Coronary Artery Bypass Graft Disease

PURPOSE: To review saphenous vein graft disease and its prevention and management. DATA SOURCES: A MEDLINE search of articles published on saphenous vein and arterial bypass grafts. STUDY SELECTION: The reference sections of articles focused the selection of key studies. DATA EXTRACTION: Relevant data representing key findings were noted. DATA SYNTHESIS: The outcome of coronary artery bypass grafting with the saphenous vein graft is unsatisfactory because vein grafts are prone to occlusive disease. By 10 years after surgery, 50% have closed, mainly because of atherosclerosis. With vein graft disease and graft closure, symptoms return. The best way to prevent vein graft disease is to use the internal mammary artery graft. This has become the preferred graft because it is not affected by atherosclerosis. Consequently, it has a much higher patency rate: 90% after more than 10 years. This provides such clinical benefits as decreased occurrence of symptoms, better left ventricular performance, decreased need for reoperation, and prolongation of life. The limited supply of mammary arteries has stimulated interest in identifying alternative arterial grafts. CONCLUSIONS: To prevent vein graft disease, surgeons should bypass diseased coronary arteries with at least one arterial graft and take measures during the surgery to avoid endothelial injury to vein grafts. Treatment with antiplatelet agents decreases the vein graft occlusion rate. When graft atherosclerosis causes symptoms, reoperation will probably prolong life if an old graft to the left anterior descending coronary artery is diseased. Reoperation increases a patient's chance for survival if the surgeon uses at least one arterial graft.