LAUSR

Myocardial ischaemia resulting from obstructive coronary artery disease is a major cause of morbidity and mortality in the developed world. Coronary artery bypass graft (CABG) surgery is the gold-standard treatment in many patients with complex multivessel coronary artery disease or left main disease. Despite substantial improvements in the outcome of patients undergoing CABG surgery in the past decade, graft patency remains the ‘Achilles’ heel’ of this procedure. Whereas the use of the left internal mammary artery as a conduit is associated with the highest 10-year patency rate (>90%), saphenous vein grafts — the most commonly used conduit in CABG surgery — fail in 40−50% of treated patients by 10 years after surgery. Vein graft disease (VGD) and failure result from complex pathophysiological processes that can lead to complete occlusion of the graft, affecting long-term clinical outcomes. Optimal harvesting techniques, intraoperative preservation strategies and intraoperative patency control have important roles in the prevention of VGD. In addition, several studies published in the past decade have reported similar mid-term patency rates between vein grafts and arterial grafts when veins are used as a composite graft based on the internal mammary artery. In this Review, we present the latest evidence on the utilization of saphenous vein grafts for CABG surgery and provide an overview of the current practices for the prevention of VGD and vein graft failure. Although saphenous vein grafts (SVGs) are the most commonly used conduit in coronary artery bypass graft surgery, vein graft failure (VGF) occurs in almost half of all patients with SVGs by 10 years after surgery. In this Review, Caliskan and colleagues discuss approaches to prevent saphenous VGF, including optimal harvesting techniques and intraoperative preservation strategies. Saphenous vein grafts (SVGs) are the most frequently used conduits for coronary artery bypass graft (CABG) surgery but are associated with 10-year vein graft failure (VGF) rates of 40−50%. Endothelial damage attributable to mechanical harm and ischaemia–reperfusion injury contribute to the development of vein graft damage (VGD) and VGF, which are mediated by thrombosis, intimal hyperplasia and atherosclerosis in the early, intermediate and late phases, respectively. Prevention of VGD and VGF requires a meticulous harvesting strategy (either open, no-touch or endoscopic) to reduce surgical trauma and avoid excessive handling and distension. Optimized intraoperative preservation of SVGs to maintain normal endothelial function and integrity of the SVG during harvest can reduce the occurrence of VGD and VGF. Traditional intraoperative preservation solutions, such as saline or autologous whole blood, cannot sufficiently preserve the endothelium and might even be harmful to SVGs. Intraoperative graft flow assessment is important in identifying grafts that have initial low flow and can provide an opportunity to correct the issue intraoperatively.