Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance

Samano, Ninos; Souza, Domingos; Pinheiro, Bruno Botelho; Kopjar, Tomislav; Dashwood, Michael

doi:10.21470/1678-9741-2019-0238

Ninos Samano Correspondence Address: Ninos Samanohttps://orcid.org/0000-0003-4249-8401 Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden. Postal Code: SE-70185 E-mail: ninos.samano@regionorebrolan.se

MD

PhD

Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.

http://orcid.org/0000-0003-4249-8401

Domingos Souza

MD

PhD

Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.

Bruno Botelho Pinheiro

MD

MSc

Department Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, GO, Brazil.

Tomislav Kopjar

MD

PhD

Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia.

Michael Dashwood

PhD

Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School, London, UK.

Correspondence Address: Ninos Samanohttps://orcid.org/0000-0003-4249-8401 Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden. Postal Code: SE-70185 E-mail: ninos.samano@regionorebrolan.se

No conflict of interest.

Figures (5)
Tables (3)

Thumbnail

Fig. 1
Differences in patency, left internal thoracic artery (LITA) vs. no-touch (NT) saphenous vein (SV) and LITA vs. conventional (C) SV at 1.5, 8.5, and 16 postoperative years. The six confidence intervals (a-f ) and the margins of 10 and 15 percentage units are the basis for comparing LITA with the SV with respect to potential equivalence and non-inferiority (Samano et al., 2015)^[¹⁷17 Samano N, Geijer H, Liden M, Fremes S, Bodin L, Souza D. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: a randomized trial. J Thorac Cardiovasc Surg. 2015;150(4):880-8. doi:10.1016/j.jtcvs.2015.07.027.
https://doi.org/10.1016/j.jtcvs.2015.07.... ^]. CI=confidence interval.

Thumbnail

Fig. 2
Examples of no-touch (NT) and conventional (C) saphenous vein (SV) grafts. The left panels show representative SV explants using both harvesting techniques. NT SV has its surrounding cushion of fat intact and has not been distended. C SV has the fat removed and has been distended to overcome spasm. The transverse section of NT SV shows an intact surrounding cushion of perivascular fat (PVF), an undamaged adventitia (ADV) and thick media (TM). As this vessel has not been distended, the lumen (L) is thrown into folds. The section of C SV exhibits various forms of damage. Much of the ADV has been stripped off, almost to the level of the external elastic lamina (small arrows). The media is thinner than that of the NT SV and L is grossly dilated, both due to high pressure intraluminal distension (Kopjar et al., 2016)^[²²22 Kopjar T, Dashwood MR. Endoscopic versus "no-touch" saphenous vein harvesting for coronary artery bypass grafting: a trade-off between wound healing and graft patency. Angiology. 2016;67(2):121-32. doi:10.1177/0003319715584126.
https://doi.org/10.1177/0003319715584126... ^].

Thumbnail

Fig. 3
Histological, cellular, and ultrastructural comparison of notouch (NT) vs. conventional (C) saphenous vein (SV) grafts. Top panels are representative examples of part transverse sections through the wall of NT and C SVs stained with Elastic van Gieson and prepared for coronary artery bypass grafting. The intima surrounding lumen (L) of NT SV is thrown into folds. The vein ‘wall’ is thick with smooth muscle cells of the media (M) separated by the internal and external elastic laminae and with an intact adventitia (ADV) in which the vasa vasorum is located (red arrow). The intimal folds are absent in C SV, the vessel wall is thinner than that from NT SV (due to distension), and the ADV is mostly removed and damaged. The white arrows near vein L indicate the internal elastic lamina. The lower panels show damage caused to C SV when compared to NT SV. Panel A shows an intact endothelial lining of the NT vein L when compared to the C vein shown in panel D. Only a proportion of the endothelial cells in D stain red using the antibody CD31 (arrow). Panel B is a transmission electron micrograph showing the uniform shape and distribution of vascular smooth muscle cells in the M of a NT SV. The appearance of smooth muscle cells in the M of C SV is very different. Panel C shows the wall of a NT SV with an intact vasa vasorum (arrows) within the ADV. The ADV of C SV (F) is mostly removed with remnants indicated by the arrows. Endothelial cells of L and vasa vasorum stain dark brown in these sections with an intact layer lining the NT vein, but regions of denudation present in the C vein. The endothelial cells of the vasa vasorum at the M/ADV border are evident in panel C, but absent in panel F (Ahmed et al., 2004)^[²⁵25 Ahmed SR, Johansson BL, Karlsson MG, Souza DSR, Dashwood MR, Loesch A. Human saphenous vein and coronary bypass surgery: ultrastructural aspects of conventional and "no-touch" vein graft preparations. Histol Histopathol. 2004;19(2):421-33. doi:10.14670/HH-19.421.
https://doi.org/10.14670/HH-19.421... ^].

