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SECTION 5 Management of cardiopulmonary bypass218
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risk of adverse outcomes in low- risk patients, while it was associated with a reduced risk in high- risk patients. e problem with
transfusion arises from the fact that its indications can be vague
and uncertain while the associated risks are substantial, giving it a
relatively narrow therapeutic margin. With no reliable method to
assess tissue oxygen delivery and consumption clinically available,
identifying the patients in whom transfusions are appropriate can
be a challenging task.
e list of complications and negative outcomes associated with
transfusion (and the studies reporting on them) grow steadily. Not
surprisingly, these studies have triggered eorts to limit transfusions
across patient populations. Several randomized controlled trials
a liberal transfusion arm get transfused and many patients in restrictive transfusion arms are eventually transfused regardless.
Additionally, some trials fail to account for all transfusion episodes
and only focus on transfusions aer randomization and within the
period specied by the trial- specied transfusion protocols. Lastly,
trials are not immune from bias and there is oen a wide gap between the clean- cut groups of patients who have sieved through the
eligibility criteria of trials and patients managed in real- world clinical setting., Awaiting more denitive results from new studies
focusing on cardiovascular procedures, the transfusion strategies
outlined in current guidelines should be followed in these patients
(Table 26.1).–
showed that restrictive transfusion strategies are feasible and associated with reduced transfusion utilization while resulting in
comparable or improved patient outcomes compared with liberal
transfusion strategies. However, patients with cardiovascular
comorbidities and those undergoing cardiovascular surgery may be
more susceptible to negative eects of anaemia and restricting transfusion in these patients oen generates scrutiny. In a recent clinical
trial, 2007 patients with haemoglobin cpncentrations less than 9 g/ dL
following cardiac surgery were randomized to either a liberal transfusion strategy (based on postoperative haemoglobin threshold of
<9 g/ dL) or a restrictive transfusion strategy (based on haemoglobin
threshold of <7.5 g/ dL). ere was reduced resource utilization and
decreased transfusion rate (almost halved) in the patients randomized to the restrictive transfusion strategy, while both study arms
had comparable primary outcomes (composite of any serious infectious or ischaemic events within 3months aer admission). ere
was no dierence in infectious events, ischaemic events, duration of
hospital stay, or pulmonary complications, while patients randomized to restrictive transfusion had increased all- cause mortality rates
within 90days of operation (4.2% vs 2.6%, hazard ratio 1.64, 95%
condence interval (CI) 1.0– 2.67). e authors concluded that while
overall comparable outcomes in the face of reduced resource utilization should make a strong case for wider use of restrictive transfusion strategies in patients undergoing cardiovascular operations,
more studies (and meta- analyses of data from existing studies with
a focus on actual transfusion status) are needed to assess the impact of restrictive versus liberal transfusions in these cardiovascular
patients. In a recent meta- analysis looking at pooled data from 8
trials, including a subset of 3323 patients undergoing cardiovascular
operations, there was a non- signicant trend towards increased
risk of ischaemic complications and early mortality in patients subjected to restrictive transfusion strategies (relative risk 1.09, 95% CI
0.97– 1.22; and 1.39, 95% CI 0.95– 2.04, respectively). In contrast, no
similar trend suggestive of increased risks appeared in other patient
populations not having cardiovascular operations.,
While it is reasonable to take a more conservative approach
among patients undergoing cardiovascular operations, the evidence on harmful eects of restrictive transfusion strategies in
these patients is far from conclusive. Awealth of data from observational studies that support the link between transfusions
and poor outcomes in patients having cardiovascular procedures
is contrasted by a handful of trials that suggest increased risk of
Patient blood management incardiacsurgery
Patient blood management (PBM) oers a dierent approach to
transfusion. Rather than debating which haemoglobin threshold to
use to make a transfusion decision, PBM focuses on the treatment
options and modalities that can be used to reduce and eliminate the
need for transfusion altogether, and more importantly achieve better
clinical outcomes for the patient. is patient- centred approach (vs
the traditional product- centred approach of transfusion medicine)
is the cornerstone of PBM.
