Invited Commentary

Abstract

The authors [1] have identified preoperative continuation of aspirin as an important factor affecting perioperative vein graft patency after off-pump coronary bypass surgery. It is timely to recall the many other factors that can also have a significant effect on early or late patency, which have been identified over the last 40 years and which remain important to the present time. Only healthy saphenous veins of good caliber should be harvested. Other important factors include careful physical handling with avoidance of crushing or stretching of the vein during harvest. The adventitia should be preserved and not stripped to "clean" the vein. These goals can be achieved equally well with skilled open or endoscopic vein harvest. After harvest, the vein should be maintained at normothermia and prepared with room temperature balanced salt solution (eg, lactated Ringer solution) under low inflation pressure. Heparinized blood or normal saline should not be used; this has been reconfirmed recently in the publication from the PREVENT IV study regarding preparation solutions [2]. These measures dramatically reduced the early development of obstructive fibromuscular medial lesions; however, early vein graft failures from thrombosis continued to occur, suggesting incomplete endothelial and medial preservation despite these measures. The demonstration by Chesebro and colleagues [3,4] that the addition of perioperative aspirin therapy improved early and late vein graft patency was an early landmark in pharmacologic protection of the vein graft. Interest in the use of statin drugs perioperatively was based initially on the recognition that many late vein graft failures were related to the late development of vein graft atherosclerosis. Although less evidence exists than for aspirin, they continuation of preoperative statin therapy may also have some benefit on early and late vein graft patency. Optimal graft patency requires not only meticulous attention to anastomoses by skilled surgeons, but also careful long-term management of the vein graft itself. References1. Wu H, Wang J, Sun H, et al. Preoperative continuation of aspirin therapy may improve perioperative saphenous venous graft patency after off-pump coronary artery bypass grafting. Ann Thorac Surg 2015;99:576-81. 2. Hasarkamp RE, Alexander JH, Schulte PJ, et al. Vein graft preservation solutions, patency, and outcomes after coronary artery bypass graft surgery: follow-up from the PREVENT IV randomized clinical trial. JAMA Surg 2014;149:798-805. 3. Chesebro JH, Fuster V, Elveback LR, et al. Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations. N Engl J Med 1984;310:209-14. 4. Chesebro JH, Clements IP, Fuster V, et al. A platelet-inhibitor drug trial in coronary-artery bypass operations: benefit of perioperative dipyridamole and aspirin therapy on early postoperative vein-graft patency. N Engl J Med 1982;307:73-8.