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Dushaj S, Häussler A, Rings L, Ntinopoulos V, Papadopoulos N, Odavic D, Rodriguez Cetina Biefer H, Dzemali O. External stenting for saphenous vein grafts reduces early postoperative graft failure. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae099. [PMID: 38775662 PMCID: PMC11162150 DOI: 10.1093/icvts/ivae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/24/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVES Multiple studies have shown that external stenting (ExSt) mitigates the progression of vein graft disease years after coronary artery bypass grafting (CABG). We used computed tomography to evaluate the effect of ExSt on perioperative vein graft patency. METHODS This study assessed graft patency rates of saphenous vein grafts (SVG) in consecutive patients with isolated coronary artery bypass grafting (CABG) between 2018 and 2021. Logistic regression analyses were conducted to compare the outcomes of supported and non-supported groups at both patient and graft levels, with age, EuroSCORE II, gender, diabetes and arterial grafts as covariates. Subgroup analyses were performed based on different covariates. The goal of the study was to provide valuable insights into the clinical outcomes of SVG in patients having CABG. RESULTS The study examined a total of 357 patients who met the inclusion criteria and evaluated 572 vein grafts. Of these, 150 patients (205 SVGs) received ExSt, whereas 207 patients (337 SVGs) did not receive ExSt. The study results indicated that the likelihood of overall SVG patency at discharge was higher in the stented group than in the non-stented group, both at the level of the grafts [93.8% vs 87.8%, odds ratio (OR) 2.1; 95% confidence interval (CI) 1.0-4.5; P = 0.05] and at the patient level (90.1% vs 83.5%, OR 1.8; 95% CI 0.9-3.6; P = 0.1). It is worth noting that the difference between the stented and non-stented groups was most significant in the subgroup that received 2 arterial grafts (96.5% vs 89.6%, OR 3.2; 95% CI 1.2-8.4; P = 0.02) and in the subgroup with a higher EuroSCORE II (median >1.1) (98.6% vs 88.6%, OR 8.8; 95% CI 1.1-72.7; P = 0.04). CONCLUSIONS The ExSt is associated with improved perioperative SVG patency at both the graft and the patient levels. Moreover, SVGs to the right territory and high-risk patients appear to have an advantage using ExSt.
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Affiliation(s)
- Stak Dushaj
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Achim Häussler
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Laura Rings
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Vasileios Ntinopoulos
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Nestoras Papadopoulos
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Dragan Odavic
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Hector Rodriguez Cetina Biefer
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
| | - Omer Dzemali
- Department for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department for Cardiac Surgery, City Hospital of Zurich—Triemli, Zurich, Switzerland
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Goldstein DJ, Chang HL, Mack MJ, Voisine P, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O'Sullivan K, Williams JB, Crestanello JA, Scavo V, Puskas JD, Acker MA, Gillinov M, Gelijns AC, O'Gara PT, Moskowitz AJ, Alexander JH, Bagiella E. Intimal hyperplasia, saphenous vein graft disease, and clinical outcomes: Insights from the CTSN VEST randomized trial. J Thorac Cardiovasc Surg 2024; 167:1782-1792.e5. [PMID: 36494209 PMCID: PMC10148927 DOI: 10.1016/j.jtcvs.2022.10.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion. METHODS VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years. RESULTS Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery. CONCLUSIONS In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.
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Affiliation(s)
- Daniel J Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
| | - Helena L Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael J Mack
- Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Tex
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - James S Gammie
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins Health System, Baltimore, Md
| | - Mary E Marks
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bradley S Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - François Dagenais
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ellen G Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen O'Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Vincent Scavo
- Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Fort Wayne, Ind
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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3
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Lee GS, Fremes SE, Tam DY. Commentary: Can the Venous Graft External Support (VEST) trials bypass surrogate outcomes? J Thorac Cardiovasc Surg 2024; 167:1793-1795. [PMID: 36496275 DOI: 10.1016/j.jtcvs.2022.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Grace S Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.
