Effect of different storage solutions on oxidative stress in human saphenous vein grafts

Background Ischemia–reperfusion injury of saphenous vein grafts (SVG) during coronary artery bypass grafting surgery negatively impacts endothelial integrity and functionality and is associated with vein graft failure. The aim of this study was to evaluate the level of oxidative stress in human SVG segments following ischemic storage in three intraoperative graft storage solutions: saline (S), autologous heparinized blood (HB) and DuraGraft (DG). Methods 3 mm tissue rings derived from surplus SVG segments from 50 patients were stored at room temperature for 30 min in DG, S or HB. Total oxidative status (TOS) and total antioxidant status (TAS) levels were determined from which the oxidative stress index (OSI: TOS/TAS ratio) was calculated. A p-value < 0.017 was considered significant implementing a Bonferroni correction. Results TOS values were significantly lower for DG stored samples in comparison to both S and HB; there was no difference between S and HB (DG: 32.6 ± 1.8, S: 39.6 ± 2.8 and HB: 40.6 ± 2.4 µmol H2O2 eqv.; DG vs. S and DG vs. HB p < 0.0001, S vs. HB p = 0.047). TAS was higher for both DG and HB in comparison to S (DG: 8.9 ± 0.9, S: 6.9 ± 1.0 and HB: 8.6 ± 0.9 mmol Trolox eqv.; DG vs S p < 0.0001, DG vs. HB p = 0.263, S vs. HB p < 0.0001). OSI differed between all groups with the lowest value for DG (DG: 3.7 ± 0.2, S: 5.8 ± 0.4 and HB: 4.7 ± 0.2 µmol H2O2 eqv./mmol Trolox eqv.; all p < 0.0001). Conclusions Saphenous veins grafts stored in DuraGraft had a lower oxidative level, higher antioxidant level and a lower oxidative stress index in comparison to saphenous vein grafts stored in saline or heparinized blood. ClinicalTrials.gov Identifier NCT02922088.

Versatility of Vein Grafts in Hand Neurovascular Reconstruction – Clinical Cases and Literature Review

Injuries to the upper limb may determine unexpected simple or complex soft tissue defects, due to different types of underlying injury mechanism, clean cut/stabs, crushing, torsion, avulsion or mixed types, which pose a challenge for the reconstructive surgeon. Ideally, all arterial, venous and nervous lesions, in the distal upper limb should be repaired in an end-to-end technique, outside of injury zones, with healthy ends, in a tension free manner. However, situations arise where, either a tension-free repair is not possible, or a considerable defect is met, often representing a challenge to the surgeon. Therefore, a timely decision is imposed in order to find the most favorable approach to restore limb or segment perfusion, ensuring efficient venous return, as well as providing a sensate repair. Usage of vein grafts represents an essential tool comprised in the reconstructive surgeon’s armamentarium, with high versatility in nerve, arterial and venous reconstruction. Not only does it provide an ideal solution, with high adaptability to each case, but it also may enhance short- and long-term outcome, offering an optimal reconstructive option in any upper limb trauma situation, regardless of etiology. We aim to describe our therapeutic strategies in a series of challenging trauma cases involving digital structures from the upper limb. Interposed vein grafts were used to re-stablish sensate function in a patient with a collateral digital nerve defect, but also to bridge vital digit arterial defect in a torsion-avulsion thumb amputation, as well as re-establishing venous flow in patients with Urbaniak II finger degloving injury.

Drug-eluting versus bare metal stents in saphenous vein grafts compared to native coronary vessels. The NORSTENT study.

Background. Drug-eluting stents (DES) reduce target lesion revascularization (TLR) with no effect on mortality or myocardial infarction (MI) compared to bare metal stents (BMS) in native vessels. Randomized stent studies in saphenous vein grafts (SVG) are few and the reported effects are ambiguous. The NORSTENT study is the first to randomize lesions to percutaneous coronary intervention (PCI) in native vessels and SVG. Aims. To compare rate of mortality, MI and TLR across stent and vessel types. Methods. In this substudy 6087 patients with a single lesion in native vessels and 164 in SVG, were followed for 5 years. Results. MI was more frequent in SVG (subdistributional hazard ratio (SHR) 4.95 (3.75 – 6.54, p<0.001), but not affected by stent type. In the first 500 days DES reduced TLR in native vessels (SHR 0.21 ( 0.15 – 0.30)p<0.001) and SVG (SHR 0.18 (0.04 – 0.80) p=0.02). Thereafter DES and BMS were equivalent in native vessels, but DES had a higher TLR rate than BMS in SVG (SHR 3.31 (1.23 – 8.94) p=0.02). After 5 years the TLR rate was still significantly lower for DES in native vessels (3.2 % versus 7.8 %, p<0.001) but not in SVG (21.4 % vs 18. 4%). Conclusion: In SVG no difference in TLR between DES and BMS was observed after 5 years in contrast to persistent benefit in native vessels. The high rate of TLR and myocardial infarction in SVG makes treatment of native vessels a preference whenever feasible and better treatment options for SVG are warranted.

