Catheterization and Cardiovascular Diagnosis 23:208-210 (1991)

Long-Term Patency of Arterialized Cephalic Vein Used as a Conduit for Coronary Artery Bypass Grafting

Sameer Mehta, MD, Steven Levine, MD, James R. Margolis, MD, Jose C. Martin, MD, Dan Krauthamer, MD, and Ernest Traad, MD

We present long-term angiographic follow-up of a patient with an arterialized segment of cephalic vein used as a conduit for aortocoronary bypass grafting.

Key words: segmental stenosis, aortocoronary bypass, intimal hyperplasia

INTRODUCTION

Since the routine use of greater saphenous veins and internal mammary arteries for coronary artery bypass grafting, less attention has been focused on alternative conduits. In patients without adequate saphenous veins due to prior stripping, previous CABG, or unsuitable anatomy, a number of aortocoronary conduits have been evaluated [ 11. These include gastroepiploic, splenic, and radial artery conduits; synthetic grafts; arterial and venous allografts; and both virgin and artificial upper extremity vein grafts [2]. We report a follow-up of a patient with previous bilateral venous stripping who re- ceived an arterialized cephalic vein as a conduit for aor- tocoronary bypass grafting of her occluded right and cir- cumflex coronary arteries.

CASE HISTORY

The patient was a 69-year-old hypertensive female. Cardiac catheterization performed for unstable angina in 1979 revealed high-grade left main and subtotal right coronary artery stenoses. She had bilateral vein stripping in the past for varicose veins. An arterio-venous fistula was created by an end-to-side anastomosis of the left cephalic vein to the radial artery employing #7-0 Prolene sutures. Two weeks later, this arterialized seg- ment was used to construct separate aortocoronary grafts to the distal RCA and obtuse marginal branch. At the same time the LIMA was also grafted to the LAD. In 1986, the patient underwent cardiac catheterization for recurrent anginal symptoms. Both arterialized cephalic vein grafts were widely patent. The LIMA filled retro- grade due to high grade stenosis at the origin of the left subclavian artery. An ascending aorta-right internal ca- rotid-left subclavian graft was then created using Dacron (12 X 6 mm), and the patient obtained clinical relief of her angina. Angiography performed in July 1990 for un-

stable angina revealed a patent arterialized graft to the obtuse marginal, a patent Y-shaped Dacron patch, but the arterialized vein graft to the RCA was now occluded.

DISCUSSION Non-Arterialized Veins for Femoropopliteal and Coronary Bypass

Use of cephalic veins as a peripheral vascular graft was first proposed by Kakkar in 1969 [3]. He followed 8 patients with cephalic veins used as femoropopliteal bypass grafts and noticed the conduits to be patent after 4-12 mo. Shulman and Badhay [6] followed 68 long bypasses using arm veins exclusively. Their long-term follow-up demonstrated that most arm veins developed early intimal hyperplasia and occluded, and the few that remained patent became elongated or aneurysmal. Stoney and associates [ 5 ] defined the patency and dura- bility of arm vein grafts used for coronary revasculariza- tion. They found arm vein grafts to have a high failure rate which was felt to result from inherent disadvantages of arm veins: they are more difficult to dissect, are thin and delicate, and are easily traumatized by previous intravenous injections. Stoney and associates further suggested segmental stenosis in arm vein grafts as a mechanism of late closure. This contrasted with the char- acteristic intimal hyperplasia seen with saphenous vein grafts. Prieto and co-investigators [4], in 1984, reported their experience with non-arterialized upper extremity autologous veins for CABG in 13 patients and expressed

From the Cardiovascular Laboratory, South Miami Hospital, Miami, F I o r i d a.

Received August 25, 1990; revision accepted February 18, 1991.

Address reprint requests to Sameer Mehta, M.D., Cardiovascular Lab- oratory, South Miami Hospital, 7400 S.W. 62nd Avenue, Miami, FL 33143.

0 1991 Wiley-Liss, Inc.

Arterialized Segment of Cephalic Vein 209

Fig. 1. Cineangiograms defining the patency of the arterializsd vein graft to the obtuse marginal artery. A: demonstrates a widely-patent conduit in a 60 degrees LAO angiographic view,

8 : origin of the arteriailzed vein graft as seen in a true lateral projection, C: a patent distal anastomotic site seen in an RAO projection.

concern that arm veins have limited application because of late occlusion.

Experience with Surgically-Created A-V Fistulae Robert L. Beals reported the results of surgically cre-

ated arteriovenous fistula which were used to augment

the cephalic vein. He reported 111 a series of 40 side- to-side anastomoses between the radial artery and the cephalic vein. He found that these veins gradually be- came arterialized and increased eter to 4-6 mm after a few weeks, and 6-10 mm after a period of months. Wall thickness was also observed to

2-4 rnm in

210 Mehta et al.

increase. Over the past two decades, various surgeons have utilized such arterialized vein grafts for aorto-cor- onary bypass grafting with the hypothesis that creation of an arterial-venous fistula overcomes the existent dis-

establishing long-term patency rates for these uncommon grafts.

REFERENCES advantages of arm vein grafts. Ernest Traad has a series of as yet un-reported 35 patients in whom such arterial- ized vein grafts were used for aorto-coronary bypass sur- S r y .

This case report demonstrates a long-term fate of such arterialized vein grafts. Arterialized veins in our patients had a probe size at operation of greater than 2 mm and demonstrated patency of the arterialized graft to the RCA between 7 and 11 yr and the grafted segment to the obtuse marginal for 11 yr so far. The use of arterialized cephalic veins may thus provide an alternative conduit for coronary artery bypass surgery in certain special cir- cumstances. Additional follow-up data is important in

2.

3.

4,

5.

6,

Beah RL: Surgically created arteriovenous fistula to augment the cephalic vein: Use as an arterial bypass graft. N Engl J Med 285:

Foster, ED, Kranc, MAT: Alternative conduits for aortocoronary bypass grafting. Circulation (Suppl) 79: 1989. Kakkar VV: The cephalic vein as a peripheral vascular graft. Surg Gynecol Obstet 128:551-556, 1969. Prieto I, Basile F, Abdulnour E: Upper extremity vein graft for aortocoronary bypass. Ann Thorac Surg 37:218-221, 1984. Stoney WS, Alford WC Jr, Bums GR, Glassford DM Jr, Petracek MR, Thomas SF Jr: The fate of arm veins for aortocoronary bypass grafts. J Thorac Cardiovasc Surg 88:522-527, 1984. Schulman ML, Badhey MR: Late results and angiographic evalu- ation of arm veins as long bypass grafts. Surgery 92:1032-1041, 1982.

29-30, 1971.