A decrease in peripheral thyroid hormone conversion efficiency in patients treated with immune checkpoint inhibitors and L-T3 as a possible alternative therapeutic escape option.

Hypothyroidism is a frequently occurring side effect in patients under treatment with immune checkpoint inhibitors (ICIs). Actually, the origin of hypothyroidism with ICI use is classified as a primary (thyroid) or as secondary/tertiary hypothyroidism (hypothalamus-pituitary). Treatment consists of levothyroxine (L-T4) substitution. Recently, we were rarely confronted with a clinically overt hypothyroidism in three patients under treatment with ICIs who were non-responsive to T4 therapy. As a therapeutical escape, liothyronine (L-T3) was started with a significant clinical and/or biochemical improvement suggesting an underlying functional defect in the peripheral free T4 (fT4) to free T3 (fT3) conversion (as supported by calculation of SPINA-GD). Against this background, we discussed our three patients along an extended review of this clinical topic.

Diagnostic Utility of Fine Needle Aspiration Cytology in the Evaluation of Peripheral Lymphadenopathy.

BACKGROUND: Patients are often referred for fine needle aspiration cytology (FNAC) on account of peripheral lymphadenopathy. Relative to the rate of referrals, very few works have been done to establish the reliability of FNAC as a first-line investigation in the evaluation of peripheral lymphadenopathy in this environment. This study aims to determine the diagnostic utility of FNAC in evaluating common causes of peripheral lymphadenopathy in a teaching hospital in North western Nigeria. STUDY DESIGN: Eighty-six patients who had FNAC and histology or cell blocks preparation of the same lymph nodes were recruited over a 5-year period. Using histology and cell blocks as gold standards, the sensitivity, specificity, predictive values and test accuracy were deduced. RESULTS: The sensitivity, specificity, positive and negative predictive values were 71.4%, 91.5%, 87.5% and 81.1% respectively. The test accuracy of FNAC was 83.7%. CONCLUSION: FNAC is reliable for screening and diagnosing peripheral lymph node lesions. However, ancillary tests such as immunocytochemistry may be necessary for improved accuracy.

Cesarean delivery rates in Down syndrome pregnancies.

OBJECTIVES: Data on rates of cesarean delivery among pregnancies diagnosed with genetic syndromes remains limited. We examined the cesarean delivery rates for Down syndrome pregnancies over a 10-year period in the US. METHODS: We used data from the 1995-2004 US delivery data files to examine cesarean delivery rates in singleton pregnancies (at ≥20 weeks' gestation) with and without Down syndrome. We further examined if the rates of cesarean deliveries in primary and repeat cesarean deliveries among Down syndrome pregnancies differed based on the presence or absence of major structural abnormalities or stillbirth or gestational age at delivery. RESULTS: There were 35 million singleton deliveries of which 19186 were diagnosed at birth with Down syndrome (1 in 2000 births after 20 weeks gestation). The primary cesarean delivery rates were higher among Down syndrome pregnancies (17.5% in 1995 and 21.5% in 2004) compared to non-Down syndrome pregnancies (12.3% in 1995 and 16.6% in 2004). Temporal trends for cesarean deliveries were steeper among Down syndrome pregnancies with gastrointestinal and heart abnormalities than in Down syndrome cases without abnormalities. Higher cesarean delivery rates were also noted among Down syndrome pregnancies ending in third trimester live born than in control. CONCLUSION: In the US, cesarean deliveries in Down syndrome pregnancies increases over time and is greater when Down syndrome is associated with structural abnormalities and delivered during the third trimester of pregnancy.

Pharmacology of airways and vessels in lung slices in situ: role of endogenous dilator hormones.

