configurations of arterial grafts : when to use a sv graft joseph f. sabik, md chairman and...

Configurations of Arterial Grafts : When to use a SV Graft

Joseph F. Sabik, MDChairman and Professor of Surgery

Department of Thoracic and Cardiovascular Surgery

Sheik Hamdam Bin Rashid Al Maktoum Distinguished Chair

Cleveland Clinic Lerner College of Medicine

When might a SV graft be better than an arterial graft ?

Graft Occlusion1. Time

2. Coronary

3. Conduit

4. Patient

with time

Varies with coronary

ITA with competitive flow

with SVG

Age ♀ DiabetesSabik, Ann Thorac Surg, 2005

TimeLAD Grafts

2 4 6 8 10 12 14 16Years from CABG

Gra

ft P

aten

cy

ITASVG

Sabik, Ann Thorac Surg, 2005

100

80

60

40

20

0

ITA PatencyCoronary Grafted

100

80

60

40

20

0

%PatentGrafts

0 2 4 6 8 10 12 14 16

ITA→RCA

ITA→Dg/Cx/PDA

ITA → LAD

Years after CABGSabik, Ann Thorac Surg, 2005

40 50 60 70 80 90 100Proximal Stenosis (%)

Competitive FlowITA Patency

%

Non-LAD

LAD

Sabik, Ann Thorac Surg, 2003

100

80

60

40

20

0

40 50 60 70 80 90 100Proximal Stenosis (%)

ITA

Pat

ency

(%

)Competitive Flow and Time

ITA Patency to LAD

1 year5 years10 years15 years

Sabik, Ann Thorac Surg, 2003

100

80

60

40

20

0

40 50 60 70 80 90 100Proximal Stenosis (%)

ITA

Pat

ency

(%

)Competitive Flow and Time

ITA Patency to Non-LAD

Sabik, Ann Thorac Surg, 2003

100

80

60

40

20

0

1 year5 years10 years15 years

ITA versus SVG• Time• Conduit

• ITA

• SVG

• Coronary

• Which One

• Competitive Flow

40 50 60 70 80 90 100

Proximal Stenosis (%)

ITASVG

LAD Graft Patency 1 Yr

%

Sabik, Ann Thorac Surg, 2005

100

80

60

40

20

0

40 50 60 70 80 90 100

Proximal Stenosis (%)

LAD Graft Patency 10 Yrs

ITA

SVG

Sabik, Ann Thorac Surg, 2005

%

100

80

60

40

20

0

40 50 60 70 80 90 100

Proximal Stenosis (%)

Dg/Cx/PDA Graft Patency 1 Yr

ITASVG

Sabik, Ann Thorac Surg, 2005

%

100

80

60

40

20

0

Dg/Cx/PDA Graft Patency 10 Yrs

ITA

SVG

40 50 60 70 80 90 100

Proximal Stenosis (%)Sabik, Ann Thorac Surg, 2005

%

100

80

60

40

20

0

RCA Graft Patency 1 Yr

40 50 60 70 80 90 100

Proximal Stenosis (%)

ITA

SVG

Sabik, Ann Thorac Surg, 2005

%

100

80

60

40

20

0

RCA Graft Patency 10 Yrs

40 50 60 70 80 90 100

Proximal Stenosis (%)

ITA

SVG

Sabik, Ann Thorac Surg, 2005

%

100

80

60

40

20

0

ITA versus SVGPatency

ITA grafts always better than SVG to• LAD• Dg• Cx• PDA

SVG better than ITA grafts to• RCA, moderate stenosis• By 10 years, ITA better

Vein Graft Patency Rates are (Likely) Better Today

Platelets inhibitors

Statins

Vein Graft Occlusion

Placebo 10% 25%Drug2% 11%

Dipyridamol Pre-op ASA postop

1 week 1 year

Chesbro et. Al NEJM (1984)

Vein Graft Atherosclerosis

Progression of Death 39% 27% <0.001

Grafts with Progression35% 24% <0.001 Occlusion

11% 6% <0.001 New Lesions 21% 10% <0.001

Improvement 4% 5% <0.52

ModerateLDL 132 - 136

AggressiveLDL 93 - 97

Lovastatin - CholastyramineLower LDL Cholesterol

Post CABG Trial NEJM 1997

Saphenous Vein GraftsOpportunities

• Better Platelet Inhibition

• Cascade

• Aggressive Lipid Reduction

• Prevention of Vein Graft Injury

• Harvesting

• Distension

Saphenous Vein Support Technology

Investigational use only under USA law.

180 Days Sheep Pathology/Histology

IVUS eSVS and Control SVG14 mths Post Implant

Control Vein LCX eSVS Vein RCA

Summary

• SV Grafts better when used to graft right coronary arteries with moderate stenosis

• SV Grafts likely better today