Preoperative Screening of Vascular Conduits for Atherosclerotic Disease Before Coronary Artery Bypass Grafting

To the Editor, Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality worldwide, with an estimated global prevalence of approximately 1.7% and more than nine million deaths annually attributable to ischemic heart disease [1]. The pathological hallmark of CAD is the accumulation and retention of atherogenic lipoproteins within the arterial intima, leading to progressive atherosclerotic plaque formation, luminal narrowing, and impaired coronary blood flow. Once coronary stenosis becomes hemodynamically significant, particularly in patients with left main coronary artery disease (LMCAD) or complex multivessel disease, myocardial revascularization through either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is recommended to restore myocardial perfusion [2]. CABG relies on autologous vascular conduits, most commonly the great saphenous vein (GSV) and the internal thoracic artery (ITA), to bypass obstructed coronary arteries. However, because atherosclerosis is a systemic vascular disease, these conduits are not inherently protected from the pathological processes affecting the native coronary circulation. Saphenous vein grafts, in particular, undergo a well-recognized sequence of pathological changes characterized by early thrombotic occlusion, subsequent intimal hyperplasia, and accelerated atherosclerotic degeneration, ultimately leading to graft failure [2,3]. Long-term graft patency therefore depends not only on surgical technique and postoperative medical therapy but also on the intrinsic structural integrity and biological quality of the conduit at the time of implantation. Despite the recognized importance of conduit quality, routine assessment of harvested grafts before implantation remains limited. In current clinical practice, conduit evaluation primarily relies on gross visual inspection and manual palpation during surgery, approaches that are inherently subjective and incapable of detecting subclinical intimal thickening, early atherosclerotic plaque, endothelial injury, or other microscopic structural abnormalities [4]. Consequently, conduits harboring occult vascular disease may be implanted unknowingly, potentially predisposing patients to premature graft dysfunction and failure. Current strategies aimed at improving graft durability focus predominantly on optimizing harvesting techniques, including conventional open, endoscopic, and no-touch approaches, intraoperative graft flow assessment, meticulous surgical handling, and aggressive postoperative secondary prevention with antiplatelet therapy, lipid-lowering agents, and other guideline-directed medical therapies [2,5]. While these interventions have undoubtedly improved clinical outcomes, they do not directly address the possibility that the harvested conduit itself may already contain pre-existing subclinical atherosclerotic disease before implantation. Advances in intravascular imaging offer a promising opportunity to bridge this gap. High-resolution modalities such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS) have demonstrated the ability to characterize vessel wall architecture, identify intimal hyperplasia, detect early atherosclerotic plaques, and assess endothelial integrity in harvested vascular conduits [2]. Although currently used primarily in research settings, these technologies may provide a practical means of identifying structurally compromised grafts before implantation, thereby allowing surgeons to select higher-quality conduits or modify surgical strategies accordingly. Such an approach has the potential to improve long-term graft patency, reduce repeat revascularization procedures, and decrease the substantial clinical and economic burden associated with graft failure. We therefore propose that prospective clinical studies should evaluate the feasibility, diagnostic accuracy, cost-effectiveness, and long-term clinical impact of routine pre-implantation vascular conduit screening in patients undergoing CABG. Given that atherosclerosis is a systemic disease and graft failure remains a major determinant of adverse long-term outcomes after surgical revascularization, incorporating objective structural assessment of vascular conduits may represent an important step toward more personalized and durable coronary bypass surgery. References Khan MA, Hashim MJ, Mustafa H, Baniyas MY, Al Suwaidi SKBM, AlKatheeri R, et al. Global epidemiology of ischemic heart disease: results from the Global Burden of Disease Study. Cureus. 2020;12(7):e9349. 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