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Emmert MY, Bonatti J, Caliskan E, Gaudino M, Grabenwöger M, Grapow MT, Heinisch PP, Kieser-Prieur T, Kim KB, Kiss A, Mouriquhe F, Mach M, Margariti A, Pepper J, Perrault LP, Podesser BK, Puskas J, Taggart DP, Yadava OP, Winkler B. Consensus statement-graft treatment in cardiovascular bypass graft surgery. Front Cardiovasc Med 2024; 11:1285685. [PMID: 38476377 PMCID: PMC10927966 DOI: 10.3389/fcvm.2024.1285685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024] Open
Abstract
Coronary artery bypass grafting (CABG) is and continues to be the preferred revascularization strategy in patients with multivessel disease. Graft selection has been shown to influence the outcomes following CABG. During the last almost 60 years saphenous vein grafts (SVG) together with the internal mammary artery have become the standard of care for patients undergoing CABG surgery. While there is little doubt about the benefits, the patency rates are constantly under debate. Despite its acknowledged limitations in terms of long-term patency due to intimal hyperplasia, the saphenous vein is still the most often used graft. Although reendothelialization occurs early postoperatively, the process of intimal hyperplasia remains irreversible. This is due in part to the persistence of high shear forces, the chronic localized inflammatory response, and the partial dysfunctionality of the regenerated endothelium. "No-Touch" harvesting techniques, specific storage solutions, pressure controlled graft flushing and external stenting are important and established methods aiming to overcome the process of intimal hyperplasia at different time levels. Still despite the known evidence these methods are not standard everywhere. The use of arterial grafts is another strategy to address the inferior SVG patency rates and to perform CABG with total arterial revascularization. Composite grafting, pharmacological agents as well as latest minimal invasive techniques aim in the same direction. To give guide and set standards all graft related topics for CABG are presented in this expert opinion document on graft treatment.
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Affiliation(s)
- Maximilian Y. Emmert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Etem Caliskan
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Martin Grabenwöger
- Sigmund Freud Private University, Vienna, Austria
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
| | | | - Paul Phillip Heinisch
- German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany
| | - Teresa Kieser-Prieur
- LIBIN Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Attila Kiss
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Adrianna Margariti
- The Wellcome-Wolfson Institute of Experimental Medicine, Belfast, United Kingdom
| | - John Pepper
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Bruno K. Podesser
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, United States
| | - David P. Taggart
- Nuffield Dept Surgical Sciences, Oxford University, Oxford, United Kingdom
| | | | - Bernhard Winkler
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Karld Landsteiner Institute for Cardiovascular Research Clinic Floridsdorf, Vienna, Austria
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5
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Kamensek T, Kalisnik JM, Ledwon M, Santarpino G, Fittkau M, Vogt FA, Zibert J. Improved early risk stratification of deep sternal wound infection risk after coronary artery bypass grafting. J Cardiothorac Surg 2024; 19:93. [PMID: 38355514 PMCID: PMC10865600 DOI: 10.1186/s13019-024-02570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Deep sternal wound infection (DSWI) following open heart surgery is associated with excessive morbidity and mortality. Contemporary DSWI risk prediction models aim at identifying high-risk patients with varying complexity and performance characteristics. We aimed to optimize the DSWI risk factor set and to identify additional risk factors for early postoperative detection of patients prone to DSWI. METHODS Single-centre retrospective analysis of patients with isolated multivessel coronary artery disease undergoing myocardial revascularization at Paracelsus Medical University Nuremberg between 2007 and 2022 was performed to identify risk factors for DSWI. Three data sets were created to examine preoperative, intraoperative, and early postoperative parameters, constituting the "Baseline", the "Improved Baseline" and the "Extended" models. The "Extended" data set included risk factors that had not been analysed before. Univariable and stepwise forward multiple logistic regression analyses were performed for each respective set of variables. RESULTS From 5221 patients, 179 (3.4%) developed DSWI. The "Extended" model performed best, with the area under the curve (AUC) of 0.80, 95%-CI: [0.76, 0.83]. Pleural effusion requiring intervention, postoperative delirium, preoperative hospital stay > 24 h, and the use of fibrin sealant were new independent predictors of DSWI in addition to age, Diabetes Mellitus on insulin, Body Mass Index, peripheral artery disease, mediastinal re-exploration, bilateral internal mammary harvesting, acute kidney injury and blood transfusions. CONCLUSIONS The "Extended" regression model with the short-term postoperative complications significantly improved DSWI risk discrimination after surgical revascularization. Short preoperative stay, prevention of postoperative delirium, protocols reducing the need for evacuation of effusion and restrictive use of fibrin sealant for sternal closure facilitate DSWI reduction. TRIAL REGISTRATION The registered retrospective study was registered at the study centre and approved by the Institutional Review Board of Paracelsus Medical University Nuremberg (IRB-2019-005).
