Interact CardioVasc Thorac Surg 2007;6:251-254. doi:10.1510/icvts.2006.149104
© 2007 European Association of Cardio-Thoracic Surgery
Best evidence topic - Coronary |
Do coronary artery bypass grafts using cephalic veins have a satisfactory patency?
Manoj Purohita and
Joel Dunningb,*
a Department of Cardiothoracic Surgery, Lancashire Cardiac Centre, Victoria Hospital, Blackpool, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Received 27 November 2006;
accepted 29 November 2006
*Corresponding author. Tel/fax: +44-780-1548122.
E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether using the cephalic vein from the arm for coronary artery bypass grafts achieves an adequate patency rate. Only 219 papers were identified on Medline using the reported search and hand-searching of reference lists. Fourteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. The patency rate seems to be in the order of 50% at around three years for cephalic veins used for coronary bypass grafting, and this was variable. In addition, we identified only 181 cephalic veins used for coronary bypass grafting in the literature from seven papers. In lower extremity bypass procedures over 900 uses of the cephalic vein have been documented but again patency seems to be around 50% at three to five years. Arterialisation of the vein using an arteriovenous fistula, or angioscopy, have both been used as an attempt to improve patency. In addition, a large proportion of the reported cephalic veins for coronary grafting were used for sequential bypass grafting which may have affected patency rates. Thus, in summary, the patency of the cephalic vein used for coronary artery bypass grafting is around 50% at three years.
Key Words: Thoracic surgery; Cephalic vein; Upper extremity vein; Graft patency
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1. Introduction
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A best evidence topic was constructed according to the structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are referred a diabetic 78-year-old gentleman with left main stem disease and triple vessel disease. He has severe varicose veins in both his legs, but he has a large first diagonal artery and you would like to place four grafts. You would like to use the left internal mammary artery, and both radial arteries and you wonder whether you could also use a cephalic vein from his arm. You resolve to check the patency of these veins in the literature prior to proceeding.
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3. Three-part question
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In [patients undergoing coronary artery bypass surgery], is the use of the [cephalic vein] associated with acceptable [vein graft patency].
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4. Search strategy
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Medline 1966 to November 2006 using OVID interface, [exp Thoracic Surgery OR Thoracic Surgery.mp OR exp Coronary Artery Bypass/ OR CABG.mp OR Cardiovascular Surgical Procedures/] and [upper extremity vein$.mp OR arm vein$.mp OR cephalic vein$.mp]
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5. Search outcome
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A total of 219 papers were identified using the reported search. Seven papers documenting the patency of the cephalic vein for coronary bypass grafting and the largest series of cephalic veins for a lower extremity bypass were documented. In addition, another six papers on lower extremity grafting with cephalic veins were briefly reviewed but not tabulated (Table 1).
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6. Results
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Licht et al. [2] reported a series of 39 patients undergoing coronary artery bypass grafting (CABG) who had a cephalic vein. Eighteen had angiographic follow up (mean 31 months). Fifty-two percent of grafts were patent, 39% of all veins had intraluminal disease, and 19% were dilated.
Wijnberg et al. [3] compared a group of 28 patients who received a cephalic vein graft with a matched group who received saphenous vein grafts. At mean 4.6-year follow up, cephalic vein patency was 47% compared to 77%.
Stoney et al. [4] assessed the patency of 56 cephalic or basilic vein grafts from 28 patients. 32/56 (57%) grafts were patent at mean 25 months while 7 (12.5%) of the patent grafts had localised stenoses.
Jarvinen et al. [5] reported the patency of 16 cephalic veins in 15 patients. At a mean follow up of 1.4 years (1–42 months), 87% (27/31 distal anastomoses) were patent angiographically although three veins also had aneurysmal dilatation.
Prieto et al. [6] examined 10 patients at different intervals. The early patency of arm vein grafts in six patients studied less than nine months after operation was 9 out of 10 grafts (90%). Four patients were followed for more than one year, after which time five out of eight grafts (63%) were patent, two of them with gross abnormalities.
Seifert et al. [7] studied 17 patients at eight months follow up, out of 35 grafts only 23 (66%) were patent. There were attempts to address the issue of delicate thin wall and poor handling of arm veins by creating arterio-venous fistulae to arterialise the vein before using it for bypass grafting.
Faries et al. [8] reported the cephalic vein graft patency of 520 lower limb bypass procedures up to 1998. Patency was assessed regularly using Doppler ultrasound and interestingly on harvesting, half of the veins had an angioscopy performed and luminal integrity was assessed, resulting in 30% of veins being spliced to resect an abnormal section. The three-year patency was 69%, and the five-year patency was 55%.
Mehta et al. [9] reported a case where two cephalic arterialised veins were used. One vein lasted at least seven years and the other was patent at 11 years.