PBM is dened as ‘the timely application of evidence- based medical and surgical concepts designed to maintain hemoglobin concentration, optimize haemostasis and minimize blood loss in an
eort to improve patient outcome’. To achieve its goal, PBM uses the
following strategies (Fig. 26.1):*
• Management of anaemia throughout the course of care.
• Optimization of coagulation and haemostasis.
• Utilization of interdisciplinary blood conservation and autotrans-
fusion modalities.
• Patient- centred decision– making.
Here we review these strategies as they pertain to surgical patients
in general, and those undergoing cardiac operations in particular.
Management ofanaemia
Timely diagnosis and management of anaemia is a key strategy
in PBM. Attention should be paid to detecting and treating anaemia prior to the operation as well as preventing, detecting, and
managing anaemia following the surgery and during the hospital
stay. Anaemia in patients undergoing cardiac surgery is oen
multifactorial with several aetiologies including iron deciency,
inammation (anaemia of inammation or anaemia of chronic
disease), and blood loss oen playing a role. As indicated earlier,
anaemia occurs commonly in patients having cardiac operations,
and persists or worsens in many patients during the course of hospitalization and beyond. Patients scheduled for elective cardiovascular procedures should be screened for anaemia ahead of time.
Ascreening timeline of 4 weeks ahead of a scheduled procedure
allows enough time for diagnostic work- ups and determination
of underlying causes(s) of anaemia. is diagnostic approach
harm when these patients are randomized to a restrictive transfusion arm compared with their peers who are transfused at more
liberal thresholds. Of note, randomizing patients to a transfusion
strategy is not the same as transfusing them. Not all patients in
* What is Patient Blood Management? From the Society for the Advancement
of Blood Management (SABM), available at http:// www.sabm.org/
Table26.1 Transfusion guidelines forsurgical patients
https://t.me/medicina_free
26 Patient blood management strategies incardiacsurgery 219
American Society of
Anesthesiology (2006)19
Target population General surgery Cardiac surgery General surgery General hospitalized
When is blood
transfusion usually
indicated?
When is blood
transfusion rarely
indicated?
Gray areas Haemoglobin 6– 10 g/ dL Patients with acute coronary
What other
factors to consider
in making the
decision?
Haemoglobin <6 g/ dL Haemoglobin <6 g/ dL
Haemoglobin >10 g/ dL Haemoglobin >10 g/ dL Haemoglobin >10 g/ dL
Ischaemia, extent/ rate of
bleeding, volume status, risk
factors for hypoxia complications
provides data for a proper therapeutic approach. Proper treatment
of anaemia in the weeks prior to a scheduled surgery allows the
patient’s body to produce the equivalent of one or more units of
blood— the patient’s own fresh whole blood with all the components and factors— which can eectively eliminate the need for
allogeneic blood transfusion and the associated risks. Fig. 26.2 depicts an algorithm for screening and management of anaemia in
surgical patients. is approach is in contrast with the ‘routine’
practice of obtaining a complete blood count during preadmission
testing just days ahead of the scheduled procedure, and taking
anaemic patients into the operating room, relying on allogeneic
Society of Thoracic Surgeons
(2011)21
Haemoglobin <7 g/ dL in
postoperative period
Possibly higher haemoglobin
levels when risk of end- organ
ischaemia exists or in patients
on cardiopulmonary bypass
with risk of critical end- organ
ischaemia/ injury
Age, severity of illness, cardiac
function, risk of ischaemia,
extent/ rate of blood loss, mixed
venous oxygen saturation (SVO2),
electrocardiogram, etc.
blood. Given the negative consequences of anaemia and transfusion, unmanaged anaemia should be considered a contraindication for elective operations. However, coronary bypass surgery
is oen urgently or even emergently scheduled, forcing clinical
teams to focus on perioperative strategies for blood conservation
and anaemia management.
