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Conduits in coronary artery bypass grafting surgery: Saphenous vein, radial and internal thoracic arteries
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.ORCID iD: 0000-0001-5585-1783
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A novel technique for saphenous vein (SV) graft harvesting, the No-touch technique (NT), has been developed at the Dept. of Cardiovascular surgery, Örebro University hospital. With NT the SV is harvested with a pedicle of surrounding tissue. This avoids graft spasm and eliminates the need for distension. The surrounding tissue acts as a structural support and is a rich source of vaso-dilating agents. A randomized controlled trial (RCT) has shown a significantly higher patency rate for NT SV grafts compared to SV grafts harvested with conventional technique (CT). This thesis evaluates some of the properties of the surrounding tissue and compares patency rates between NT SV and radial artery (RA) grafts and patency rates for internal thoracic artery (ITA) grafts harvested with and without surrounding tissue. Paper I investigated vasa vasorum (VV) in SV grafts and showed that the NT preserves an intact VV whereas CT does not. This could be one of the mechanisms underlying the improved patency for NT SV grafts. Paper II evaluated VV and associated nitric oxide (NO) in SV and arterial grafts. SV grafts showed a higher number and larger VV, which correlated with NO production, compared to arterial grafts. NT SV grafts showed higher activity for e-NOS compared to CT SV grafts. Paper III is a RCT comparing patency rates between NT SV and RA grafts, three years after surgery, showing a significantly higher patency rate for NT SV grafts. Paper IV is a RCT comparing patency rates for ITA graft harvested with and without surrounding tissue and did not show any difference between graft preparations. In conclusion, the NT for SV graft harvesting preserves an intact vasa vasorum and associated NO production. NT SV grafts show a higher patency rate than RA grafts. Harvesting of ITA with or without surrounding tissue does not affect patency rate. 

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2013. , 65 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 93
Keyword [en]
Cardiac surgery, Coronary artery bypass, Saphenous vein, Radial artery, Internal thoracic artery, Vasa vasorum, Nitric oxide, Graft patency
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
URN: urn:nbn:se:oru:diva-33265ISBN: 978-91-7668-960-8 (print)OAI: oai:DiVA.org:oru-33265DiVA: diva2:690480
Public defence
2013-10-11, Wilandersalen, Universitetssjukhuset, Örebro, Södra Grev Rosengatan, 703 62 Örebro, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-01-23 Created: 2014-01-23 Last updated: 2017-10-17Bibliographically approved
List of papers
1. The ‘‘no-touch’’ harvesting technique for vein grafts in coronary artery bypass surgery preserves an intact vasa vasorum
Open this publication in new window or tab >>The ‘‘no-touch’’ harvesting technique for vein grafts in coronary artery bypass surgery preserves an intact vasa vasorum
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2011 (English)In: The Internet Journal of Thoracic and Cardiovascular Surgery, ISSN 1524-0274, Vol. 141, no 1, 145-150 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Our objective was to evaluate the impact of vein graft harvesting technique on structure and function of vasa vasorum.

Methods: Paired segments of great saphenous veins harvested either with conventional harvesting technique or no-touch technique were obtained from 9 consecutive patients undergoing coronary artery bypass grafting. Quantitative measurements, using immunohistochemistry and morphometry, were performed. Ultrastructural analyses of vasa vasorum were performed with electron microscopy. Video footage of superficial vasa vasorum in an implanted saphenous vein graft harvested with the no-touch technique was captured during a coronary bypass operation and is presented for online viewing.

Results: The total area of vasa vasorum in vein grafts harvested with the conventional technique was significantly reduced both in the media (P¼.007) and in the adventitia (P¼.014) compared with vein grafts harvested with the no-touch technique. Ultrastructural findings indicated that the no-touch technique preserved an intact vasa vasorum whereas the conventional technique did not. Video footage showed retrograde flow in the vasa vasorum in vein graft harvested with the no-touch technique.

Conclusions: These findings showthat the no-touch technique for saphenous vein graft harvesting for coronary bypass grafting preserves an intact vasa vasorum. This could represent one of the mechanisms underlying the improved patency of saphenous vein grafts harvested with this technique.

Place, publisher, year, edition, pages
New York, USA: Elsevier, 2011
National Category
Medical and Health Sciences Cardiac and Cardiovascular Systems
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-33266 (URN)10.1016/j.jtcvs.2010.02.005 (DOI)000285407500026 ()20381817 (PubMedID)2-s2.0-78650266270 (Scopus ID)
Available from: 2014-01-23 Created: 2014-01-23 Last updated: 2017-12-06Bibliographically approved
2. The Vasa Vasorum and Associated Endothelial Nitric Oxide Synthase is More Important for Saphenous Vein Than Arterial Bypass Grafts
Open this publication in new window or tab >>The Vasa Vasorum and Associated Endothelial Nitric Oxide Synthase is More Important for Saphenous Vein Than Arterial Bypass Grafts
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2013 (English)In: Angiology, ISSN 0003-3197, E-ISSN 1940-1574, Vol. 64, no 4, 293-299 p.Article in journal (Refereed) Published
Abstract [en]

No-touch (NT) saphenous vein (SV) grafts are superior to SVs harvested by the conventional technique (CT), with a patency comparable with the internal thoracic artery (ITA). Preservation of the vasa vasorum is implicated in the success of NT harvesting. We compared the vasa vasorum and endothelial nitric oxide synthase (eNOS) in NT SV with ITA and radial artery (RA) grafts. Skeletonized SV (SSV) was also analyzed. The NT SV had a higher number and larger vasa vasorum compared with ITA (P = .0001) and RA (P = .0004) that correlated with eNOS protein. Activity of eNOS in SSV grafts was significantly lower than NT SV grafts (P = 004). Since a high proportion of the vasa vasorum are removed in SSV using the CT, we suggest that preservation of the vasa vasorum and eNOS-derived NO contributes to the high patency for NT as compared with SSV grafts.