Small airway and vessels play a critical role in chronic airway and pulmonary vascular diseases, but their pharmacology has not been well characterised. We have studied airway and vascular responses in rat lung slices and separately in vitro using myography. In lung slices, under basal conditions, acetylcholine contracted airways, but had no vascular effect. The thromboxane mimetic, U46619 contracted both vessels and airways. In the presence of U46619, acetylcholine dilated vessels, but further contracted airways, an effect that was blocked by the nitric oxide synthase inhibitor L-NG-nitro-L-arginine or apamin plus charybdotoxin, which inhibit endothelial-derived hyperpolarising factor. Airway responses in lung slices were unaffected by L-NGnitro-L-arginine methyl ester, indomethacin or apamin plus charybdotoxin. By contrast, apamin plus charybdotoxin contracted bronchi studied in isolation. Our observations are the first to identify mechanisms of endothelium dependent dilations in precision cut lung slices and the potential for transverse hormonal communication between airways and vessels.

Oscillation in the activities of MEK/ERK1/2 during cardiopulmonary bypass in pigs.

BACKGROUND: Because cardiopulmonary bypass (CPB) is associated with edema and vasoreactive dysfunction and ERK1/2 pathway is involved in vascular contractility and permeability, a time course study was performed to monitor MEK/ERK1/2/Elk-1 activities during CPB. METHODS: Pigs were subjected to normothermic CPB for 90 minutes followed by post-CPB perfusion for 180 minutes. Atrial myocardium was sampled before CPB, 5 minutes after CPB onset, 5 minutes after weaning from CPB, and at the end of post-CPB. Skeletal muscle and mesenteric vessels samples were harvested before CPB, 5 minutes after CPB institution, and every 30 minutes thereafter to the end of post-CPB. Samples were analyzed by immunoblotting and immunofluorescence microscopy with the use of specific antibodies against active (phosphorylated) forms of ERK1/2, MEK1/2, and Elk-1. RESULTS: Pigs that were subjected to CPB showed an increase in phospho-ERK1/2 after 30 minutes of CPB, followed by a decrease after 90 minutes. Another phosphorylation peak was observed 30 to 60 minutes of post-CPB, followed by a decrease to below baseline at the end of reperfusion. MEK1/2 and Elk-1 activation profiles paralleled ERK1/2 activity peaks. Control samples showed no significant increase above basal levels. CONCLUSIONS: Activation of MEK/ERK1/2/Elk-1 pathways closely follows major CPB surgical manipulations (institution and termination) and could be related to morbidity during and after CPB.

Nonadrenergic, noncholinergic relaxation of human isolated corpus cavernosum induced by scorpion venom.

OBJECTIVES: To examine the effects of Tityus serrulatus scorpion venom (TSV) on human corpus cavernosum (HCC) using a bioassay cascade. Priapism is occasionally observed in scorpion envenomation, mostly in children. METHODS: HCC strips were suspended in a cascade system and superfused with aerated and warmed Krebs' solution at 5 mL/min. Noradrenaline (3 micromol/L) was infused to induce a submaximal contraction of the HCC strips. The release of cyclooxygenase products was prevented by infusing indomethacin (6 micromol/L). RESULTS: N(omega)-nitro-L-arginine methyl ester (10 micromol/L; n = 10) increased the tone of the preparations and significantly reduced (P <0.01) the acetylcholine (ACh) and TSV-induced relaxations. Subsequent infusion of L-arginine (300 micromol/L) partially reversed the increased tone and significantly restored the relaxations induced by TSV and ACh (P <0.01). The soluble guanylyl cyclase inhibitor ODQ (10 micromol/L; n = 8) markedly reduced (P <0.01) the relaxations induced by TSV, ACh, glyceryl trinitrate, and bradykinin. 7-Nitroindazole (10 micromol/L; n = 8) inhibited the relaxations induced by TSV by 84% (P <0.01) and also caused small, but significant, reductions in the ACh and bradykinin-induced HCC relaxations (P <0.05). Atropine (1 micromol/L; n = 6) abolished the relaxations evoked by ACh (P <0.01), but had no effect on those elicited by TSV. Tetrodotoxin (1 micromol/L; n = 6) abolished the relaxations induced by TSV (P <0.01) and also reversed the established TSV-induced relaxation (n = 4). CONCLUSIONS: Our results indicate that TSV relaxes HCC through the release of nitric oxide from nonadrenergic, noncholinergic (NANC) nerves. The elucidation of the mechanism responsible for the TSV-induced relaxations might be useful for a better understanding of the development of priapism in cases of scorpion envenomation.

