Commentary: The saphenous vein in coronary artery bypass grafting: Optimizing our workhorse

Abstract

Coronary artery bypass grafting remains the gold standard therapy for the management of advanced multivessel coronary artery disease. Integral to the procedure remains the selection of appropriate graft conduits to maximize graft patency and longevity while minimizing complications such as surgical site infection, poor wound healing, and mediastinitis.Vervoort and colleagues 1 review several aspects currently under different stages of investigation to improve saphenous vein graft (SVG) patency. By addressing different targets of saphenous graft failure, such as external stenting to reduce intimal hyperplasia, pharmacologic targets to suppress long-term vein graft atherosclerosis and thrombosis, saphenous vein storage solutions, and Y-grafting onto an arterial conduit to manipulate vein graft pressures and perfuse the vein graft with endogenous vasodilators, our specialty's research and clinical communities appear aligned on the importance of this issue.The saphenous vein is considered by many as a fourthrate conduit, after the left internal thoracic artery, right internal thoracic artery, and radial artery. Nevertheless, the saphenous vein remains the most commonly used conduit worldwide. This is due to its relative ease of harvest, freedom from vasospasm, freedom from manipulation during coronary angiography, length of conduit, and relatively fast recovery from harvest. Traditionally quoted patency rates included early graft failure rates of 20% and longterm patency of SVGs of 50% at 10 years. However, as surgical and adjunctive medical therapies continue to improve, so do the outcomes of saphenous conduit. For example, in the recent Graft Patency Between no-touch Vein Harvesting Technique and Conventional Approach in Coronary Artery Bypass Graft Surgery (PATENCY) trial, Tian and colleagues 2 demonstrated early SVG failure rates of 2.8% with no-touch SVG harvest and 4.8% (P<.001) with conventional SVG harvesting. At 1 year, graft patency was 94.3% in the no-touch SVG group and 93.5% in the conventional harvest group (P < .001). Using the saphenous vein as a conduit for Y-grafting off of an in situ left internal thoracic artery has also shown great potential. In the recent Saphenous Vein versus Right Internal Thoracic Artery (SAVE-RITA) trial, Kim and colleagues 3 demonstrated that Y-grafts constructed using the SVG had no difference in patency compared with those constructed using the right internal thoracic artery at 10 years (93.1% vs 96.4%, respectively [P ¼ .21]).Achieving optimal outcomes is dependent on a number of preoperative, intraoperative, and postoperative factors. The first step in ensuring graft patency is the selection of appropriate targets for revascularization. Target vessel stenosis and distal vessel diameter have long been known to affect From the