Treatment of anaemia should be guided by the aetiologies present.
e main therapeutic choices include intravenous (IV) iron and
erythropoiesis- stimulating agents (ESAs). Iron deciency is seen
in as high as one- third to one- half of cardiovascular patients and
is linked to worse outcomes independent of anaemia. Similarly,
Italian Society of
Transfusion Medicine and
Immunohaematology
(2011)22– 24
Haemoglobin <6 g/ dL
Haemoglobin 6– 8 g/ dL in
presence of risk factors
Haemoglobin 6– 10 g/ dL if
symptoms of hypoxia are
present
Rate of blood loss, risk factors,
symptoms of hypoxia/ ischaemia
American Association of
Blood Banks
(2012)20
Haemoglobin ≤7 g/ dL in critically
ill patients
Haemoglobin ≤8 g/ dL in surgical
patients, or patients with preexisting cardiovascular disease
When symptoms of hypoxia are
present in context of anaemia
syndrome
Symptoms of hypoxia (chest
pain, orthostatic hypotension,
unresponsive tachycardia, heart
failure)
Fig.26.1 Key strategies that are utilized in patient blood management (PBM) to achieve the goal of improved outcomes.
Society for the Advancement of Blood Management.
• Use quantitative and qualitative measures to
Optimzing Haemostasis Blood Conservation Modalities
assess coagulation status
• Assess the cause(s) of coagulopathy
• Use goal-directed therapies to correct
coagulation abnormalites
• Follow evidence-based rationale for use of
plasma and other components/factors
IMPROVED
PATIENT
OUTCOMES
Patient-Centred Decision-Making
• Listen to patient needs and concerns
• Explore treatment possibilities (including PBM) and
provide patient with information on risks, benefits,
and alternatives
• Integrate patient values and choices in decisionmaking process
• Document and communicate patient’s preferences
• Employ meticulous surgical techniques
incorporating available methods of haemostasis
• Choose minimally invasive approaches
• Be vigilant to diagnose and arrest bleeding quickly
• Use autotransfusion modalities
• Use methods to measure and assess blood loss
• Limit diagnostic blood loss
Anaemia Management
• Continuous screening for anaemia
• Enhance physiological tolerance of anaemia by
minimizing oxygen consumption
• Determine causes and risk factors of anaemia
• Use pharmacological interventions to support
haematopoiesis
• Evidence-based use of blood transfusions
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TSAT < 20%
Rule out iron
deficiency
Iron deficiency
Consider referral to
gastroenterologist to
rule out malignancy
Hb < 12 g dl–1 for females
Hb < 13 g dl
Evaluation necessary
–1
for males
Yes
Iron status?
No
No action required
TSAT > 20%
Serum creatinine
GFR < 60 GFR > 60
Chronic kidney
disease
Consider
referral to
nephrologist
GFR
Normal
Vitamin B
and/or folic acid
Folic acid and/or
vitamin B
therapy
12
Low
12
Response
ACIMH MDS
Iron therapy
(i) Oral iron in divided doses
(ii) I.V. iron if intolerance to oral iron,
gastrointestinal uptake problems (hepcidin),
or short timeline before surgery
No response
ESA therapy
Refer to
hematologist
Fig.26.2 Proposed algorithm for detection, diagnosis, and treatment of anaemia in surgical patients. ACI, anaemia of inflammation; ESA,
erythropoiesis- stimulating agent; GFR, glomerular filtration rate; Hb, haemoglobin; MDS, myelodysplastic syndrome; MH, malignant haematology
(e.g. chronic lymphocytic leukaemia); SF, serum ferritin.
Reproduced from Shander, A., Goodnough, L.T., Javidroozi, M., Auerbach, M., Carson, J., Ershler, W.B., Ghiglione, M., Glaspy, J., & Lew, I.2014, Iron deficiency anemia— bridging the
knowledge and practice gap, Transfus Med Rev., vol. 28, no.3, pp.156– 166 with permission from Elsevier.
treatment with iron has been shown to improve outcomes. In a
randomized trial in 60 non- anaemic patients undergoing cardiac
procedures, a single dose of IV iron given prior to the operation
was associated with signicantly higher haemoglobin levels 4 weeks
following the operation and a similar safety prole compared with
placebo. While data specic to cardiac surgery patients is more
limited, a meta- analysis of 72 randomized trials in over 10,000 patients found that IV iron was associated with a mean haemoglobin
increase of 0.65 g/ dL and reduced transfusion (relative risk of 0.74,
95% CI 0.62– 0.88) compared with no iron or oral iron. e ecacy
of treatment is even higher when IV iron is used in combination
with ESAs. In a more recent meta- analysis of 64 trials (including
ve in patients with heart failure), both oral and IV iron were associated with reduced transfusions and increased haemoglobin levels
compared with placebo, while IV iron was associated with greater
increases in haemoglobin. e results were similar in patients with
or without heart failure. Some studies suggest an increased risk of
infection following use of IV iron, while others do not.