Thumbnail

Fig. 3
Histological, cellular, and ultrastructural comparison of notouch (NT) vs. conventional (C) saphenous vein (SV) grafts. Top panels are representative examples of part transverse sections through the wall of NT and C SVs stained with Elastic van Gieson and prepared for coronary artery bypass grafting. The intima surrounding lumen (L) of NT SV is thrown into folds. The vein ‘wall’ is thick with smooth muscle cells of the media (M) separated by the internal and external elastic laminae and with an intact adventitia (ADV) in which the vasa vasorum is located (red arrow). The intimal folds are absent in C SV, the vessel wall is thinner than that from NT SV (due to distension), and the ADV is mostly removed and damaged. The white arrows near vein L indicate the internal elastic lamina. The lower panels show damage caused to C SV when compared to NT SV. Panel A shows an intact endothelial lining of the NT vein L when compared to the C vein shown in panel D. Only a proportion of the endothelial cells in D stain red using the antibody CD31 (arrow). Panel B is a transmission electron micrograph showing the uniform shape and distribution of vascular smooth muscle cells in the M of a NT SV. The appearance of smooth muscle cells in the M of C SV is very different. Panel C shows the wall of a NT SV with an intact vasa vasorum (arrows) within the ADV. The ADV of C SV (F) is mostly removed with remnants indicated by the arrows. Endothelial cells of L and vasa vasorum stain dark brown in these sections with an intact layer lining the NT vein, but regions of denudation present in the C vein. The endothelial cells of the vasa vasorum at the M/ADV border are evident in panel C, but absent in panel F (Ahmed et al., 2004)^[²⁵25 Ahmed SR, Johansson BL, Karlsson MG, Souza DSR, Dashwood MR, Loesch A. Human saphenous vein and coronary bypass surgery: ultrastructural aspects of conventional and "no-touch" vein graft preparations. Histol Histopathol. 2004;19(2):421-33. doi:10.14670/HH-19.421.
https://doi.org/10.14670/HH-19.421... ^].

Thumbnail

Fig. 4
Unsupported and supported saphenous vein (SV) grafts for coronary artery bypass grafting. A) An example of a conventionally harvested SV with outermost tissue removed (Rueda et al.^[³⁶36 Rueda Fd, Souza D, Lima Rde C, Menezes A, Johansson B, Dashwood M, et al. Novel no-touch technique of harvesting the saphenous vein for coronary artery bypass grafting. Arq Bras Cardiol. 2008;90(6):356-62. doi:10.1590/s0066-782x2008000600002.
https://doi.org/10.1590/s0066-782x200800... ^], 2008). Insert, examples of DacronTM ‘EXTENT’ and ‘VEST’ external supports (Mawhinney et al.^[⁵⁸58 Mawhinney JA, Mounsey CA, Taggart DP. The potential role of external venous supports in coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2017;53(6):1127-34. doi:10.1093/ejcts/ezx432.
https://doi.org/10.1093/ejcts/ezx432... ^], 2017). B) An example of a no-touch (NT) harvested SV with external tissue intact (Rueda et al.^[³⁶36 Rueda Fd, Souza D, Lima Rde C, Menezes A, Johansson B, Dashwood M, et al. Novel no-touch technique of harvesting the saphenous vein for coronary artery bypass grafting. Arq Bras Cardiol. 2008;90(6):356-62. doi:10.1590/s0066-782x2008000600002.
https://doi.org/10.1590/s0066-782x200800... ^], 2008). C) Angiogram of an SV with VEST at 12-month follow-up (Mawhinney et al.^[⁵⁸58 Mawhinney JA, Mounsey CA, Taggart DP. The potential role of external venous supports in coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2017;53(6):1127-34. doi:10.1093/ejcts/ezx432.
https://doi.org/10.1093/ejcts/ezx432... ^], 2017). D) NT SV harvesting prevents kinking of excessively long graft (Rueda et al.^[³⁶36 Rueda Fd, Souza D, Lima Rde C, Menezes A, Johansson B, Dashwood M, et al. Novel no-touch technique of harvesting the saphenous vein for coronary artery bypass grafting. Arq Bras Cardiol. 2008;90(6):356-62. doi:10.1590/s0066-782x2008000600002.
https://doi.org/10.1590/s0066-782x200800... ^], 2008).

