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Research Letter |

The Preservation and Handling of Vein Grafts in Current Surgical Practice Findings of a Survey Among Cardiovascular Surgeons of Top-Ranked US Hospitals FREE

Judson B. Williams, MD, MHS1,2; Ralf E. Harskamp, MD3; Saideep Bose, MD, MPH1; Jeffrey H. Lawson, MD, PhD1; John H. Alexander, MD, MHS2,4; Peter K. Smith, MD1,2; Renato D. Lopes, MD, PhD2,4
[+] Author Affiliations
1Department of Surgery, Duke University Medical Center, Durham, North Carolina
2Duke Clinical Research Institute, Duke University, Durham, North Carolina
3Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
4Department of Medicine, Duke University Medical Center, Durham, North Carolina
JAMA Surg. 2015;150(7):681-683. doi:10.1001/jamasurg.2015.0404.
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Despite the recognized importance of vein graft preservation, a paucity of data exists regarding how vein grafts are handled and preserved in everyday practice. As such, we sought to characterize the techniques of vein graft preservation and handling among a large cohort of high-performing US cardiovascular hospitals and to report the findings.

An anonymous, voluntary, electronic survey instrument consisting of 15 questions pertaining to vein graft use, harvesting, handling, and preservation was created. After internal and external reviews of the survey items for content validity, a final version (Table) was formatted using Qualtrics survey software (Qualtrics LLC). A total of 100 medical centers were considered for inclusion in our study based on recognition by the US News and World Report as top-performing hospitals in cardiology and cardiac surgery.1 Respective division heads and practicing surgeons received a letter via email signed by study investigators (J.B.W., R.E.H., and P.K.S.) requesting participation on behalf of their medical centers. The institutional review board of Duke University determined that the study met the criteria for exemption from approval.

Responses were received from 90 of the 100 centers. Please note that, even though the total number of centers responding was 90, some did not answer every survey question. The geographic distribution of the participating centers included 25 Northeastern (29.4%), 20 Midwestern (23.5%), 24 Southern (28.2%), and 16 Western medical centers (18.8%). The mean volume of coronary artery bypass graft surgery was 390.6 (95% CI, 344-437) procedures per year. Most centers (79 [87.8%]) reported that more than 75% of veins were harvested endoscopically. Few centers (5 [5.6%]) left the vein graft in situ until the aortocoronary bypass was performed. With regard to storage solutions, saline solution was used by 26 centers (28.9%), pH-buffered solution (any commercially available or “homegrown” solution designed to resist changes in pH) by 36 centers (40.0%), autologous blood by 24 centers (26.7%), and other solutions by 4 centers (4.4%) (Figure). A chilled solution was used in 23 centers (25.6%). Heparin sodium was used in the preservation solution 89% of the time overall and 100% of the time if the preservation solution was blood-based. The majority of centers (51 [56.7%]) stored the vein grafts ex vivo for more than 15 minutes, 23 centers (25.6%) for 10 to 15 minutes, 13 centers (14.4%) for 5 to 10 minutes, and only 3 centers (3.3%) for less than 5 minutes. Ink lines (placed with sterile surgical marking pen to assist with orientation) were used in 48 centers (53.3%). Side branches were mainly ligated with clips in 40 centers (44.4%), ties in 13 centers (14.4%), and both in 36 centers (40.0%).

Place holder to copy figure label and caption
Figure.
Histogram Demonstrating the Variance in Vein Graft Preservation Solutions Used
Graphic Jump Location

The findings reveal a particular heterogeneity with regard to preservation mediums (28.9% saline solution, 40.0% pH-buffered solution, and 26.7% autologous blood), a rich area for potential improvement in practice. Although high-profile studies have examined the operative technique for vein graft harvesting,2 as well as lipid-lowering medications and low-dose anticoagulation effects on vein grafts,3 clinical data regarding the optimal preservation solution are lacking. A number of ex vivo studies investigating storage media have been performed using saphenous vein graft segments, finding endothelial cell loss by electron microscopy with use of warm saline or pressurized storage.4 In vivo data are sparse with regard to preservation solutions, with only 2 studies5,6 to date presenting clinical data on the topic. This includes a study in the 1980s by Catinella et al5 comparing saline vs blood-based solutions in only 40 patients, which suggests that blood-based solutions may not be beneficial, and a secondary analysis of a large coronary artery bypass graft trial from the early 2000s, which suggests that the use of pH-buffered solutions was associated with lower vein graft failure rates compared with the use of blood-based and saline-based solutions.6 The present study reveals significant process variance among a large cohort of highly ranked US cardiovascular medical centers with regard to the preservation and handling of saphenous vein grafts. In particular, the paucity of clinical outcomes data combined with the discovered variability herein supports clinical equipoise for the prospective randomized study of vein graft handling practices, potentially impacting many surgical specialties.