In a study of 600 cardiac surgical patients with preoperative
haemoglobin concentrations of 14.5 g/ dL or less, patients randomized to a single dose of an ESA had signicantly lower transfusion
rates (relative risk 0.436) compared with controls, but the advantage was only present in the subgroup of patients with a preoperative
haemoglobin concentration of less than 13 g/ dL. Rates of adverse
events and all- cause mortality at 45days were similar between the
study arms. Some evidence suggests that the use of ESAs in the
perioperative period in patients undergoing cardiac procedures
might confer some protective eects against organ injury (such as
acute kidney injury associated with cardiac procedures), but more
studies are needed to better evaluate this potential benet. While
several studies across various surgical populations show ecacy of
preoperative use of ESAs to increase haemoglobin levels and reduce
transfusion, reports of increased risk of thrombotic events and
mortality temper enthusiasm for widespread use of ESAs in these
patients. Current evidence suggests that the risk of adverse events
with the use of ESAs is lower in surgical patients. Reasons for this
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reduced thrombotic risk in surgical patients is uncertain but may
be related to concomitant use of anticoagulants, double antiplatelet
therapy, and use of ESAs for a shorter duration of time (compared
with other chronically anaemic populations who receive ESAs for
longer periods of time). Following treatment with ESAs and as
haematopoiesis increases, available iron stores might not be able to
keep up with the increased demand, resulting in functional iron deciency. As indicated previously, studies suggest that combined use
of IV iron and ESAs reduces the required dose of ESAs needed for
repletion of haemoglobin levels.
An important aspect of the management of anaemia is the prevention of HAA. In one study of over a hundred thousand patients
who were not anaemic at admission, three- quarters developed HAA
(30% severe anaemia), and HAA (even mild) was associated with increased length of stay and mortality. ere is increased awareness
and recognition of the signicant role of diagnostic blood draws in
the development of HAA. e impact of such a seemingly mundane
and routine practice on blood loss can be quite shocking:a mildly
anaemic patient with baseline haemoglobin of 11 g/ dL can become
severely anaemic with a haemoglobin of 7 g/ dL within 1– 2 weeks
if subjected to just 43 mL of daily diagnostic blood draws. e
remedy for this iatrogenic blood loss is simple:standing orders and
orders for tests that are not likely to aect the course of care should
be avoided and any necessary tests must be carried out with the
minimum amount of blood needed to complete the test. ese are
foundational measures required in any cardiac surgical blood conservation programme.
Optimization ofhaemostasis
Management of risk of bleeding and prompt arrest of any sources of
bleeding during the perioperative period is another key strategy in
PBM that underscores the emphasis of PBM on preventive measures
to avoid anaemia and/ or its exacerbation. It has been shown that
bleeding in cardiac surgery patients (even mild bleeding in low- risk
patients) is independently associated with increased risk of various
adverse events.
Assessment of risk of bleeding involves history taking, physical
examination, review of medications, and quantitative and qualitative coagulation tests. Many patients who are candidates for cardiac
operations are on various anticoagulants and antiplatelet medications. Whenever possible, their medications should be reviewed and
revised in collaboration with the prescribing physicians to reduce
the risk of medication- induced coagulopathy and/ or platelet- related
bleeding disorders in the perioperative period.
Various pharmaceutical agents are available to optimize haemostasis and reduce blood loss. One widely available and much used
group includes the antibrinolytic agents that work by inhibiting
the brinolytic pathway to protect brin clots from unintended or
untimely lysis. is group of medication was once led by aprotinin.