Thumbnail

Fig. 5
Saphenous vein (SV) histology of endoscopic vein harvesting (EVH) vs. no-touch (NT) techniques. Left panel is a transverse section of an SV prepared with EVH. The perivascular layers and endothelium are damaged. The arrow shows intimal tearing (Kiani et al.^[⁶⁹69 Kiani S, Poston R. Is endoscopic harvesting bad for saphenous vein graft patency in coronary surgery? Curr Opin Cardiol. 2011;26(6):518-22. doi:10.1097/HCO.0b013e32834b9f6d.
https://doi.org/10.1097/HCO.0b013e32834b... ^], 2011). Middle panel to the left shows a diagram with a small incision above the knee used for insertion of EVH instruments. To the right, it shows a long incision in thigh and calf used for both open vein harvesting and NT harvesting. Right panel is a transverse section of a NT harvested SV with perivascular fat and adventitia intact and endothelium undamaged (Kopjar et al.^[²²22 Kopjar T, Dashwood MR. Endoscopic versus "no-touch" saphenous vein harvesting for coronary artery bypass grafting: a trade-off between wound healing and graft patency. Angiology. 2016;67(2):121-32. doi:10.1177/0003319715584126.
https://doi.org/10.1177/0003319715584126... ^], 2016).

Thumbnail

Abbreviations, acronyms & symbols ADRF = Adipocyte-derived relaxing factor NICE = National Institute for Health and Care Excellence ADV = Adventitia NO = Nitric oxide C = Conventional NT = No-touch CABG = Coronary artery bypass grafting NYHA = New York Heart Association ok CI = Confidence interval OVH = Open vein harvesting EACTS = European Association for Cardio-Thoracic Surgery PVAT = Perivascular adipose tissue ESC = European Society of Cardiology PVF = Perivascular fat EVH = Endoscopic vein harvesting RA = Radial artery ITA = Internal thoracic artery SV = Saphenous vein L = Lumen SVG = Saphenous vein graft LITA = Left internal thoracic artery TM = Thick media M = Media VSMCs = Vascular smooth muscle cells

Thumbnail

Table 1
Ratio of number of patent grafts to total number of grafts for the two surgical techniques at three follow-up time points (Samano et al.^[17], 2015).

Thumbnail

Authors' roles & responsibilities NS Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published DS Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published BBP Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published TK Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published MD Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published

Abbreviations, acronyms & symbols
ADRF	= Adipocyte-derived relaxing factor	NICE	= National Institute for Health and Care Excellence
ADV	= Adventitia	NO	= Nitric oxide
C	= Conventional	NT	= No-touch
CABG	= Coronary artery bypass grafting	NYHA	= New York Heart Association ok
CI	= Confidence interval	OVH	= Open vein harvesting
EACTS	= European Association for Cardio-Thoracic Surgery	PVAT	= Perivascular adipose tissue
ESC	= European Society of Cardiology	PVF	= Perivascular fat
EVH	= Endoscopic vein harvesting	RA	= Radial artery
ITA	= Internal thoracic artery	SV	= Saphenous vein
L	= Lumen	SVG	= Saphenous vein graft
LITA	= Left internal thoracic artery	TM	= Thick media
M	= Media	VSMCs	= Vascular smooth muscle cells

	Conventional (C)			No-touch (NT)			Group difference in % patency^* * Tested with multilevel logistic regression, except for sequential grafts, for which Fisher's exact test had to be used because of small numbers and cells with no occluded grafts.
Follow-up (years)	1.5	8.5	16	1.5	8.5	16	1.5	8.5	16
No. of patients	46	37	27	45	37	27
Single grafts	96/107 (90%)	68/87 (78%)	41/63 (65%)	103/109 (94%)	78/87 (90%)	55/67 (82%)	0.23	0.05	0.06
Sequential grafts	16/20 (80%)	10/14 (71%)	5/9 (56%)	15/15 (100%)	14/14 (100%)	7/8 (87%)	0.12	0.10	0.29
All grafts	112/127 (89%)	78/101 (77%)	46/72 (64%)	118/124 (95%)	92/101 (91%)	62/75 (83%)	0.08	0.01	0.03

Authors' roles & responsibilities
NS	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
DS	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
BBP	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
TK	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
MD	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published

[1] Correspondence Address: Ninos Samanohttps://orcid.org/0000-0003-4249-8401 Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden. Postal Code: SE-70185 E-mail: ninos.samano@regionorebrolan.se

Brasil

Brasil

Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance

Abstract