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Affiliation(s)
- Tina Kamensek
- Faculty of Health Sciences, University of Ljubljana, Zdravstvena pot 5, Ljubljana, 1000, Slovenia
| | - Jurij Matija Kalisnik
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, 1000, Slovenia.
- Department of Cardiothoracic and Vascular Surgery, University of Graz affiliated Clinic KABEG, Klagenfurt am Wörthersee, Feschnigstrasse 11, Klagenfurt, 9020, Austria.
| | - Mirek Ledwon
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Giuseppe Santarpino
- Paracelsus Medical University, Campus Nuremberg, Ernst Nathan Straße 1, 90419, Nuremberg, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Ferdinand Aurel Vogt
- Paracelsus Medical University, Campus Nuremberg, Ernst Nathan Straße 1, 90419, Nuremberg, Germany
| | - Janez Zibert
- Faculty of Health Sciences, University of Ljubljana, Zdravstvena pot 5, Ljubljana, 1000, Slovenia
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Gemelli M, Addonizio M, Geatti V, Gallo M, Dixon LK, Slaughter MS, Gerosa G. Techniques and Technologies to Improve Vein Graft Patency in Coronary Surgery. Med Sci (Basel) 2024; 12:6. [PMID: 38249082 PMCID: PMC10801616 DOI: 10.3390/medsci12010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Vein grafts are the most used conduits in coronary artery bypass grafting (CABG), even though many studies have suggested their lower patency compared to arterial alternatives. We have reviewed the techniques and technologies that have been investigated over the years with the aim of improving the quality of these conduits. We found that preoperative and postoperative optimal medical therapy and no-touch harvesting techniques have the strongest evidence for optimizing vein graft patency. On the other hand, the use of venous external support, endoscopic harvesting, vein preservation solution and anastomosis, and graft configuration need further investigation. We have also analyzed strategies to treat vein graft failure: when feasible, re-doing the CABG and native vessel primary coronary intervention (PCI) are the best options, followed by percutaneous procedures targeting the failed grafts.
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Affiliation(s)
- Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Mariangela Addonizio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Veronica Geatti
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Lauren K. Dixon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London WC2A 3PE, UK;
| | - Mark S. Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
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7
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Soletti GJ, Dimagli A, Harik L, Cancelli G, Perezgrovas-Olaria R, Alzghari T, Dell’Aquila M, Leith J, Castagnini S, Lau C, Girardi LN, Gaudino M. External Stenting for Saphenous Vein Grafts in Coronary Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7395. [PMID: 38068447 PMCID: PMC10707268 DOI: 10.3390/jcm12237395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 02/01/2024] Open
Abstract
The external stenting of saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) has been proven to reduce intimal hyperplasia (IH) in animal models, paving the way for human randomized controlled trials (RCTs) to be conducted. Herein, we performed a study-level meta-analysis to assess the impact of the Venous External SupporT (VEST) device, an external stent, on the outcomes of SVGs. A systematic search was conducted to identify all RCTs comparing VEST-stented to non-stented SVGs in patients undergoing CABG. The primary outcome was graft occlusion. The main secondary outcomes were repeat revascularization, SVG IH area, and intimal-medial thickness. Two RCTs totaling 407 patients were included. At a mean follow-up of 1.5 years, there was no difference in graft occlusion between groups (incidence rate ratio: 1.11; 95% confidence interval (CI): 0.80-1.53). The rate of repeat revascularization was also similar (odds ratio: 0.66; 95% CI: 0.27-1.64). The IH area (standardized mean difference (SMD): -0.45; 95% CI: -0.79 to -0.10) and intimal-medial thickness (SMD: -0.50; 95% CI: -0.90 to -0.10) were significantly reduced in the VEST group. Our findings show that significant reductions in the IH area and the intimal-medial thickness in VEST-stented SVGs do not currently translate into a lesser need for repeat revascularization or less graft occlusion events compared to non-stented SVGs at 1.5 years after CABG.
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Affiliation(s)
- Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | | | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Michele Dell’Aquila
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Jordan Leith
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Sabrina Castagnini
- Department of Cardiac Surgery, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA (T.A.)