Accepted for Publication: February 23, 2015.

Corresponding Author: Judson B. Williams, MD, MHS, Duke Clinical Research Institute and Department of Surgery, Duke University Medical Center, PO Box 3850, Durham, NC 27705 (judson.williams@dm.duke.edu).

Published Online: May 13, 2015. doi:10.1001/jamasurg.2015.0404.

Author Contributions: Dr Williams had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Williams, Harskamp, Bose, Smith, Lopes.

Drafting of the manuscript: Williams, Bose.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Bose.

Obtained funding: Alexander.

Administrative, technical, or material support: Williams, Harskamp.

Study supervision: Williams, Harskamp, Lawson, Alexander, Smith, Lopes.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by the Duke Clinical Research Institute.

Role of the Funder/Sponsor: The Duke Clinical Research Institute had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Best Hospitals for Adult Cardiology & Heart Surgery.US News and World Report website. http://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery. Accessed September 28, 2014.
Williams  JB, Peterson  ED, Brennan  JM,  et al.  Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308(5):475-484.
PubMed   |  Link to Article
Post Coronary Artery Bypass Graft Trial Investigators.  The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation on obstructive changes in saphenous-vein coronary-artery bypass grafts. N Engl J Med. 1997;336(3):153-162.
PubMed   |  Link to Article
Chester  AH, O’Neil  GS, Tadjakarimi  S, Borland  JA, Yacoub  MH.  Effect of peri-operative storage solution on the vascular reactivity of the human saphenous vein. Eur J Cardiothorac Surg. 1993;7(8):399-404.
PubMed   |  Link to Article
Catinella  FP, Cunningham  JN  Jr, Srungaram  RK,  et al.  The factors influencing early patency of coronary artery bypass vein grafts: correlation of angiographic and ultrastructural findings. J Thorac Cardiovasc Surg. 1982;83(5):686-700.
PubMed
Harskamp  RE, Alexander  JH, Schulte  PJ,  et al.  Vein graft preservation solutions, patency, and outcomes after coronary artery bypass graft surgery: follow-up from the PREVENT IV randomized clinical trial. JAMA Surg. 2014;149(8):798-805.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Histogram Demonstrating the Variance in Vein Graft Preservation Solutions Used
Graphic Jump Location

References

Best Hospitals for Adult Cardiology & Heart Surgery.US News and World Report website. http://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery. Accessed September 28, 2014.
Williams  JB, Peterson  ED, Brennan  JM,  et al.  Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308(5):475-484.
PubMed   |  Link to Article
Post Coronary Artery Bypass Graft Trial Investigators.  The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation on obstructive changes in saphenous-vein coronary-artery bypass grafts. N Engl J Med. 1997;336(3):153-162.
PubMed   |  Link to Article
Chester  AH, O’Neil  GS, Tadjakarimi  S, Borland  JA, Yacoub  MH.  Effect of peri-operative storage solution on the vascular reactivity of the human saphenous vein. Eur J Cardiothorac Surg. 1993;7(8):399-404.
PubMed   |  Link to Article
Catinella  FP, Cunningham  JN  Jr, Srungaram  RK,  et al.  The factors influencing early patency of coronary artery bypass vein grafts: correlation of angiographic and ultrastructural findings. J Thorac Cardiovasc Surg. 1982;83(5):686-700.
PubMed
Harskamp  RE, Alexander  JH, Schulte  PJ,  et al.  Vein graft preservation solutions, patency, and outcomes after coronary artery bypass graft surgery: follow-up from the PREVENT IV randomized clinical trial. JAMA Surg. 2014;149(8):798-805.
PubMed   |  Link to Article

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