Aprotinin was shown to be highly eective in reducing surgical
blood loss and transfusions in patients undergoing cardiac surgery,
but there was a question of increased risk of mortality in certain subgroups. is medication was voluntarily withdrawn from the market
in the United States by the manufacturer (Bayer Pharmaceuticals),
but is still available and used in other countries, and its application
in PBM remains limited.,
With aprotinin largely out of picture, lysine analogues such
as tranexamic acid (TXA) (globally) and epsilon aminocaproic
acid (EACA) (mainly in the United States) have become the main
antibrinolytic agents used in cardiac procedures. TXA reduces surgical bleeding and transfusion rates in patients having cardiac operations, and some studies suggest additional benets in reducing
mortality rates. EACA is also highly eective in reducing blood loss
and transfusion rates while having a substantially lower cost than
TXA. While some studies are suggestive that TXA might be marginally more eective than EACA, use of both medications is supported
to reduce blood loss and transfusion in cardiac surgeries.
In a recent two- by- two factorial trial on 4631 patients undergoing coronary artery surgery, patients were randomized to receive
aspirin versus placebo and TXA versus placebo. Compared with
placebo, patients who were randomized to TXA had lower risk of
bleeding and fewer transfusions, while the risk of thrombotic complications and mortality remained comparable. e only remarkable
downside of use of TXA was increased risk of seizures. Arecent
meta- analysis of 16 published reports of over 45,000 adult patients
undergoing cardiac operations concluded that use of TXA in these
patients is associated with an over fourfold increased risk of seizures. While further studies are needed to better dene the risk–
benet proles of these medications, it should be remembered that
the alternative— allogeneic blood transfusion— is not free of risk
either, and clinicians should carefully weigh the risks of various options when deciding on treatments.
One strategy to reduce the complications of these agents is to use
them topically rather than systemically, and studies suggest that topical use of TXA applied locally at the end of the operation reduces
surgical blood loss and cuts the transfusion rate in half. Several
other topical haemostatic agents including brin sealants are available and are eective in reducing blood loss and transfusions.
roughout the course of cardiac procedures, particularly in the
immediate perioperative period, awareness of unchecked blood loss
and aggressive control of any sources of bleeding are mandatory. If
bleeding is suspected, returning the patient to the operating room
for surgical re- exploration and control of bleeding should be considered. Other strategies employ point- of- care coagulation testing
and functional coagulation assessments. Goal- directed use of blood
components and available factors should be considered to address
specic deciencies.
Autotransfusiontechniques
Increased awareness of the risks of allogeneic blood transfusions fuelled eorts to develop various autologous transfusion techniques.
Some of the earlier approaches required the patients to donate their
blood during the weeks leading up to the elective surgery. e donated blood was to be stored and used in the perioperative period
whenever a transfusion was needed. is technique, known as preoperative autologous donation, requires signicant logistic burden
and renders patients anaemic near the time of operation. For these
reasons, use of autologous predonation is no longer used to any great
extent in clinical practice.
Another autologous transfusion technique is acute normovolaemic
haemodilution. e theory behind this is that one can eectively
reduce the actual amount of blood loss by intentionally diluting
the blood circulating in the patient’s body. is is achieved by
drawing a precalculated amount of blood from the patient just before the operation and replacing it with IV uids to keep the patient
normovolaemic (hence the name of the technique). e drawn blood
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is kept at the bedside during the operation and used whenever a transfusion is needed, while any blood that the patient loses during the procedure is already diluted by the IV uid given to replace the volume
of drawn blood. While the theoretical basis for acute normovolaemic
haemodilution is sound, it is clear that this technique can only be
helpful in cases where signicant blood loss is expected. Otherwise,
the drawn blood is at risk of being wasted while the patient is rendered
haemodiluted with no benet.
Unlike the autotransfusion strategies discussed so far that essentially make bets against future blood losses, blood cell recovery
(cell salvage) systems work by retrieving, washing, and ltering the
blood that is already shed in the surgical eld and is otherwise lost.
e primary concern with cell salvage is the quality of the salvaged
blood and the possibility of introducing unwanted agents— debris,
topical pharmaceuticals, bacteria, or malignant cells— into the circulation. Induction of a systemic inammatory response can occur
with a large volume of cell salvage. Nonetheless, the use of cell salvage signicantly reduces allogeneic blood transfusion rates without
negatively aecting patient outcomes in various surgical patient
populations including patients undergoing cardiac operations with
or without cardiopulmonary bypass pump.