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8
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Soletti GJ, Dell’Aquila M, Harik L, Cancelli G, Alzghari T, Perezgrovas-Olaria R, Dimagli A, An KR, Leith J, Rossi CS, Barile CF, Demetres M, Lau C, Girardi LN, Gaudino M. The VEST External Support for Saphenous Vein Grafts in Coronary Surgery: A Review of Randomized Clinical Trials. J Cardiovasc Dev Dis 2023; 10:453. [PMID: 37998511 PMCID: PMC10672571 DOI: 10.3390/jcdd10110453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.
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Affiliation(s)
- Giovanni Jr. Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Michele Dell’Aquila
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Roberto Perezgrovas-Olaria
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Jordan Leith
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Camilla Sofia Rossi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Christopher F. Barile
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, NY 10021, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA
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Chen H, Wang Z, Si K, Wu X, Ni H, Tang Y, Liu W, Wang Z. External stenting for saphenous vein grafts in coronary artery bypass grafting: A meta-analysis. Eur J Clin Invest 2023; 53:e14046. [PMID: 37395498 DOI: 10.1111/eci.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/03/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES Autologous saphenous vein grafts (SVGs) are the most commonly used bypass conduits in coronary artery bypass grafting (CABG) with multivessel coronary artery disease. Although external support devices for SVGs have shown promising outcomes, the overall efficacy and safety remains controversial. We aimed to evaluate external stenting for SVGs in CABG versus non-stented SVGs. METHODS MEDLINE, EMBASE, Cochrane Library and clinicaltrails.gov were searched for randomized controlled trials (RCTs) to evaluate external-stented SVGs versus non-stented SVGs in CABG up to 31 August 2022. The risk ratio and mean difference with 95% confidence interval were analysed. The primary efficacy outcomes included intimal hyperplasia area and thickness. The secondary efficacy outcomes were graft failure (≥50% stenosis) and lumen diameter uniformity. RESULTS We pooled 438 patients from three RCTs. The external stented SVGs group showed significant reductions in intimal hyperplasia area (MD: -0.78, p < 0.001, I2 = 0%) and thickness (MD: -0.06, p < 0.001, I2 = 0%) compared to the non-stented SVGs group. Meanwhile, external support devices improved lumen uniformity with Fitzgibbon I classification (risk ratio (RR):1.1595, p = 0.05, I2 = 0%). SVG failure rates were not increased in the external stented SVGs group during the short follow-up period (RR: 1.14, p = 0.38, I2 = 0%). Furthermore, the incidences of mortality and major cardiac and cerebrovascular events were consistent with previous reports. CONCLUSIONS External support devices for SVGs significantly reduced the intimal hyperplasia area and thickness, and improved the lumen uniformity, assessed with the Fitzgibbon I classification. Meanwhile, they did not increase the overall SVG failure rate.
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Affiliation(s)
- Huiru Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
| | - Ke Si
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoxiao Wu
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Hanyu Ni
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Yanbing Tang
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Wei Liu
- Department of Medicine, The Tianjin North China Hospital, Tianjin, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
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Raval AJ, Parikh JK, Desai MA. A review on the treatment of intimal hyperplasia with perivascular medical devices: role of mechanical factors and drug release kinetics. Expert Rev Med Devices 2023; 20:805-819. [PMID: 37559556 DOI: 10.1080/17434440.2023.2244875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Intimal hyperplasia (IH) is a significant factor limiting the success of revascularization surgery for blood flow restoration. IH results from a foreign body response and mechanical disparity that involves complex biochemical reactions resulting in graft failure. The available treatment option utilizes either different pharmacological interventions or mechanical support to the vascular grafts with limited success. AREAS COVERED This review explains the pathophysiology of IH, responsible mechanical and biological factors, and treatment options, emphasizing perivascular devices. They are designed to provide mechanical support and pharmacology actions. The perivascular drug delivery concept has successfully demonstrated efficacy in various animal studies. Accurate projections of drug release mechanisms using mathematical modeling could be used to formulate prolonged drug elution devices. Numerical modeling aspects for the prediction of design outcomes have been given due importance that fulfills the unmet clinical need for better patient care. EXPERT OPINION IH could be effectively prevented by simultaneous mechanical scaffolding and sustained local drug delivery. Future perivascular medical devices could be designed to integrate these essential features. Numerical modeling for device performance prediction should be utilized in the development of next-generation perivascular devices.