Inactivation of the MEK/ERK pathway in the myocardium during cardiopulmonary bypass.

OBJECTIVES: A general pro-inflammatory response after cardiopulmonary bypass (CPB) may involve changes in signal transduction and in part be responsible for arrhythmias and myocardial dysfunction after cardiac surgery. The MEK/ERK (mitogen-activated protein kinase kinase/extracellular regulated kinase) pathway is common to many stimuli and may play a pivotal role in morbidity associated with CPB. We investigated the changes in MEK/ERK pathway and related enzymes after CPB in pigs. METHODS: We examined ventricular and atrial tissue from pigs before 90 minutes of normothermic CPB and after 90 minutes of post-CPB perfusion. The activities and protein levels of kinases MEK1/2, ERK1/2, a cellular tyrosine kinase (c-Src), protein kinase B (Akt), and the protein levels of mitogen-activated protein kinase phosphatase (MKP-1) were studied by immunoblotting ventricular and atrial myocardium lysates and labeling sections with antibodies that recognize the activated forms of the kinases and the phosphatase. Control pigs were subjected to sternotomy and heparinization but not CPB. RESULTS: We found a consistent inactivation of MEK/ERK pathway in both ventricular and atrial myocardium with an increase in MKP-1, a negative regulator of ERK1/2. The activities and protein levels of c-Src and Akt were not significantly modified before or after CPB, suggesting a certain degree of specificity for the MEK/ERK pathway. Such changes were not observed in controls. The decrease of ERK1/2 and MEK1/2 phosphorylation 90 minutes after termination of CPB (as well as the increase of nuclear MKP-1 protein levels) was also apparent by confocal microscopy. CONCLUSIONS: These results collectively reveal a prevalence of inhibitory mechanisms in the MEK/ERK signal transduction machinery in myocardium subjected to CPB.

The role of heart rate in the modulation of the decreased cardiac output induced by acute nitric oxide synthesis inhibition in anaesthetized dogs.

1. The role of the heart rate modulating the decrease in cardiac output induced by the nitric oxide synthesis inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME) was investigated in anaesthetized dogs. This was achieved in dogs in which a positive pacemaker (PM) cable was located at the right ventricle. 2. The haemodynamic events were evaluated: mean arterial blood pressure (MABP), systemic vascular resistance index (SVRI), stroke volume index (SVI), heart rate (HR) and cardiac index (CI). 3. The infusion of L-NAME (0.01-10 mg kg(-1)) in the animals with the PM off caused a dose-dependent rise in MABP and SVRI, accompanied by significant decreases of HR and SVI. A resulting decrease in CI was observed at all doses of L-NAME used. 4. In the animals with the PM on, HR was maintained stable. Under this condition, the increase in MABP and SVRI as well as the decrease in SVI induced by the L-NAME infusion did not significantly differ from the PM-off animals. However, the resulting decreased CI was markedly attenuated compared to PM-off animals but significant decreases in CI were still observed at higher doses of L-NAME. 5. The results suggest that HR plays an important role in the L-NAME-mediated decreased cardiac output but other factors might also be involved.

Ethanol reduces the endothelin-B receptor-mediated increase in portal inflow resistance in the isolated, perfused canine liver.

Ethanol can affect the regulation of liver hemodynamics through the release of vasoactive mediators such as nitric oxide and endothelins (ETs). The purpose of this study was to investigate the effects of ethanol on the changes in arterial and portal perfusion pressure induced by ET receptor activation. Ethanol significantly reduced portal, but not arterial perfusion pressure. ET-1 and norepinephrine (used as an ET receptor-independent vasoconstrictor) induced changes in hepatic arterial or portal inflow resistance that were not affected by ethanol treatment. However, an IRL 1620-induced increase in portal, but not arterial, inflow resistance was significantly reduced in ethanol-perfused preparations, an effect observed after either intra-arterial or intraportal administration of the agonist. These results suggest that ethanol can diminish the responsiveness of the portal vascular bed of the canine liver to ETB receptor activation.

Characterization of endothelin receptors in isolated, perfused human spleen.