Other supportivemeasures
While several PBM strategies target prevention and management
of anaemia, other strategies are intended to minimize the negative
consequences of anaemia and improve the physiological tolerance
of anaemia. Any unnecessary organ stress that can increase the
oxygen demand should be avoided. Muscle relaxants help reduce
which led to a signicant reduction of transfusion rates to almost
half of the baseline. Importantly, hospital mortality rates and the incidence of cerebral vascular accidents remained unchanged, while
the rate of postoperative kidney injury, length of hospital stay, and
total adjusted direct costs of hospital stay decreased following implementation of the PBM programme. Similarly, impressive improvements occurred following the establishment of a PBM programme
in cardiac surgery departments at other centres. Importantly, these
impressive improvements occurred without proper management of
anaemia which is a cornerstone of PBM (Fig. 26.1) and likely might
result in even better outcomes.
More recently, publication of data from health system- wide implementation of a PBM programme, involving over 600,000 patients
undergoing various elective operations, showed signicant reductions of transfusion rates, anaemic admissions, and pretransfusion
haemoglobin levels. ese changes occurred along with riskadjusted decreased hospital mortality rate, length of hospital stay,
hospital- acquired infections, acute myocardial infarctions, and
strokes.
What is evident from these reports and similar studies from other
surgical populations is that PBM programmes are eective in reducing transfusion rates and resource utilization while achieving
similar or improved patient outcomes. PBM represents a new
standard of care. Additionally, given the high prevalence of anaemia, high transfusion rates, and signicant negative outcomes
of anaemia and transfusions in patients undergoing cardiac operations, these patients are likely to receive additional benets from
multimodality PBM programmes.
the systemic oxygen needs, while avoidance of tachycardia protects
the heart muscle. Tachycardia is usually caused by hypovolaemia
and it requires prompt attention. Coagulation function is optimal
Acknowledgement
at physiological temperature; hypothermia increases the risk of
bleeding and should be avoided or minimized unless indicated for
other reasons such as cardioplegia.
e authors thank Mazyar Javidroozi, MD, PhD for assistance in
statistical review.
Anaemic patients require supplemental oxygen for support.
Oxygen supplied at higher percentage and/ or higher pressure dissolves more readily in the plasma, o- setting the reduced blood
Conflicts ofinterest
oxygen- carrying capacity due to reduced haemoglobin concentration. is strategy underlies the rationale for hyperbaric oxygen
therapy that supplies the extra oxygen needed to improve survival in
severely anaemic patients who cannot be treated with transfusions.
AS has been a consultant or speaker with honorarium for or received
research support from, Masimo, Gauss, and Vifor; he is a founding
member of the Society for the Advancement of Blood Management
(SABM). VF declares no conicts of interest.
Outcomes ofpatient blood management
programmes
As PBM is increasingly recognized and adopted by various agencies as the standard of care, data on the real- world impacts of PBM
programmes on outcomes of patients are emerging. Following
implementation of a multimodality PBM programme (which included meticulous surgical technique, a goal- directed coagulation
algorithm, and restrictive transfusion strategies) in cardiac surgery in a single centre, data on 2275 patients were compared with
387 patients who were admitted prior to the PBM programme.
