Double Saphenous Vein Graft Patency 23 Years Following Coronary Artery Bypass Surgery

Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, Northern Ireland, UK

FIG. 1 Selective contrast injection into the SVG to the right coronary artery at angiography. Although the graft is ectatic, it is widely patent, supplying the distal right coronary system.

FIG. 2 Selective contrast injection into the SVG to the left anterior descending artery. Again, the graft is patent and functioning, though ectatic in nature.

A 78-year-old man presented with recurrence of angina and associated exertional dyspnea 23 years following double coronary artery bypass grafting. Clinical examination and echocardiography revealed the presence of severe calcific aortic stenosis. Cardiac catheterization confirmed the diagnosis of aortic stenosis and showed both saphenous vein grafts (SVG) to be patent and functioning, with no significant lesion in either (Figs. 1, 2). The native left circumflex artery (LCA), however, was found to have a new proximal 75% stenosis. The heavily calcified tricuspid aortic valve was replaced with a St. Jude HP™ size 19 mechanical prosthesis, and bypass grafting to the distal LCA using a further segment of saphenous vein was performed. The in-situ grafts were not disturbed at this time.

The natural history of aorto-coronary SVG has been well established. Technical factors such as improper handling and anastomoses may contribute to thrombosis and early occlusion. Intimal hyperplasia leading to vein graft atherosclerosis has been shown to be a factor in late graft failure. It has been demonstrated that by 7 years only 45% of SVG remain fully patent.¹ It is therefore notable to find a patient with two patent functioning vein grafts after 23 years with no evidence of significant occlusive disease affecting either of them–particularly considering the concomitant disease progression in the native coronary system.

At present the use of the saphenous vein combined with the left internal mammary artery still has a role in contemporary cardiac surgery despite the advent of “total arterial revascularization.” With careful handling, good anastomotic technique, and effective risk-factor modification, long-term patency of SVG may still be achieved, as demonstrated here. To the authors’ knowledge, longer patency of aorto-coronary SVG has not been reported.

Reference

Lytle BW, Loop FD, Cosgrove DM, Ratliff NB, Easley K, Taylor PC: Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248–258