At present, there is no information on endothelin-1 (ET-1)-mediated vascular effects in the human spleen. The objectives of this study were to investigate the in vitro vascular responses to ET-1 using pharmacologic probes (selective ET receptor agonists/antagonists) and to characterize the ET receptor population in the human spleen. Spleens (n = 6) were removed from patients for treatment of underlying disease. The organs were perfused with warmed (37 degrees C), oxygenated (95% O2/5% CO2) Krebs solution at constant flow, with continuous recording of splenic arterial perfusion pressure (SAPP). The increases in SAPP caused by injection of ET-1 (ETA/ETB agonist) were markedly reduced in the presence of the selective ETA antagonist FR-139317, whereas those induced by IRL-1620 (an ETB agonist) and norepinephrine (NE) were unchanged. The increases in SAPP induced by intra-arterial bolus injections of NE and ET-1 were significantly (p < 0.05) potentiated by indomethacin [INDO; a cyclo-oxygenase (COX) inhibitor] alone and the responses to both peptides (ET-1 and IRL-1620) were significantly (p < 0.05) potentiated by INDO and L-NAME [a nitric oxide (NO) synthase inhibitor] together. We conclude that ET-1 contributes to the regulation of vascular tone in human spleen through activation of both ETA and ETB receptors and that these responses are modulated by concomitant release of prostaglandins and NO.

Characterisation of functional endothelin receptors in the canine isolated perfused spleen.

The endothelin receptor subtypes involved in the vasoconstriction, capsular smooth muscle contraction, prostaglandin E2 and prostacyclin release induced by endothelin-1 have been investigated in the canine isolated perfused spleen using both the endothelin ETA receptor antagonist FR 139317 and the endothelin ETB receptor agonist IRL 1620. THe isolated canine spleen was perfused with warmed (37 degrees C) and oxygenated (95% O2/5% CO2) Krebs solution at constant flow with continuous recording of splenic arterial perfusion pressure and spleen weight. Samples of splenic venous effluent were collected to determine the amounts of prostaglandin E2 and prostacyclin, measured by radioimmunoassay. Endothelin-1 (4-200 pmol) and IRL 1620 (20-1000 pmol) dose-dependently increased splenic arterial perfusion pressure but the former was more potent on a molar basis (the molar dose ratio IRL/endothelin-1 required to increase splenic arterial vascular resistance by 25% was approximately 33). The infusion of the nitric oxide inhibitor N omega-nitro-L-arginine methyl ester (10 microM), but not of the enantiomer N omega-nitro-D-arginine methyl ester, significantly potentiated the increase in splenic arterial vascular resistance induced by endothelin-1. The infusion of FR 139317 (1 microM) markedly attenuated the increased splenic arterial perfusion pressure induced by endothelin-1 without affecting that evoked by IRL 1620. At the highest dose (200 pmol), endothelin-1 induced a small but significant capsule contraction as reflected by the reduction in the spleen weight. The infusion of FR 139317 (1 microM) abolished this contractile effect. IRL 1620 (in doses up to 1000 pmol) did not significantly affect the capsule tone.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of carrageenin-induced rat paw oedema by crotapotin, a polypeptide complexed with phospholipase A2.