Implementation of the PBM programme was associated with a signicant decrease of blood loss and lower pre- transfusion haemoglobin levels (indicative of more restrictive transfusion strategies),
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https://t.me/medicina_free
SECTION 6
Conduits forcoronary artery
bypass gra surgery
Section editors:Tristan D.Yan, Ki- Bong Kim, Paul G.Bannon, and Mario Gaudino
27. Early vein graft failure 227
Alexios S.Antonopoulos and Charalambos Antoniades
28. The selection of conduits for coronary artery
bypass surgery 233
Mario Gaudino, Martin Misfeld, and R.John. L.Brereton
29. Storage solutions for vein grafts 237
Minh Quan Vu, Pierre- Emmanuel Noly, Walid Ben Ali,
and Louis P.Perrault
30. No- touch saphenous vein grafts in coronary
artery bypass surgery:a comprehensive
review 243
Ninos Samano and Domingos Souza
31. External stenting of vein grafts in coronary artery
bypass graft surgery 249
David P.Taggart
32. Revascularization using the saphenous vein as a
composite graft 255
Ki- Bong Kim
33. Personal perspectives on the early development
of internal thoracic artery grafting and the role of
bilateral internal thoracic artery grafting 259
George E.Green and Bruce W.Lytle
34. Bilateral internal thoracic arteries:implications
of the 10- year outcomes of the Arterial
Revascularisation Trial (ART) 269
David P.Taggart
35. The radial artery 275
Robert F.Tranbaugh, Mario Gaudino, Brian F.Buxton,
and James Tatoulis
36. The right gastroepiploic artery graft 281
Hisayoshi Suma, Giuseppe Tavilla, and Ki- Bong Kim
37. Total arterial revascularization 285
Bobby Yanagawa, David P.Taggart, and John D.Puskas
38. Harvesting conduits:open versus endoscopic 291
Alice Wang and Peter K.Smith
39. Harvesting arterial conduits:skeletonized versus
pedicle versus semi- skeletonized 295
Umberto Benedetto, Brian F.Buxton, and David P.Taggart
40. Pharmacology to prevent spasm in conduits 299
Guo- Wei He
https://t.me/medicina_free
https://t.me/medicina_free
27
Early vein grafailure
Alexios S. Antonopoulos and Charalambos Antoniades
Introduction
Coronary artery bypass gra (CABG) surgery is a widely used
revascularization strategy for complex multivessel coronary artery disease that improves prognosis and patient quality of life.
Despite the clinical benets of surgical coronary revascularization,
a common complication post CABG is gra thrombosis or failure,
dened as the total occlusion of the gra and impaired blood ow
to the revascularized part of the heart. Surgical revascularization
with the use of arterial gras (e.g. internal thoracic artery or radial
artery) has become the preferred method of revascularization and
is associated with acceptable long- term gra patency. Nonetheless,
saphenous vein gras (SVGs) are still the most widely used conduit
aer internal thoracic artery and are characterized by increased
early and late gra failure, which can be as high as 42% at 10years
post surgery. While previously the diagnosis of gra occlusion was
mainly based on invasive coronary angiography, nowadays the use
of computed tomography angiography provides an alternative noninvasive method with excellent diagnostic accuracy for SVG occlusion (Fig. 27.1). Gra occlusion may lead to angina recurrence
poor quality of life for patients, and heart failure development and
revascularization of occluded SVG is technically challenging with a
high risk for complications.
Vein redoxstate
Aer harvesting, SVGs undergo a period of ischaemia and reperfusion which may result in vascular wall injury. Distention of SVGs
during harvesting also causes mechanical damage to vein wall, and
increases production of reactive oxygen species. Ex vivo studies
of human SVGs have provided important evidence on the role of
superoxide radical formation in vein gra wall and their role in
Mechanisms ofvein graftfailure
e mechanisms of gra failure are multifactorial and discreet according to the time frame post surgery. e insights into gra failure
mechanisms are mainly derived from studies on SVGs. Early SVG
failure is typically attributed to thrombotic or technical factors,
while intimal hyperplasia may also contribute to gra stenosis in the
rst year post CABG.
Late aer bypass surgery gra atherosclerosis becomes the dominant cause of gra failure. Typically, atherosclerosis in vascular
gras is characterized by a concentric and diuse pattern, with a less
well- dened brous cap compared to coronary atheromas, which
is more prone to rupture. An overview of the pathophysiological
mechanisms involved in SVG failure is provided in Fig. 27.2.
Fig.27.1 Diagnosis of vein graft occlusion by computed tomography
angiography. Representative example of an occluded saphenous vein
graft as shown on three- dimensional reconstructed images from a
computed tomography angiography scan (yellow arrow denotes the
aortic stump); next to it, a fully patent vein graft towards the major
diagonal branch of the left anterior descending artery can be seen.
Courtesy of Dr Antoniades.
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