Pregnancy-associated spontaneous coronary artery dissection: multidisciplinary management, challenges and literature review

A 30-year-old woman in her second pregnancy, which was complicated by gestational diabetes mellitus. She had an uneventful spontaneous vaginal delivery at 38 weeks+3 days of gestation. Day 1 postpartum, she developed sudden chest pain radiating to her jaw and neck. Her observations were normal, and ECG showed lateral ST elevation in keeping with acute myocardial infarction. The troponin-T level was elevated at 21 ng/L at 0 hour, and >10 000 ng/L at 12 hours, respectively. Coronary angiography confirmed spontaneous dissection of the proximal left anterior descending (LAD) and proximal circumflex coronary arteries. She became unstable during percutaneous coronary intervention and consequently had a successful coronary artery bypass surgery with left saphenous vein grafts to the first obtuse marginal artery and LAD. Echocardiogram revealed moderate to severe impairment of the left ventricular function postoperatively.

Quality of life after percutaneous coronary intervention in no-touch saphenous vein grafts is significantly better than in conventional vein grafts

Objectives: To compare health-related quality of life of patients primarily treated with a no-touch saphenous vein graft with that of patients who received a conventional graft. Methods: The study included all individuals treated with a percutaneous coronary intervention on a saphenous vein graft between January 2006 and June 2020. The RAND-36 health survey was used to assess health-related quality of life. The Mann–Whitney U test was used to test differences in health-related quality of life between the two groups. Effect size was estimated via Cohen’s d. The average treatment effect between the groups was tested by propensity score matching. Results: Of the 346 patients treated with a percutaneous coronary intervention in a stenosed or occluded saphenous vein graft, 165 responded to RAND-36 (no-touch: n=48; conventional: n=117). Patients with a no-touch graft reported better mean values on seven of the eight health survey domains. Statistically significant differences were observed for four of the domains, all in favour of the no-touch group. The effect size estimates indicated a small difference for five domains, with the largest values (>0.40) seen for the general health and energy/fatigue domains. Propensity score matching confirmed a statistically significant difference for the physical functioning and general health domains. Conclusions: At a mean follow-up of 5.4 years, patients who received a percutaneous coronary intervention in no-touch vein grafts showed significantly better health-related quality of life than those who received a percutaneous coronary intervention in conventional vein grafts.

The RAGE Trial (Radial Arterial Graft in the Elderly)- A Pilot Study

Use of radial artery (RA) as a second arterial conduit in Coronary Artery Bypass Grafting (CABG) is well established and appreciated for its higher long-term patency rate compared to vein grafts. This study tends to investigate if there are any detrimental consequences when it is used in elderly (aged 60 and above) population of Bangladesh. A total of 71 patients who received RA grafts at elective, isolated CABG operation were consecutively enrolled in this study from May 2018 to September 2019. 31 patients were in the Elderly group and 40 patients were in the Non-elderly group. The groups were compared for baseline characteristics and co-morbidities; preoperative techniques, findings, events and procedures; and postoperative outcomes or end-point variables inclusive of local complications related to RA harvesting wound. Elderly and Non-elderly groups had statistically different age (p=0.000) and Society of Thoracic Surgery (STS) Score predicted mortality (p=0.000). Operative techniques, events, findings and procedures were similar. Clinical outcomes were found to be similar with no statistical difference between the groups. Number of deaths also was not statistically different. There were no local complications related to RA harvesting wound in either of the two groups. Harvesting and grafting of radial artery in suitable patients, using meticulous "no-touch" technique and for ideal target coronary artery stenosis is as safe in the elderly patients as in the younger ones. CBMJ 2020 July: Vol. 09 No. 02 P: 08-13