Physiopathology and improvement of the saphenous vein graft in coronary artery bypass graft

We read with great interest the study by Stevens et al. [1], in which, in a randomized non-inferiority trial (AMI-PONT trial), the authors compared 2 strategies for revascularization of the myocardial anterolateral territory: the left internal mammary artery to saphenous vein bridge grafting strategy (LSVB), in which a segment of saphenous vein (SV) is anastomosed from the left anterior descending coronary artery to an anterolateral coronary branch, with subsequent anastomosis of the left internal thoracic artery (LITA) to the SV; and the conventional strategy, with LITA anastomosis to the left anterior descending coronary artery, and an aortocoronary SV graft for an artery of the anterolateral territory. The results, after 1 year, demonstrated non-inferiority between these strategies, and are encouraging, since they illustrate that technical innovations in coronary artery bypass grafting (CABG) are still feasible, with constant improvement of this procedure, even after almost 60 years of clinical application. The LSVB strategy has several positive aspects: it is technically reproducible, and conceivably less arduous than other revascularization techniques, such as sequential anastomoses, or Y- or T-composite grafts, thus allowing the intrinsic characteristics of the LITA to benefit >1 coronary artery territory, while mitigating the disadvantages of SV grafts, with the additional gain of not handling the ascending aorta, when performed without cardiopulmonary bypass.