No-Touch Saphenous Veins in Coronary Artery Bypass Grafting : Long-term Angiographic, Surgical, and Clinical Aspects

Ischemic heart disease is currently the leading cause of death globally. Coronary artery bypass grafting (CABG) is considered the best treatment for many patients and its success depends on the long-term patency of the conduits. Greater use of arterial grafts has been advocated because of their higher long-term patency compared to saphenous vein grafts (SVGs). Despite this, SVGs account for up to 80% of all grafts used in CABG. Consequently, the long-term patency of the saphenous vein (SV) is one of the most crucial challenges in cardiovascular surgery. The no-touch (NT) SV in CABG has shown a superior patency rate, slower progression of atherosclerosis, and better clinical outcome compared to conventional veins up to 8.5 years postoperatively. The aim of this thesis was to study the long-term angiographic, echocardiographic, and clinical aspects of CABG patients receiving either NT or conventional vein grafts and to investigate the health-related quality of life (HRQoL) in this patient group. Studies I-II report a randomized trial between NT and conventional veins where 74 patients were followed-up at a mean of 16 years postoperatively. Study III is a prospective cohort trial in which 97 patients with NT vein grafts anastomosed to the left anterior descending artery (LAD) were included and followed-up at a mean of 6 years postoperatively. Study IV included 257 patients in whom HRQoL and graft patency were studied during the same follow-up visit. Overall, NT vein grafts showed a higher patency compared to conventional veins at a mean of 16 years, 83% vs. 64% (p=0.03), which was similar to the patency of the left internal thoracic artery, 88%. The NT group had a better left ventricular ejection fraction compared to the conventional group, 57.9% vs. 49.4% (p=0.011). After a mean of 6 years, the patency rate of NT SVs to the LAD was 95.6% and to non-LAD targets, 93.9%. Graft patency was an independent predictor of HRQoL in CABG patients. These patients reported a function and wellbeing similar to that of the Swedish population and clearly higher health status than those in the same disease group in the general population

Surgical Aspects of No-Touch Saphenous Vein Graft Harvesting in CABG: Clinical and Angiographic Follow-Up at 3 Months

Abstract With more than 800,000 coronary artery bypass grafting (CABG) operations annually worldwide and the saphenous vein being the most common conduit used, there is no question that improving saphenous vein graft patency is one of the most important tasks in CABG. This video describes the no-touch harvesting procedure of the saphenous vein on an 80-year old man with hypertension, hyperlipidemia and a previous myocardial infarction with percutaneous coronary intervention to the right coronary artery. He was complaining of exertional chest pain and was diagnosed with stable angina pectoris. The coronary angiography showed advanced three vessel disease with significant stenoses in the left anterior descending (LAD) artery, two marginal arteries (MAs) and the posterior descending artery (PDA), in addition to an occluded diagonal artery (DA). The patient received a triple sequential no-touch vein graft to the PDA and two MAs together with a double sequential no-touch vein graft to the DA and LAD. A vein graft was used to bypass the LAD due to the age of the patient and the low degree of stenosis in the LAD. The no-touch harvesting technique is described in detail in the film with complete narration. A follow-up of this patient was performed at three months both clinically and with a computed tomography angiography (CTA). No angina pectoris symptoms were reported by the patient and the wounds in the chest and lower limb were completely healed. The CTA showed patent no-touch saphenous vein grafts to all the distal anastomoses

The no-touch vein graft for coronary artery bypass surgery preserves the left ventricular ejection fraction at 16 years postoperatively : long-term data from a longitudinal randomised trial

OBJECTIVES: To assess the left ventricular heart function and the clinical outcome 16 years after coronary artery bypass surgery. DESIGN: In a randomised trial, the no-touch (NT) vein graft in coronary artery bypass surgery has shown a superior patency rate, a slower progression of atherosclerosis and better clinical outcome compared to the conventional (C) vein graft at 8.5 years. All patients at mean time 16 years were offered an echocardiographic and clinical examination. RESULTS: In the NT-group 34 patients and in the C-group 31 patients underwent an echocardiography examination. A significantly better left ventricle ejection fraction was seen in the NT-group compared to the C-group (57.9% vs 49.4%; p=0.011). The size of the left atrium in NT was 21.7 cm(2) compared to 23.9 cm(2) in C; p=0.034. No patient in NT had atrial fibrillation compared to five patients in C (p=0.021). Patients with a brain natriuretic peptide value (BNP) ≥150 was 30% in NT compared to 38% in C. Total mortality was 25% in NT vs 27% in C. Cardiac-related deaths were 8% and 12% in NT and C respectively. CONCLUSIONS: The NT vein graft preserves the left ventricular ejection fraction after 16 years. A smaller left atrium, a lower BNP and no atrial fibrillation indicates an improved diastolic left ventricular function in the NT-group. TRIAL REGISTRATION: The study is registered with clinicaltrials.gov (NCT01686100) and The Research and Development registry in Sweden (no. 102841)

Calcium Load in the Aortic Valve, Aortic Root, and Left Ventricular Outflow Tract and the Risk for a Periprocedural Stroke

Background: Periprocedural stroke during transcatheter aortic valve implantation is a rare but devastating complication. The calcified aortic valve is the most likely source of the emboli in a periprocedural stroke. The total load and distribution of calcium in the leaflets, aortic root, and left ventricular outflow tract varies from patient to patient. Consequently, there could be patterns of calcification that are associated with a higher risk of stroke. This study aimed to explore whether the pattern of calcification in the left ventricular outflow tract, annulus, aortic valve, and ascending aorta can be used to predict a periprocedural stroke. Methods: Among the 3282 consecutive patients who received a transcatheter aortic valve implantation in the native valve in Sweden from 2014 to 2018, we identified 52 who had a periprocedural stroke. From the same cohort, a control group of 52 patients was constructed by propensity score matching. Both groups had one missing cardiac computed tomography, and 51 stroke and 51 control patients were blindly reviewed by an experienced radiologist. Results: The groups were well balanced in terms of demographics and procedural data. Of the 39 metrics created to describe calcium pattern, only one differed between the groups. The length of calcium protruding above the annulus was 10.6 mm (interquartile range 7-13.6) for patients without stroke and 8 mm (interquartile range 3-10) for stroke patients. Conclusions: This study could not find any pattern of calcification that predisposes for a periprocedural stroke