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Invited Presentation: Ex Vivo Storage of Vein Grafts

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Invited Presentation: Ex Vivo Storage of Vein Grafts

  1. 1. The Link between Ex Vivo Storage Interval and Subsequent Failure of Vein Grafts Robert Poston, MD Chairman, Department of Cardiothoracic Surgery St Francis Medical Center, Trenton, NJ
  2. 2. Choice of conduit • Arterial vs. venous: OR 10 Harvesting conduit • “No touch” vs. conventional: OR 3.1 • Open vs. endoscopic: OR 2 Storage of conduit Anastomotic technique • Interrupted vs. continuous: OR 1.4 • On-pump vs. off-pump: OR 1.3 Postoperative management • Aggressive vs. standard statin therapy: OR 1.3 • Aspirin vs. no aspirin: OR 2.2 Factors that influence graft patency post-CABG ?
  3. 3. Mechanism of early graft failure Endothelial dysfunction Arterial conduits Meticulous harvest Statin therapy Hypercoagulability Anti-platelet therapy Abnormal flow Perfect anastomotic technique THROMBOSIS
  4. 4. Status of bypass graft endothelium In situ (baseline) Ex vivo storage (after explant) After grafting onto the heart ? Normal endothelium Disrupted endothelium
  5. 5. Recovery of venous endothelium after grafting • Large animal studies • Venous vs. prosthetic grafts
  6. 6. HANDLE WITH CARE
  7. 7. The Vascular Conduit as a Transplant Organ • Veins/arteries are organs: • differentiated structures comprised of two or more tissues working together to provide a specific function • Respond to a variety of complex signals including hormones, other molecules and nerve impulses to adjust blood flow • Correct functioning is dependent upon proper integrated functioning of vessel’s constituent tissues • Majority of vascular grafts are transplanted autologous vein or artery derived grafts- • Vascular grafts and heterologous organ transplants are subject to many of the same graft failure mechanisms: • Oxidative damage • Storage lesions • Ischemia Reperfusion Injury
  8. 8. Subanalysis of preservation solutions from the PREVENT IV Trial1 • Multicenter, randomized, placebo-controlled trial of edifoligide during CABG • Enrolled 3014 patients at 107 US sites from 8/1/02 – 10/22/03 • Analyzed the impact of preservation solution on graft patency Saline Blood Buffered saline 1. Harskamp et al. JAMA Surg. 2014;149(8):798-805
  9. 9. Choice of conduit • Arterial vs. venous: OR 10 Harvesting conduit • “No touch” vs. conventional: OR 3.1 • Open vs. endoscopic: OR 2 Storage of conduit Anastomotic technique • Interrupted vs. continuous: OR 1.4 • On-pump vs. off-pump: OR 1.3 Postoperative management • Aggressive vs. standard statin therapy: OR 1.3 • Aspirin vs. no aspirin: OR 2.2 Factors that influence graft patency post-CABG Buffered solution vs. other alternatives: OR 1.7
  10. 10. Ischemic damage is “invisible” • Bypass graft failure often asymptomatic • Whole organ failure never asymptomatic Saline/blood standard of care • Informational cascade Saline/blood used when training • Reputational cascade Selective emphasis of risk factors • Easy to see the influence of technical/anatomic factors • Difficult to see the analogy to organ transplant Factors that influenced choice of vein solution

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