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