Aortocoronary Saphenous Vein Graft Disease

Abstract

Aortocoronary saphenous vein graft disease, with its increasing clinical sequelae, presents an important and unresolved dilemma in cardiological practice. During the 1st month after bypass surgery, vein graft attrition results from thrombotic occlusion, while later the dominant process is atherosclerotic obstruction occurring on a foundation of neointimal hyperplasia. Although the risk factors predisposing to vein graft atherosclerosis are broadly similar to those recognized for native coronary disease, the pathogenic effects of these risk factors are amplified by inherent deficiencies of the vein as a conduit when transposed into the coronary arterial circulation. A multifaceted strategy aimed at prevention of vein graft disease is emerging, elements of which include: continued improvements in surgical technique; more effective antiplatelet drugs; increasingly intensive risk factor modification, in particular early and aggressive lipid-lowering drug therapy; and a number of evolving therapies, such as gene transfer and nitric oxide donor administration, which target vein graft disease at an early and fundamental level. At present, a key measure is to circumvent the problem of vein graft disease by preferential selection of arterial conduits, in particular the internal mammary arteries, for coronary bypass surgery whenever possible.

Diagnostic accuracy of 64-slice multidetector computed tomography in evaluation of post-coronary artery bypass grafts in correlation with invasive coronary angiography

“…Our study confirms that arterial grafts are associated with superior long-term patency compared with saphenous vein grafts. Our results are in concordant with the previous studies 13,17,18 where arterial grafts were found to have better lifetime of graft patency than venous grafts.…”

Coronary vein graft disease: Pathogenesis and prevention

“…As in native coronary arteries, vein graft atheromas can rupture and cause thrombotic occlusion of the graft (1). Vein graft atheromas are more diffuse and concentric, less calcified and have poorly developed or absent fibrous caps (2). Not long after coronary artery bypass grafting surgery was described, several reports presented follow-up angiographic data on large cohorts of patients, demonstrating that approximately one-half of saphenous vein grafts fail within 10 to 15 years of surgery and that graft failure is associated with worse clinical outcomes.…”

Intimal hyperplasia induced by vascular intervention causes lipoprotein retention and accelerated atherosclerosis

“…Accelerated atherosclerosis diminishes the long term patency of SVGs and may be a major cause of late stent failure (Motwani and Topol 1998; Kang et al. 2011; Otsuka et al.…”

“…However, this view is criticized since it is difficult to distinguish formation of a new atherosclerotic lesion from expansion of the old atherosclerotic lesion that was the target for the intervention (Andreou and Stone 2016). Interestingly, high prevalence of atherosclerosis is also seen following insertion of coronary artery bypass grafts (CABG), especially when using saphenous vein‐grafts (Motwani and Topol 1998; Kim et al. 2013; Yahagi et al.…”

“…2016). The atherosclerotic lesions appear already within 1 year after implantation, and between 2 and 5 years after intervention complex lesions with necrotic cores are seen (Motwani and Topol 1998; Kim et al. 2013).…”