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


'''Associate Editors-In-Chief:''' {{CZ}}, Jason C. Choi, M.D., Xin Yang, M.D.
==[[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]]==
 
==[[SVG Anatomy]]==
 
==[[Saphenous Vein Graft Harvesting]]==
 
==[[Saphenous Vein Graft Nomenclature]]==


==[[Assessment of Target Vessels for Saphenous Vein Grafting]]==
==[[Assessment of Target Vessels for Saphenous Vein Grafting]]==
==[[Pathophysiology of Saphenous Vein Graft Disease]]==
==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]]===


==Diagnosis and Evaluation of SVG Disease==
==Diagnosis and Evaluation of SVG Disease==


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


===[[Chest X-Ray in the Patient with Saphenous Vein Grafts]]===
=====[[Chest X-Ray in the Patient with Saphenous Vein Grafts|Chest X-Ray]]=====


===Coronary Angiography===
=====[[CT Angiography in the Assessment of Saphenous Vein Graft Disease|CT]]=====
Coronary angiography is often used to ascertain the patency and percent stenoses of saphenous vein grafts.
====Technique====
Most often a Judkin's Right 4 catheter (JR 4) catheter is used to engage the saphenous vein grafts. If this diagnostic catheter has insufficient "reach" to engage the SVG ostium, then an Amplatz catheter can be used. The optimal view to engage the ostium of the SVG varies from operator to operator. The most popular views to engage the ostium are the left anterior oblique 45 degrees view (LAO 45) with no cranial angulation. Some operator will use the right anterior oblique view (RAO) with 45 degrees of angulation and no cranial angulation. It should be noted that the SVGs supplying the left coronary arteries will come off of the left hand side of the screen and those supplying the right coronary artery will come off of the right hand side of the screen.


If an SVG is known from the operative report to exist, but cannot be selectively engaged, then a non-selective aortogram can be performed to aid in identifying the presence and location of patent SVGs.  The aortogram is performed with an injection through an angled pigtail catheter with the camera gantry located in the 45 degree left anterior oblique (LAO) position with no cranial angulation.
=====[[Cardiac Catheterization]]=====


In order to engage the [[left internal mammary artery]] (which is not a saphenous vein graft but is often interrogated during the process of evaluating SVGs), a view with slight cranial, and slight left anterior oblique (LAO) angulation is used.  a Judkin's Right 4 catheter (JR 4) catheter is used to engage the ostium of the [[subclavian artery]].  With the catheter near the anticipated origin of the [[subclavian artery]], a counterclockwise motion of the catheter is needed to engage the ostium.  Once the ostium is engaged, an '''''exchange length''''' 0.038 J tipped wire is then advance into the [[subclavian artery]].  A [[left internal mammary artery]] ([[LIMA]]) catheter is then exchanged to engage the origin of the [[left internal mammary artery]].  Again, this engagement is accomplished with counterclockwise motion of the catheter.  An injection with the camera in this angulation is a suitable first view of the [[LIMA]], with careful attention in this view paid to the ostium of the [[LIMA]].  the next view is often a left anterior oblique (LAO) view with 90 degrees of angulation (LAO 90). This allows for accurate assessment of the [[LIMA]] anastomosis to the [[left anterior descending artery]].
=====[[Saphenous Vein Graft Pathology|Pathology]]=====


====Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters====
==Saphenous Vein Graft Failure and Patency==
One technique that has been used to improve the ascertainment of SVG patency and stenosis is the placement of radio-opaque markers. Use of such markers has been  associated with shorter cardiac catheterization procedure times and  reduced contrast agent volume for postoperative coronary artery bypass  graft (CABG) catheterizations.  In the large PREVENT 4 study <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><ref name="pmid18222256">{{cite journal | author = Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM | title = Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters | journal = [[The Annals of Thoracic Surgery]] | volume = 85 | issue = 2 | pages = 520–4 | year = 2008 | month = February | pmid = 18222256 | doi = 10.1016/j.athoracsur.2007.10.061 | url = http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 | issn = | accessdate = 2010-10-31}}</ref>, approximately half the patients had SVG markers present (51.2% or 910 of 1,778 patients)  and half the SVGs (52.3% of SVGs or 2,228 of 4,240).  If the patient had a totally occluded SVG (n = 911), visual identification of the occluded SVG was obtained more  frequently among those patients who had an SVG marker (90.7% vs 72.1%, p < 0.001).  The identification of SVG stenosis which were <u>></u> 70% did not differ by the use of  SVG markers (25.8% with marker vs 24.4% without marker, p = not  significant). These findings were also consistent in ostial lesions (n =  942). The use of an SVG marker was not associated with a difference in the long-term risk of death or myocardial infarction (MI). However, it was noted that the rate of  perioperative CABG MI was higher among patients who had an SVG  marker (10.1% vs 5.5%, odds ratio adjusted 1.86, p = 0.021).
 