1. The effect of purified crotapotin, a non-toxic non-enzymatic chaperon protein normally complexed to a phospholipase A2 (PLA2) in South America rattlesnake venom, was studied in the acute inflammatory response induced by carrageenin (1 mg/paw), compound 48/80 (3 micrograms/paw) and 5-hydroxytryptamine (5-HT) (3 micrograms/paw) in the rat hind-paw. The effects of crotapotin on platelet aggregation, mast cell degranulation and eicosanoid release from guinea-pig isolated lung were also investigated. 2. Subplantar co-injection of crotapotin (1 and 10 micrograms/paw) with carrageenin or injection of crotapotin (10 micrograms/paw) into the contralateral paw significantly inhibited the carrageenin-induced oedema. This inhibition was also observed when crotapotin (10-30 micrograms/paw) was administered either intraperitoneally or orally. Subplantar injection of heated crotapotin (15 min at 60 degrees C) failed to inhibit carrageenin-induced oedema. Subplantar injection of crotapotin (10 micrograms/paw) also significantly inhibited the rat paw oedema induced by compound 48/80, but it did not affect 5-HT-induced oedema. 3. In adrenalectomized animals, subplantar injection of crotapotin markedly inhibited the oedema induced by carrageenin. The inhibitory effect of crotapotin was also observed in rats depleted of histamine and 5-HT stores. 4. Crotapotin (30 micrograms/paw) had no effect on either the histamine release induced by compound 48/80 in vitro or on the platelet aggregation induced by both arachidonic acid (1 nM) and platelet activating factor (1 microM) in human platelet-rich plasma. The platelet aggregation and thromboxane B2 (TXB2) release induced by thrombin (100 mu ml-1) in washed human platelets were also not affected by crotapotin. In addition, crotapotin (10 microg/paw) did not affect the release of 6-oxo-prostaglandin Fla, and TXB2 induced by ovalbumin in sensitized guinea-pig isolated lungs.5. Our results indicate that the anti-inflammatory activity of crotapotin is not due to endogenous corticosteroid release or inhibition of cyclo-oxygenase activity. It is possible that crotapotin may interact with extracellular PLA2 generated during the inflammatory process thereby reducing its hydrolytic activity.

Role of endothelin ETA and ETB receptors in the arterial vasculature of the isolated canine liver.

The vascular effects of endothelin-1 (ET-1; ETA/ETB agonist), sarafotoxin 6b (S6b; ETA agonist), and IRL 1620 (ETB agonist) were investigated in the isolated canine liver arterial circuit before and after infusions of indomethacin (cyclo-oxygenase inhibitor) and N omega L-nitro arginine methyl ester (L-NAME; nitric oxide synthesis inhibitor). Norepinephrine (NE) was used as vasconstrictor control agent. The portal vein, hepatic artery, and vena cava were cannulated in vitro and the liver was perfused via the hepatic artery and portal vein with oxygenated (95%) O2/5% CO2) Krebs solution at 37 degrees C. Intra-arterial bolus injections of either ET-1 (0.4-400 pmol) or S6b (0.4-400 pmol) induced dose-dependent and long-lasting vasoconstriction accompanied by significant prostacyclin release. The vasoconstrictor responses to these peptides were slightly increased during infusion of indomethacin. Subsequent infusion of L-NAME potentiated both ET-1- and S6b-induced vasoconstriction (p < 0.05). IRL 1620 (up to 1.2 nmol) had no effect on the hepatic arterial vascular resistance even during indomethacin and L-NAME infusions. Infusion of the ETA receptor antagonist FR-139317 (0.3 microM) markedly reduced both ET-1- and S6b-induced vasoconstriction without affecting that evoked by NE. Our results indicate that pressor responses to ET-1 and S6b in the isolated canine liver are modulated by concomitant release of vasodilator mediators, including prostacyclin and nitric oxide. These effects appear to depend primarily on the activation of ETA receptor subtypes. IRL 1620 (but not ET-1) induced a significant release of hemoglobin into the venous effluent, suggesting that ETB receptors are located in the venous side of the intrahepatic circulation.

Clinical and angiographic experience with intraoperative transluminal balloon-catheter dilatation and coronary artery bypass graft surgery.

