Principles of preparation of vein bypass grafts to maximize patency

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✓ Experience in cardiovascular and peripheral vascular surgery with saphenous vein bypass conduits is reviewed. It is clear that meticulous technique and graft preparation are crucial to short-term and long-term patency. The risk of early thrombosis is related to damage to the graft 's native intima, graft flow, and coagulability of the patient 's blood. Attention to atraumatic harvesting techniques and perfection of anastomoses are crucial to minimizing intimal damage. Graft inflow and outflow are fundamental principles. The use of vitamin K antagonists and platelet inhibitors may improve graft survival. Subacute occlusion is related to structural alterations in the grafts themselves. These include intimal hyperplasia and medial fibrosis as the grafts become “arterialized,” valve fibrosis, aneurysmal dilatation, clamp stenosis, and suture stenosis. Long-term patency is threatened primarily by atherosclerosis in the graft itself. There is some evidence that care in vein harvesting and implantation as well as the use of anticoagulant agents affect the development of this complication.

A technique for graft preparation is presented that is based on the experience of the authors in harvesting grafts for both cerebral and coronary bypass conduits.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

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Figures

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    The six most common subacute or chronic changes in vein grafts are illustrated. The prevalence of intimal thickening is 8.1% with a mean onset time of 16.2 months after graft placement. Atherosclerosis is found in 7.7% of grafts with a mean postoperative onset at 45.2 months. Fibrotic valve changes occur in 5.8% of cases with a mean onset at 14 months after surgery. Fibrotic changes from trauma to the graft due to clamping (clamp stenosis) are found in 4.2% of cases with a mean onset at 19.1 months after grafting. Suture stenosis is found to occur in 3.1% of grafts at 9 months, and aneurysmal dilatation in 3.9% with a mean postoperative onset at 28 months. The above data are summarized from work of Szilagyi, et al.49

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    Intimal hyperplasia at the distal anastomosis develops in the heel of the graft and on the floor of the recipient artery opposite to the graft.

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    The great saphenous vein is harvested from the leg or thigh. There is considerable variability from patient to patient in the size of this vessel and in the number of branches. A: Small branches are ligated with 5-0 Prolene stick-ties and large branches with 3-0 or 4-0 silk free ties. Sometimes it is preferable to close large tributary vessels with a running 5-0 suture rather than ligate the vessel with a larger suture as the simple ligation with a tie sometimes distorts the lumen of the vein. B: The Garrett orientation line should be placed in the adventitia of the vein before it is harvested as there is frequently 360° to 720° rotation of the vein with distention after it is harvested. The proper orientation at that time cannot be determined. C: The vein is distended to 200 mm Hg with the Shiley distention kit. It is preferable to leave the vein in situ after the tributaries have been ligated and to harvest it only after exposure of the intracranial recipient vessel and the cervical carotid arteries.

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    The vein should be harvested by incising the connective tissue surrounding the vessel several millimeters from the wall. This minimizes the handling of the vein itself and therefore limits both trauma and vasospasm. This technique also provides adequate room for subsequently ligating any small branches that are missed while explanting the vessel.

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