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Affiliation(s)
- Ankur J Raval
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
- Research and Development Department, Sahajanand Medical Technologies Ltd, Surat, Gujarat, India
| | - Jigisha K Parikh
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
| | - Meghal A Desai
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
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11
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Narayan P. VEST III trial - should we support the vein grafts? Indian J Thorac Cardiovasc Surg 2023; 39:319-321. [PMID: 37124604 PMCID: PMC10140207 DOI: 10.1007/s12055-023-01492-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
VEST III trial is the largest randomized controlled trial to date to evaluate the role of external stents on late graft failure. In this study, an external stent was applied to vein grafts and compared with another unsupported vein graft in the same patient. The groups were compared for overall graft patency and intimal hyperplasia. Patent vein grafts were further assessed and graded based on the Fitzgibbon patency scale. This review discusses the strengths and weaknesses of the trial.
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Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, 124, EM Bypass, Mukundapur Kolkata, 700099 India
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12
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Gemelli M, Gallo M, Addonizio M, Pahwa S, Van den Eynde J, Trivedi J, Slaughter MS, Gerosa G. Venous External Support in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101687. [PMID: 36931334 DOI: 10.1016/j.cpcardiol.2023.101687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES Neointimal hyperplasia and lumen irregularities are major contributors to vein graft failure and the use of VEST(R) should prevent this. In this review, we aim to evaluate the angiographic outcomes of externally supported vein grafts. METHODS Medline, Embase and Cochrane Library were systematically reviewed for randomized clinical trials published by August 2022. The primary outcome was graft failure. Secondary outcomes included graft ectasia, intimal hyperplasia area and thickness, and graft non-uniformity. Odds ratios (OR) for dichotomous variables and mean difference (MD) for continuous variables with 95% confidence intervals (CI) were pooled using a fixed-effects model. RESULTS Three randomized controlled trials with a total of 437 patients were included with follow-up ranging from 1 to 2 years. The odds of graft failure were similar in the two groups (OR 1.22; 95%CI 0.88 to 1.71; I²=0%). Intimal hyperplasia area [MD -0.77 mm2; 95%CI -1.10 to -0.45; I2=0%] and thickness [MD -0.06 mm; 95%CI -0.08 to -0.04; I2=0%] were significantly lower in the VEST group. Fitzgibbon Patency Scale of II or III (representing angiographic conduit non-uniformity; OR 0.67; 95%CI 0.48 to 0.94; I2=0%) and graft ectasia (OR 0.53; 95%CI 0.32 to 0.88; I2=33%) were also significantly lower in the VEST group. CONCLUSIONS At short-term follow-up, VEST does not seem to reduce the incidence of graft failure, although it is associated with attenuation of intimal hyperplasia and non-uniformity. Longer angiographic follow-up is warranted to determine whether these positive effects might translate into a positive effect in graft failure and in long-term clinical outcomes.
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Affiliation(s)
- Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA.
| | - Mariangela Addonizio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
| | - Siddharth Pahwa
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Mark S Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
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13
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Dimagli A, Soletti G, Harik L, Perezgrovas Olaria R, Cancelli G, An KR, Alzghari T, Mack C, Gaudino M. Angiographic Outcomes for Arterial and Venous Conduits Used in CABG. J Clin Med 2023; 12:2022. [PMID: 36902809 PMCID: PMC10004690 DOI: 10.3390/jcm12052022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.