We identified several other studies that documented the use of the cephalic vein for lower extremity bypass. We did not tabulate these but the patency was: Schulman [10] in 64 patients, five-year patency 31% for femoropopliteal bypass and 15% for femorotibial bypass; Holzenbein [11] in 250 cephalic vein grafts, three-year patency 52%; Harris [12] in 67 patients, 68% at five years; Brochado-Neto [13] in 35 cephalic veins: 42% two-year patency; Harward [14] in 43 patients, 49% at three years; Seston [15] in 34 patients 40% three-year patency.
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7. Clinical bottom line
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The patency rate seems to be in the order of 50% at around three years for cephalic veins used for coronary bypass grafting, and this was variable. In addition, we identified only 181 cephalic veins used for coronary bypass grafting in the literature. In lower extremity bypass procedures over 900 uses of the cephalic vein have been documented but again patency seems to be around 50% at three to five years. Arterialisation of the vein using an arteriovenous fistula, and angioscopy have both been used as an attempt to improve patency in some papers. In addition, a large proportion of the reported cephalic veins for coronary grafting were used for sequential bypass grafting which may have affected patency rates. Thus, in summary the patency of the cephalic vein used for coronary arterial bypass grafting is around 50% at three years.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
- Licht P, Jacobsen E, Lerbjerg G, Andersen PE, Alstrup P. Cephalic veins in coronary artery bypass surgery. Eur J Cardio Thorac Surg 1996; 10:327–330.[Abstract]
- Wijnberg DS, Boeve WJ, Ebels T, van GI, van den Toren EW, Lie KI, Homan van der Heide JN. Patency of arm vein grafts used in aorto-coronary bypass surgery. Eur J Cardio Thorac Surg 1990; 4:510–513.[Abstract]
- Stoney WS, Alford WC Jr, Burrus GR, Glassford DM Jr, Petracek MR, Thomas CS Jr. The fate of arm veins used for aorta-coronary bypass grafts. J Thorac Cardiovasc Surg 1984; 88:522–526.[Abstract]
- Jarvinen A, Harjula A, Mattila S, Valle M, Harjola PT. Experience with arm veins as aorto-coronary bypass grafts. J Cardiovasc Surg 1984; 25:344–347.[Medline]
- Prieto I, Basile F, Abdulnour E. Upper extremity vein graft for aortocoronary bypass. Ann Thorac Surg 1984; 37:218–221.[Abstract]
- Seifert D, Bircks W, Jehle J, Schulte HD. Aorto-coronary bypass grafts using cephalic veins. Thorac Cardiovasc Surg 1982; 30:Suppl15–16.
- Faries PL, Arora S, Pomposelli FB Jr, Pulling MC, Smakowski P, Rohan DI, Gibbons GW, Akbari CM, Campbell DR, LoGerfo FW. The use of arm vein in lower-extremity revascularization: results of 520 procedures performed in eight years. J Vasc Surg 2000; 31:50–59.[CrossRef][Medline]
- Mehta S, Levine S, Margolis JR, Martin JC, Krauthamer D, Traad E. Long-term patency of arterialized cephalic vein used as a conduit for coronary artery bypass grafting. Catheter Cardio Diag 1991; 23:208–210.
- Schulman ML, Badhey MR. Late results and angiographic evaluation of arm veins as long bypass grafts. Surgery 1982; 92:1032–1041.[Medline]
- Holzenbein TJ, Pomposelli FB Jr, Miller A, Contreras MA, Gibbons GW, Campbell DR, Freeman DV, LoGerfo FW. Results of a policy with arm veins used as the first alternative to an unavailable ipsilateral greater saphenous vein for infrainguinal bypass. J Vasc Surg 1996; 23:130–140.[CrossRef][Medline]
- Harris RW, Andros G, Dulawa LB, Oblath RW, Salles-Cunha SX, Apyan R. Large-vessel arterial occlusive disease in symptomatic upper extremity. Arch Surg 1984; 119:1277–1282.[Abstract/Free Full Text]
- Brochado-Neto FC, Albers M, Pereira CA, Gonzalez J, Cinelli M Jr. Prospective comparison of arm veins and greater saphenous veins as infrageniculate bypass grafts. Eur J Vasc Endovasc Surg 2001; 22:146–151.[CrossRef][Medline]
- Harward TR, Coe D, Flynn TC, Seeger JM. The use of arm vein conduits during infrageniculate arterial bypass. J Vasc Surg 1992; 16:420–426. discussion 426–427.[CrossRef][Medline]
- Sesto ME, Sullivan TM, Hertzer NR, Krajewski LP, O'Hara PJ, Beven EG. Cephalic vein grafts for lower extremity revascularization. J Vasc Surg 1992; 15:543–549.[CrossRef][Medline]
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Top
Abstract
1. Introduction