====Use of Coronary Angiography of Saphenous Vein Graft Disease as Endpoint in Clinical Trials Evaluating Pharmacotherapy and Device Based Therapies====
=====SVG Patency and SVG Narrowing as a Surrogate Endpoint for Clinical Events=====
One issue that arises is the suitability of SVG patency, and SVG narrowing as a [[surrogate endpoint]] for clinical events.
 
There are multiple studies demonstrating that SVG closure or failure is associated with clinical events.  The association of SVG failure or narrowing with clinical events is complex and should be interpreted in light of the following nuances:
#The SVG may close and the native artery may remain open minimizing the symptoms associated with SVG failure.  SVG failure may therefore by clinically "silent" or may not be closely associated with "hard endpoints" such as [[myocardial infarction]]([[MI]]).
#Placement of SVGs has been associated with improved survival over medical therapy particularly in patients with left main disease and three vessel disease.  In so far as the mechanism of clinical benefit of SVGs is predicated upon their ongoing patency, this supports the relevance of SVG patency as a surrogate endpoint.
#Despite the native artery remaining open after SVG failure, it should be realized that placement of an SVG is associated with more rapid disease progression in the grafted native coronary artery.  SVG placement therefore exposes the patient to a risk of more rapid native disease progression. There is a 4 to 6 fold increase in the risk of proximal native vessel occlusion following the placement of an SVG, while there is limited impact upon disease progression downstream from the SVG <ref name="pmid18268427">{{cite journal | author = Borowski A, Vchivkov I, Ghodsizad A, Gams E | title = Coronary artery disease progression in patients who need repeat surgical revascularisation: the surgeon's point of view | journal = [[Journal of Cardiovascular Medicine (Hagerstown, Md.)]] | volume = 9 | issue = 1 | pages = 85–8 | year = 2008 | month = January | pmid = 18268427 | doi = 10.2459/JCM.0b013e328011439e | url = http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1558-2027&volume=9&issue=1&spage=85 | issn = | accessdate = 2010-10-31}}</ref><ref name="pmid11292927">{{cite journal | author = Hamada Y, Kawachi K, Yamamoto T, Nakata T, Kashu Y, Watanabe Y, Sato M | title = Effect of coronary artery bypass grafting on native coronary artery stenosis. Comparison of internal thoracic artery and saphenous vein grafts | journal = [[The Journal of Cardiovascular Surgery]] | volume = 42 | issue = 2 | pages = 159–64 | year = 2001 | month = April | pmid = 11292927 | doi = | url = | issn = | accessdate = 2010-10-31}}</ref><ref name="pmid8869860">{{cite journal | author = Rupprecht HJ, Hamm C, Ischinger T, Dietz U, Reimers J, Meyer J | title = Angiographic follow-up results of a randomized study on angioplasty versus bypass surgery (GABI trial). GABI Study Group | journal = [[European Heart Journal]] | volume = 17 | issue = 8 | pages = 1192–8 | year = 1996 | month = August | pmid = 8869860 | doi = | url = http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8869860 | issn = | accessdate = 2010-10-31}}</ref><ref name="pmid312703">{{cite journal | author = Guthaner DF, Robert EW, Alderman EL, Wexler L | title = Long-term serial angiographic studies after coronary artery bypass surgery | journal = [[Circulation]] | volume = 60 | issue = 2 | pages = 250–9 | year = 1979 | month = August | pmid = 312703 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=312703 | issn = | accessdate = 2010-10-31}}</ref> . While long-term studies demonstrate that as many as 22/23 grafted vessels occlude proximal to the SVG insertion site, the patency beyond the SVG insertion remains better (only 8 of 39 segments failed)<ref name="pmid312703">{{cite journal | author = Guthaner DF, Robert EW, Alderman EL, Wexler L | title = Long-term serial angiographic studies after coronary artery bypass surgery | journal = [[Circulation]] | volume = 60 | issue = 2 | pages = 250–9 | year = 1979 | month = August | pmid = 312703 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=312703 | issn = | accessdate = 2010-10-31}}</ref>. Progression of native disease is more rapid in segments bypassed by and SVG than those bypassed by an arterial conduit (p = 0.001, odds ratio = 2.03)<ref name="pmid9800822">{{cite journal | author = Manninen HI, Jaakkola P, Suhonen M, Rehnberg S, Vuorenniemi R, Matsi PJ | title = Angiographic predictors of graft patency and disease progression after coronary artery bypass grafting with arterial and venous grafts | journal = [[The Annals of Thoracic Surgery]] | volume = 66 | issue = 4 | pages = 1289–94 | year = 1998 | month = October | pmid = 9800822 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(98)00757-7 | issn = | accessdate = 2010-10-31}}</ref>. In summary, if the SVG fails, the patient most often is left with greater progression of the underlying native vessel disease than they would have had had they not had an SVG placed. It is difficult to ascertain the impact of native vessel disease acceleration given the limited duration of follow-up in trials of SVGs. The impact of disease progression may not be apparent for many years and may be underestimated in current trials and analyses.
#As a nuance of the above, the impact of SVG failure may depend in part upon when it occurs.
#SVG failure not only leads to a potential reduction in antegrade blood flow to the bypassed segment as a result of vessel closure, there is also the potential for embolizaiton from a large occluded conduit into the downstream native circulation.  SVGs do not have sidebranches and there is therefore no capacity for alternate run off when occlusion occurs. As a result, SVGs often occlude back to the origin of the SVG. Furthermore, the diameter of SVG often exceeds that of native arteries. As a result of the fact that the SVG occludes back to the ostium and is of a larger volume than a native coronary artery, there is a much larger embolic burden associated with a SVG.
#Consistent with the embolic hazard cited above, is the fact that dilation of an SVG failure does not lead to improved clinical outcomes. The fact that opening a closed SVG does not lead to improved outcomes may lead to inappropriate confusion surrounding SVG failure as a relevant clinical outcome.  While it may be intuitive that opening an occluded or failed SVG would lead to improved outcomes (consistent with SVG failure being a surrogate), opening the occluded SVG may instead lead to embolizaiton of a large amount of the thrombotic material downstream.  <u>'''''Preventing SVG occlusion may be related to improved outcomes, but treating SVG occlusion after it occurs may not be related to improved outcomes.'''''</u> The failure of reopening an occluded SVG to improve outcomes should not detract from the importance and relevance of preventing SVG occlusion in the first place as a valid surrogate endpoint.
#The patient is the unit of randomization, but the SVG is the unit most closely related to clinical events.
 