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Affiliation(s)
- Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | | | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Charles Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
- Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, NY 11355, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA
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14
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Lobo Filho JG, Pimentel MD, Lobo Filho HG. Composite graft and remodeling of the saphenous vein in coronary artery bypass graft. JTCVS OPEN 2022; 11:129-130. [PMID: 36172421 PMCID: PMC9510823 DOI: 10.1016/j.xjon.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Soletti GJ, Gaudino M. Reply: In search of a better saphenous vein graft. JTCVS OPEN 2022; 11:131. [PMID: 36172415 PMCID: PMC9510808 DOI: 10.1016/j.xjon.2022.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Biodegradable external wrapping promotes favorable adaptation in an ovine vein graft model. Acta Biomater 2022; 151:414-425. [PMID: 35995404 DOI: 10.1016/j.actbio.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022]
Abstract
Vein grafts, the most commonly used conduits in multi-vessel coronary artery bypass grafting surgery, have high intermediate- and long-term failure rates. The abrupt and marked increase in hemodynamic loads on the vein graft is a known contributor to failure. Recent computational modeling suggests that veins can more successfully adapt to an increase in mechanical load if the rate of loading is gradual. Applying an external wrap or support at the time of surgery is one way to reduce the transmural load, and this approach has improved performance relative to an unsupported vein graft in several animal studies. Yet, a clinical trial in humans has shown benefits and drawbacks, and mechanisms by which an external wrap affects vein graft adaptation remain unknown. This study aims to elucidate such mechanisms using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, hemodynamics using computational fluid dynamics, structure using histology, and transcriptional changes using bulk RNA-sequencing in an ovine carotid-jugular interposition vein graft model, without and with an external biodegradable wrap that allows loads to increase gradually. We show that a biodegradable external wrap promotes luminal uniformity, physiological wall shear stress, and a consistent vein graft phenotype, namely, it prevents over-distension, over-thickening, intimal hyperplasia, and inflammation, and it preserves mechanotransduction. These mechanobiological insights into vein graft adaptation in the presence of an external support can inform computational growth and remodeling models of external support and facilitate design and manufacturing of next-generation external wrapping devices. STATEMENT OF SIGNIFICANCE: External mechanical support is emerging as a promising technology to prevent vein graft failure following coronary bypass graft surgery. While variants of this technology are currently under investigation in clinical trials, the fundamental mechanisms of adaptation remain poorly understood. We employ an ovine carotid-jugular interposition vein graft model, with and without an external biodegradable wrap to provide mechanical support, and probe vein graft adaptation using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, fluid flow using computational fluid dynamics, vascular composition and structure using histology, and transcriptional changes using bulk RNA sequencing. We show that the wrap mitigates vein graft failure by promoting multiple adaptive mechanisms (across biological scales).
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17
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Goldstein DJ, Puskas JD, Alexander JH, Chang HL, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Yarden O, Orion E, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O’Sullivan K, Williams JB, Crestanello JA, Jessup M, Rose EA, Scavo V, Acker MA, Gillinov M, Mack MJ, Gelijns AC, O’Gara PT, Moskowitz AJ, Bagiella E, Voisine P. External Support for Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Clinical Trial. JAMA Cardiol 2022; 7:808-816. [PMID: 35675092 PMCID: PMC9178499 DOI: 10.1001/jamacardio.2022.1437] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Intimal hyperplasia and subsequent saphenous vein graft failure may have significant adverse clinical effects in patients undergoing coronary artery bypass surgery. External support of saphenous vein grafts has the potential to prevent vein graft dilation and hence slow the rate of intimal hyperplasia and increase long-term vein patency. Objective To determine efficacy, as measured by intimal hyperplasia, and safety of an external saphenous vein graft support device in patients undergoing a coronary bypass graft procedure. Design, Setting, and Participants This within-patient randomized, open-label, multicenter study was conducted at 17 Cardiothoracic Surgical Trials Network centers in North America. Between January 2018 and February 2019, 224 patients with multivessel coronary artery disease undergoing isolated bypass surgery were enrolled. For each patient, 1 of 2 vein grafts was randomized to receive external support or no support. Interventions External vein graft support or no support. Main Outcomes and Measures The primary efficacy end point was intimal hyperplasia area assessed by intravascular ultrasound at 12 months postrandomization for each study graft. Secondary confirmatory end points were lumen diameter uniformity assessed by angiography and graft failure (≥50% stenosis) by quantitative coronary angiography. Major cardiac and cerebrovascular events were collected through month 12. Results Among 224 patients (mean [SD] age, 65.8 [8.3] years; 178 [79.5%] male), 203 (90.6%) were eligible for intravascular ultrasound, of which 85 (41.9%) had at least 1 study graft occluded or severely diseased at 12 months (55 supported, 56 unsupported). After imputation of data missing because of graft occlusion or severe disease, the estimated mean (SE) intimal hyperplasia area was 5.11 (0.16) mm2 in supported grafts and 5.79 (0.20) mm2 in unsupported grafts (P = .07). In a sensitivity analysis of 113 patients with both grafts imaged, the mean intimal hyperplasia area was 4.58 (0.18) mm2 and 5.12 (0.23) mm2 in supported and unsupported grafts, respectively (P = .04). By 12 months, 5 patients (2.2%) died and 16 patients (7.1%) experienced a major cardiac or cerebrovascular event. Conclusions and Relevance The 12-month difference in intimal hyperplasia area between supported and unsupported grafts did not achieve statistical significance. Cumulative mortality and major cardiac or cerebrovascular events rates were similar to those in other randomized coronary artery bypass trials. Further investigation to assess the effect of external graft support devices on long-term graft patency and clinical outcomes is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT03209609.
