Mechanisms, Prevention and Treatment of Saphenous Vein Graft Disease

doi:10.1016/j.amjcard.2021.05.040

The American Journal of Cardiology

Volume 154, 1 September 2021, Pages 41-47

https://doi.org/10.1016/j.amjcard.2021.05.040 Get rights and content

Saphenous vein grafts are imperfect yet indispensable conduits commonly used for coronary artery bypass grafting. Their degeneration ultimately leading to occlusion results from the pathological response of the vein to altered blood rheology and several types of vascular injury. Surgical techniques minimizing vessel damage, and prolonged antiplatelet and lipid-lowering treatment are established methods of mitigating the degeneration process hence preventing graft occlusions. Percutaneous interventions in degenerated vein grafts carry high risk of embolization, periprocedural myocardial infarction and restenosis. Thus, native vessel should be the preferred treatment target in case of graft failure whenever technically feasible.

Section snippets

Pathophysiology

The continuum of SVG failure begins with harvesting, which causes vessel ischemia followed by reperfusion injury ultimately, leading to endothelial damage.³ Extracellular matrix proteins become exposed to blood flow, inducing adhesion and activation of platelets. Activated platelets generate thrombogenic, chemotactic and vasoconstricting agents, as well as express superficial adhesion molecules that bind circulating leukocytes, that facilitate their migration into the vessel wall.³

Symptoms and Sequelae of SVG Failure

The risk of SVG disease progression, ultimately leading to graft occlusion, is highest in the grafts already showing evidence of disease.⁵ The patency of angiographically normal or mildly changed SVGs is favorable and absence of graft disease is a strong predictor of survival after CABG. Importantly, while not every SVG occlusion is symptomatic, there is an association of SVG failure with increased rates of adverse cardiac events. A retrospective study with 7-year follow-up (n = 1243), revealed

Prevention of SVG Failure

CABG performed on a beating heart without the use of cardiopulmonary bypass (off-pump) has been proposed as an alternative to a conventional procedure. However, as extracorporeal oxygenation induces platelet dysfunction, it may be paradoxically beneficial in terms of early vein graft patency. Conversely, off-pump CABG induces a transient state of hypercoagulability and aspirin resistance in post-operative period. In a metaanalysis of 12 RCTs SVG patency was higher after on-pump (RR = 1.41; 1.24

Interventional Treatment of SVG Failure

Diffuse nature of SVG degeneration challenges the possibilities of interventional treatment. PCI to the most diseased segment is an effective strategy to relieve ischemic symptoms, but has no influence on the course of SVG degeneration in non-stented segments. Majority of ischemic events following PCI to SVG result from disease progression in non-treated SVG segments. SOS trial subanalysis reported rapid progression of untreated intermediate SVG lesions to obstructive disease (28, 47 and 84% at

Conflict of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.