In summary there are multiple mechanisms whereby SVG patency is related to clinical outcomes.
#Closure of the conduit may reduce antegrade blood flow
#There may be embolization into the native vessel from the thrombosed SVG conduit, the diameter of which often exceeds the native coronary artery
#The SVG may have accelerate native vessel disease which predisposes the patient to adverse outcomes when the vessel occludes
 
Is the timing of SVG failure relevant?  If an anticoagulant (either [[antiplatelet]] or [[antithrombin]]) is undergoing evaluation of its efficacy in the prevention of thrombotic graft closure, then it is irrelevant if this thrombotic closure is early (in the immediate peri-operative period) or late.  It could be hypothesized that the clinical benefit of the anticoagulant agent would be operative during both the early and late follow-up periods.


=====Potential for Ascertainment Bias=====
=====[[Definition of Saphenous Vein Graft Failure]]=====
There are several issues that arise with respect to ascertainment bias in the use of coronary angiograms as an endpoint.
#'''The patient may not return for follow-up angiography.'''  Maybe the patient is feeling so well they don't feel compelled to return for repeat angiography (you missed a positive treatment effect), or maybe they are so sick they can't show up (you missed a negative treatment effect).  If patients died, traditionally they are counted or imputed as having SVG failure on both a per patient and a per SVG conduit basis. The percent of patients who returned for follow-up angiography was 80% in the PREVENT 4 study <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 patient may return for follow-up angiography, but one or more of the SVGs cannot be engaged and selectively injected.''' As stated above, in the PREVENT 4 study, the use of saphenous vein graft markers improved the odds of finding SVGs in particular occluded SVGs <ref name="pmid18222256">{{cite journal | author = Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM | title = Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters | journal = [[The Annals of Thoracic Surgery]] | volume = 85 | issue = 2 | pages = 520–4 | year = 2008 | month = February | pmid = 18222256 | doi = 10.1016/j.athoracsur.2007.10.061 | url = http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 | issn = | accessdate = 2010-10-31}}</ref>. However, the SVG stenosis 70% or greater at follow-up did not differ by use of markers (25.8% with marker vs 24.4% without marker, p = not significant). In other words, there does not seem to be ascertainment bias whereby failure to find the SVG results in a different outcome (the outcomes in patients with SVG markers with a greater degree of ascertainment of the endpoint were no different).


=====Per Patient versus Per SVG as the Unit of Analysis=====
=====[[Historical Rates of Saphenous Vein Graft Failure]]=====
Analyses should be presented on both a per patient basis (the unit of randomization) and a per SVG basis (the unit that is associated with clinical events).  Because the behavior of multiple SVGs may be correlated, and this within patient correlation may reduce the estimate of the variance in the population, an adjustment for the within patient correlation must be provided when presenting the results on a per SVG basis<ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>.  The within patient conocrdance can be adjusted for using a General Linear Model of Intraclass Correlation (GLIMIC) <ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>.


===[[CT Angiography in the Assessment of Saphenous Vein Graft Disease]]===
=====[[Determinants of Sapheous Vein Graft Patency]]=====


===[[Saphenous Vein Graft Pathology]]===
=====[[Saphenous vein graft failure as a Surrogate Endpoint in Clinical Trials]]=====


==[[Treatment of Saphenous Vein Graft Disease]]==
==[[Saphenous vein graft disease treatment|Treatment]]==


===[[Saphenous Vein Graft Intervention Complications]]===
====[[Saphenous vein graft disease treatment#2011 ACCF/AHA/SCAI Guideline Recommendations: Saphenous vein grafts|2011 ACCF/AHA/SCAI Guideline Recommendations]]====


==Clinical Trials==
==Clinical Trials==
Line 116: 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==
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{{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
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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

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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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