Bare Metal Stents=====
 
=====Drug Eluting Stents=====
 
=====Excimer Laser Coronary Angioplasty (ELCA) of Saphenous Vein Grafts=====
 
At the end of 80's <ref>Litvack F, Grundfest WS, Goldenberg T, et al. Percutaneous excimer laser angioplasty of aortocoronary saphenous vein grafts. J Am CoIlCardiol 1989; 14:803-8.</ref>, ELCA was introduced and thought to be particularly suitable for saphenous vein grafts that were otherwise difficult to treat with balloon angioplasty alone.<ref>Bittl JA, Sanborn TA, Tcheng JE, et al. Clinical success, complications and restenosis rates with excimer laser coronary angioplasty. Am J Cardiol 1992; 70: 1533-9. </ref>
 
===Cardiac Surgery (Re-do) ===
 
==Number of bypasses==
 
The terms ''single bypass'', ''double bypass'', ''triple bypass'', ''quadruple bypass'' and ''quintuple bypass'' refer to the number of coronary arteries bypassed in the procedure.
 
In other words, a double bypass means two coronary arteries are bypassed (e.g. the [[left anterior descending|left anterior descending (LAD)]] coronary artery and [[right coronary artery|right coronary artery (RCA)]]); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, [[left circumflex artery|left circumflex artery (LCX)]]); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five.  Less commonly more than four coronary arteries may be bypassed.
 
A greater number of bypasses does not imply a person is "sicker," nor does a lesser number imply a person is "healthier."<ref>{{cite journal |author=Ohki S, Kaneko T, Satoh Y, ''et al'' |title=[Coronary artery bypass grafting in octogenarian] |language=Japanese |journal=Kyobu geka. The Japanese journal of thoracic surgery |volume=55 |issue=10 |pages=829–33; discussion 833–6 |year=2002 |pmid=12233100 |doi=}}</ref>  A person with a large amount of [[coronary artery disease|coronary artery disease (CAD)]] may receive fewer bypass grafts owing to the lack of suitable "target" vessels. 
 
A coronary artery may be unsuitable for bypass grafting if it is small (< 1 mm or < 1.5 mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart).  Similarly, a person with a single [[stenosis]] ("narrowing") of the [[Left coronary artery|left main]] coronary artery requires only two bypasses (to the LAD and the LCX).  However, a left main lesion places a person at the highest risk for death from a cardiac cause.
 
The surgeon reviews the [[coronary angiogram]] prior to surgery and identifies the lesions (or "blockages") in the coronary arteries and will estimate the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart.
 
==Videos==
 
===Saphenous Vein Harvesting===
 
<youtube v=VbdE6JWdY1s/>
<br clear="left"/>
<youtube v=QthyR0bTHzc/>
<br clear="left"/>
<youtube v=sV-qE2SIkJU/>
<br clear="left"/>
 
===Animation: Saphenous Vein Grafts Use in CABG===
 
<youtube v=3Nf6Q2skGOM/>


==Clinical Trials==
==Clinical Trials==
Line 248: Line 72:
* [http://clinicaltrials.gov/ct2/show/NCT00777777 The eSVS (TM) Mesh External Saphenous Vein Support Trial]
* [http://clinicaltrials.gov/ct2/show/NCT00777777 The eSVS (TM) Mesh External Saphenous Vein Support Trial]


==References==
==Related Chapters==
{{Reflist|2}}
* [[Percutaneous Coronary Intervention (PCI): Basic Principles and Guidelines]]
* [[CABG]]
* [[Hybrid bypass]]
* [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]]
* [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
 
==Guideline Resources==
*[http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions]<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011 |month=December |pmid=22070837 |doi=10.1016/j.jacc.2011.08.006 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0 |accessdate=2011-12-08}}</ref>


==Additional Resources==
==Additional Resources==
Line 298: Line 129:
{{refend}}
{{refend}}


==See Also==
==References==
 
{{Reflist|2}}
* [[CABG]]
* [[Hybrid bypass]]
* [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]]
* [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
 
==External Links==
*[http://www.texheartsurgeons.com/ Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures]
*[http://www.ctsnet.org/ CTSNet: The Cardiothoracic Surgery Network]
*[http://info.med.yale.edu/intmed/cardio/imaging/ Yale: Introduction to Cardiothoracic Imaging]
 
 
{{SIB}}
 


[[Category:Cardiology]]
[[Category:Cardiology]]

Latest revision as of 19:38, 25 October 2012

Saphenous vein graft
Saphenous vein grafts for coronary arteries

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Overview

Anatomy

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Nomenclature

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Assessment of Target Vessels for Saphenous Vein Grafting

Diagnosis and Evaluation of SVG Disease

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CT

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Saphenous Vein Graft Failure and Patency

Definition of Saphenous Vein Graft Failure

Historical Rates of Saphenous Vein Graft Failure

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Jason C. Choi, M.D.; Xin Yang, M.D.

Overview

Anatomy

Harvesting

Nomenclature

Pathophysiology

Assessment of Target Vessels for Saphenous Vein Grafting

Diagnosis and Evaluation of SVG Disease

Symptoms
Chest X-Ray
CT
Cardiac Catheterization
Pathology

Saphenous Vein Graft Failure and Patency

Definition of Saphenous Vein Graft Failure
Historical Rates of Saphenous Vein Graft Failure
Determinants of Sapheous Vein Graft Patency
Saphenous vein graft failure as a Surrogate Endpoint in Clinical Trials

Treatment

2011 ACCF/AHA/SCAI Guideline Recommendations

Clinical Trials

Related Chapters

Guideline Resources

Additional Resources

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  • A. Coolong, D. S. Baim, R. E. Kuntz, A. J. O'Malley, S. Marulkar, D. E. Cutlip, J. J. Popma, and L. Mauri. Saphenous Vein Graft Stenting and Major Adverse Cardiac Events: A Predictive Model Derived From a Pooled Analysis of 3958 Patients. Circulation, February 12, 2008; 117(6): 790 - 797.
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  • M. Hilker, T. Langin, U. Hake, F.-X. Schmid, W. Kuroczynski, H.-A. Lehr, H. Oelert, and M. Buerke Gene expression profiling of human stenotic aorto-coronary bypass grafts by cDNA array analysis Eur. J. Cardiothorac. Surg., April 1, 2003; 23(4): 620 - 625.
  • J. L. Sperry, C. B. Deming, C. Bian, P. L. Walinsky, D. A. Kass, F. D. Kolodgie, R. Virmani, A. Y. Kim, and J. J. Rade Wall Tension Is a Potent Negative Regulator of In Vivo Thrombomodulin Expression Circ. Res., January 10, 2003; 92(1): 41 - 47.
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References

  1. ↑ Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions". Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)

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