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Affiliation(s)
- Daniel J. Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, New York
| | - John H. Alexander
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Helena L. Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James S. Gammie
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins Health System, Baltimore, Maryland
| | - Mary E. Marks
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bradley S. Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore
| | - Orit Yarden
- Vascular Graft Solutions Ltd, Tel Aviv, Israel
| | - Eyal Orion
- Vascular Graft Solutions Ltd, Tel Aviv, Israel
| | - François Dagenais
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor
| | - Michael W. A. Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen G. Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen O’Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judson B. Williams
- Cardiovascular Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina
| | | | | | - Eric A. Rose
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vincent Scavo
- Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Ft Wayne, Indiana
| | - Michael A. Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael J. Mack
- Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Texas
| | - Annetine C. Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patrick T. O’Gara
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alan J. Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Quebec, Canada
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18
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Choi K, Locker C, Fatima B, Schaff HV, Stulak JM, Lahr BD, Villavicencio MA, Dearani JA, Daly RC, Crestanello JA, Greason KL, Khullar V. Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients. Mayo Clin Proc 2022; 97:1257-1268. [PMID: 35738944 DOI: 10.1016/j.mayocp.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG). METHODS We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality. RESULTS Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality. CONCLUSION Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.
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Affiliation(s)
- Kukbin Choi
- Department of Cardiovascular Surgery, Rochester, MN
| | - Chaim Locker
- Department of Cardiovascular Surgery, Rochester, MN
| | | | | | | | - Brian D Lahr
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
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19
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Sandner SE, Taggart DP. Reply to Dashwood et al. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6608694. [PMID: 35703940 DOI: 10.1093/ejcts/ezac331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/29/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Sigrid E Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - David P Taggart
- Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
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20
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Sandner SE, Donovan TJ, Edelstein S, Puskas JD, Angleitner P, Krasopoulos G, Channon K, Gehrig T, Rajakaruna C, Ladyshenskij L, De Silva R, Bonaros N, Bolotin G, Jacobs S, Thielmann M, Choi YH, Ohri S, Lipey A, Friedrich I, Taggart DP. Effects of the harvesting technique and external stenting on progression of vein graft disease 2 years after coronary artery bypass. Eur J Cardiothorac Surg 2022; 62:ezac045. [PMID: 35312782 DOI: 10.1093/ejcts/ezac045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/25/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES In a post hoc analysis of the VEST III trial, we investigated the effect of the harvesting technique on saphenous vein graft (SVG) patency and disease progression after coronary artery bypass grafting. METHODS Angiographic outcomes were assessed in 183 patients undergoing open (126 patients, 252 SVG) or endoscopic harvesting (57 patients, 114 SVG). Overall SVG patency was assessed by computed tomography angiography at 6 months and by coronary angiography at 2 years. Fitzgibbon patency (FP I, II and III) and intimal hyperplasia (IH) in a patient subset were assessed by coronary angiography and intravascular ultrasound, respectively, at 2 years. RESULTS Baseline characteristics were similar between patients who underwent open and those who underwent endoscopic harvesting. Open compared with endoscopic harvesting was associated with higher overall SVG patency rates at 6 months (92.9% vs 80.4%, P = 0.04) and 2 years (90.8% vs 73.9%, P = 0.01), improved FP I, II and III rates (65.2% vs 49.2%; 25.3% vs 45.9%, and 9.5% vs 4.9%, respectively; odds ratio 2.81, P = 0.09) and reduced IH area (-31.8%; P = 0.04) and thickness (-28.9%; P = 0.04). External stenting was associated with improved FP I, II and III rates (odds ratio 2.84, P = 0.01), reduced IH area (-19.5%; P < 0.001) and thickness (-25.0%; P < 0.001) in the open-harvest group and reduced IH area (-12.7%; P = 0.01) and thickness (-9.5%; P = 0.21) in the endoscopic-harvest group. CONCLUSIONS A post-hoc analysis of the VEST III trial showed that open harvesting is associated with improved overall SVG patency and reduced IH. External stenting reduces SVG disease progression, particularly with open harvesting.