Keyword
coronary artery bypass surgery, saphenous vein, internal thoracic artery, radial artery, vasa vasorum, endothelial nitric oxide synthase
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-33267 (URN)10.1177/0003319712443729 (DOI)000317008800007 ()
Available from: 2014-01-23 Created: 2014-01-23 Last updated: 2017-12-06Bibliographically approved
3. The No-Touch Saphenous Vein as the Preferred Second Conduit for Coronary Artery Bypass Grafting
Open this publication in new window or tab >>The No-Touch Saphenous Vein as the Preferred Second Conduit for Coronary Artery Bypass Grafting
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2013 (English)In: Annals of Thoracic Surgery, ISSN 0003-4975, E-ISSN 1552-6259, Vol. 96, no 1, 105-111 p.Article in journal (Refereed) Published
Abstract [en]

Background. Injury incurred while saphenous veins are being obtained results in poor graft patency and impairs the results of coronary artery bypass grafting. A novel method of obtaining veins, the no-touch technique, has shown improved long-term saphenous vein graft patency. Methods. This randomized trial included 108 patients undergoing coronary artery bypass grafting and compared the patency of no-touch saphenous vein with that of radial artery grafts. Each patient was assigned to receive one no-touch saphenous vein and one radial artery graft to either the left or the right coronary territory to complement the left internal thoracic artery. Results. Angiography was performed in 99 patients (92%) at a mean of 36 months postoperatively. Graft and grafted coronary artery patency was evaluated. The patency of grafts for no-touch saphenous vein and radial artery was 94% versus 82% (p = 0.01), respectively. The patency of coronary arteries grafted with no-touch saphenous vein and radial artery grafts was 95% versus 84% (p = 0.005), respectively. Eighty-nine of 96 (93%) left internal thoracic artery grafts were patent. Conclusions. No-touch saphenous vein grafts showed a significantly higher patency rate than the radial artery grafts and the patency was comparable to the patency for left internal thoracic artery grafts. This highlights the improvement in saphenous vein graft quality with the no-touch technique and increases the number of situations in which saphenous veins may be preferable to radial artery grafts as conduits in coronary artery bypass grafting. (C) 2013 by The Society of Thoracic Surgeons

National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-33269 (URN)10.1016/j.athoracsur.2013.01.102 (DOI)000321741300027 ()
Conference
Late-Breaking Clinical Trial Abstract Session at the 49th Annual Meeting of the Society-of-Thoracic-Surgeons, JAN 26-30, 2013, Los Angeles, CA
Available from: 2014-01-23 Created: 2014-01-23 Last updated: 2017-12-06Bibliographically approved
4. To skeletonize or not to skeletonize the internal thoracic artery: a randomized trial
Open this publication in new window or tab >>To skeletonize or not to skeletonize the internal thoracic artery: a randomized trial
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background The left internal thoracic artery (LITA) is the gold standard conduit for grafting of the left anterior descending (LAD) coronary artery in coronary artery bypass grafting (CABG) surgery due to superior long-term patency rates and evidence of improved long-term outcomes. The LITA grafts are traditionally harvested with a pedicle of surrounding tissue (PLITA). Alternatively the LITA can be harvested in a skeletonized fashion (S-LITA) where the graft is being dissected from all surrounding tissues. Advocates of skeletonization postulate that this technique reduces sternal devascularisation, the incidence of chest wall pain and dysesthesia, wound healing problems, and increase the number of arterial anastomoses per patient by increasing the length of the LITA. To our knowledge this is the first randomised trial comparing angiographic mid-term patency rates between skeletonized andpedicled ITAs.

Methods This randomized trial included 109 patients undergoing coronary artery bypass grafting surgery and compared the patency for P-LITA and S-LITA. The patients were assigned to receive either one P-LITA or one S-LITA to the LAD. Complementary grafting was performed using both No-touch saphenous vein and radial artery grafts.

Results Graft patency was evaluated with angiography in 100 patients (92 %) at mean 36 months postoperatively. The patency rate for P-LITA (46/48, 96 %) did not differ (p=0.44) compared to S-LITA (47/52, 90 %). All failed grafts, except one with a localised stenosis, (S-LITA) were connected to LAD coronary arteries with a stenosis less than 70%.

Conclusions The evidence presented here demonstrates that in terms of patency, both P-LITA and S-LITA provide excellent results. It seemed that the most important factor for ITA occlusion was the degree of stenosis of the LAD and not the technique used for their preparation.

Clinical Trial registration 

NCT01310725 ClinicalTrials.gov [http://clinicaltrials.gov/ct2/show/NCT01310725]

National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-33420 (URN)
Available from: 2014-01-29 Created: 2014-01-29 Last updated: 2017-10-17Bibliographically approved

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