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Affiliation(s)
- Sigrid E Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | | | | | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, USA
| | | | - George Krasopoulos
- Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Keith Channon
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Thomas Gehrig
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany
| | - Cha Rajakaruna
- Department of Cardiothoracic Surgery, University Hospitals Bristol, UK
| | - Leonid Ladyshenskij
- Department of Cardiothoracic Surgery, Immanuel Klinikum Bernau, Herzzentrum Brandenburg, Germany
| | - Ravi De Silva
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Gil Bolotin
- Department of Cardiothoracic Surgery, Rambam Medical Center, Israel
| | - Stephan Jacobs
- Department of Cardiothoracic Surgery, German Heart Centre Berlin, Germany
| | - Matthias Thielmann
- Department of Cardiothoracic Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Germany
| | - Yeong-Hoon Choi
- Kerkhoff-Klinik Bad Nauheim, Campus Kerkhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Sunil Ohri
- Department of Cardiothoracic Surgery, University Hospital Southampton, UK
| | - Alexander Lipey
- Department of Cardiothoracic Surgery, Sheba Medical Center, Israel
| | - Ivar Friedrich
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany
| | - David P Taggart
- Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
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21
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Sandner S, Angleitner P, Netuschill C, Stasek S, Manville E, Siller-Matula J, Laufer G, Zimpfer D. External stenting of saphenous vein grafts for coronary artery bypass: a single-center analysis of clinical outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:187-194. [PMID: 35005876 DOI: 10.23736/s0021-9509.22.12008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Angiographic studies have shown that external stenting reduces disease progression in saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG). However, reports of clinical outcomes of external SVG stenting are limited. METHODS We conducted a retrospective analysis using a prospectively maintained national registry to evaluate clinical outcomes in patients undergoing either isolated CABG or combined (CABG + valve) procedures with use of an external SVG stent between December 2015 and December 2019. Median follow-up was 36.2 months (IQR: 24.4-41.6 months). The primary endpoint was ischemia-driven target vessel revascularization at 1 year. Secondary endpoints included all-cause death, non-fatal myocardial infarction (MI), stroke, and the composite of death, non-fatal MI or stroke at 1 year. Kaplan-Meier rates of survival, freedom from the composite of death, non-fatal MI or stroke and freedom from repeat revascularization were calculated at 3 years. RESULTS The study population included 74 patients (isolated CABG, N.=61; combined procedure, N.=13). Mean age was 65.5±9.2 years, and 81% were male. External stenting of one SVG was performed in 63 patients (85%) and external stenting of 2 SVG in 11 patients (15%). External stenting was most frequently performed on an SVG to the right coronary artery (N.=45 patients; 53%). Ischemia-driven target-vessel revascularization occurred in 0% at 1 year. All-cause death, MI, stroke, and the composite of death, MI, or stroke at 1 year occurred in 2.7% (2/74), 0% (0/74), 1.4% (1/74), and 4.1% (3/74), respectively. At 3 years, the rates of survival, freedom from the composite of death, non-fatal MI or stroke, and freedom from repeat revascularization were 89.7% (95% CI: 78.0-95.3), 88.3% (95% CI: 76.5-94.4), and 94.8% (95% CI: 84.6-98.3), respectively. CONCLUSIONS Clinical outcomes with external SVG stenting are excellent without ischemia-driven target-vessel revascularization at 1 year, and low rates of repeat revascularization at 3 years. Further follow-up will show whether external stenting reduces SVG failure with a benefit on long-term clinical outcomes.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria -
| | - Philipp Angleitner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Stefanie Stasek
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Emely Manville
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Jolanta Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Department of Experimental and Clinical Pharmacology, Center for Preclinical Research and Technology - CEPT, Medical University of Warsaw, Warsaw, Poland
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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22
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Rationale and design of a randomized trial evaluating an external support device for saphenous vein coronary grafts. Am Heart J 2022; 246:12-20. [PMID: 34936861 PMCID: PMC9857318 DOI: 10.1016/j.ahj.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets. Long-term failure of these grafts, however, continues to limit the benefits of surgery. METHODS The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.
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23
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Vervoort D, Malik A, Fremes SE. The evolving evidence base for coronary artery bypass grafting and arterial grafting in 2021: How to improve vein graft patency. JTCVS Tech 2022; 10:102-109. [PMID: 34977712 PMCID: PMC8691822 DOI: 10.1016/j.xjtc.2021.09.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/20/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Malik
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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24
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Commentary: A device solution for the saphenous vein graft's infamous foible? J Thorac Cardiovasc Surg 2021; 164:1543-1545. [PMID: 33985808 DOI: 10.1016/j.jtcvs.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/20/2022]
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