Between April, 1980 and October, 1983, 40 patients with chronic stable angina pectoris underwent intraoperative transluminal balloon-catheter dilatation and coronary artery bypass graft (CABG) surgery. The main indication for this combined procedure was diffuse symptomatic coronary artery disease with at least one coronary artery having two or more areas of narrowing. Intraoperative dilatation was performed upon 42 coronary arteries involving 57 narrowed arterial segments where dilatation was attempted. The balloon-tipped catheter could not be passed through two stenotic sites. There was no documented perforation but unrecognized intimal injury was observed in two patients at postoperative catheterization. There was one perioperative myocardial infarction, one operative death and 97% early relief of angina pectoris. In 25 distal arterial narrowings that were studied angiographically in the early postoperative period (mean 10 days), 15 (60%) were unchanged, 2 (8%) were worse and 8 (32%) were improved compared to the preoperative angiogram. Patients with discrete narrowings did better than those who had balloon dilatation for diffuse narrowings; 49% of the former as compared to 17% of the latter had angiographic evidence for improvement. During the follow-up period (mean 30 months), three patients developed recurrent angina pectoris and one died of congestive heart failure. Thirteen distal arterial narrowings were studied angiographically late postoperatively (mean 12 months). In these 13 areas, 6 (46%) were unchanged, 3 (23%) were worse and 4 (31%) were improved compared to preoperative angiograms. Additionally, 10 arterial narrowings were observed angiographically, both early and late postoperatively. Nine of these serially observed segments remained unchanged while one became worse.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency coronary artery bypass graft surgery for threatened acute myocardial infarction related to coronary artery catheterization.

In 20 patients undergoing cardiac catheterization, usually involving balloon-catheter dilation or streptokinase infusion, catheter-induced coronary artery intimal damage resulted in severe chest pain, electrocardiographic evidence of obstruction or dissection of a major coronary artery. These patients were surgically revascularized within 8 hours after the onset of the acute chest pain syndrome. Our experience with pharmacological and catheter-related manipulations to improve coronary blood flow after the ischemic episode but before operation suggested that the additional time spent in the catheterization laboratory was worthwhile. The injured coronary artery was the left anterior descending in 10 patients, the right in 8, the left main in 1 patient, and an obtuse marginal branch of the circumflex in 1. The average number of grafts per patient was 2.5; only 6 patients had single bypass grafts. In 5 patients, intraaortic balloon pumping was used either preoperatively or postoperatively. Inotropic support was used postoperatively in 5 patients, and 7 patients received lidocaine for ventricular irritability. Abnormal elevation of the serum isoenzyme of creatine kinase (CK-MB) was seen in 8 patients, and new Q waves were noted in 4 patients; 3 of these 4 patients with new Q waves also had abnormal serum CK-MB levels. Global ejection fraction obtained by the equilibrium-gated blood pool scan postoperatively was 60 +/- 3%, which was similar to the 62 +/- 3% obtained from the contrast-determined ventriculogram done preoperatively prior to the catheter-related injury. There were no early or late deaths, but morbidity was much higher in the group who had emergency coronary artery bypass grafting (CABG) compared with those who had elective CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary artery bypass graft surgery: relative efficacy of initial proximal versus distal anastomoses.

Controversy exists concerning the most appropriate sequence of anastomoses in coronary artery bypass grafting (CABG) procedures. While the more commonly employed method of distal coronary anastomoses first has withstood a long clinical experience, a recent study and several cardiac surgical groups have suggested that construction of the proximal anastomoses first offers certain advantages. In 30 patients undergoing CABG, we performed a prospective, randomized trial comparing both techniques. Relative efficacy was assessed by hemodynamic, radionuclide, electrocardiographic, enzymatic, thermographic, and clinical evaluation. The length of cardiopulmonary bypass was longer in the group having the distal anastomoses done first. Myocardial temperature mapping was similar between groups. Hemodynamic changes, including cardiac output, ejection fraction, and regional wall motion, were nearly identical between the groups. The incidence of myocardial damage reflected by levels of myocardial-specific isoenzymes (serum CK-MB) and electrocardiographic changes was also similar. In conclusion, the sequence of anastomoses is not critical in routine CABG operations. However, we speculate that each technique may have certain advantages under different clinical circumstances found on occasion. Ideally, each method should be part of the coronary surgeon's armamentarium.

Biochemical and ultrastructural integrity of the saphenous vein conduit during coronary artery bypass grafting. Preliminary results of the effect of papaverine.

Factors associated with early and late graft patency related to aorta-coronary artery bypass grafting with a reversed segment of saphenous vein are clinically important. The present investigation examines the biochemical and electron microscopic integrity of this venous conduit intraoperatively with regard to pharmacologic manipulation with papaverine. Portions of saphenous vein were analyzed in 22 patients undergoing coronary artery bypass operations. Levels of a stable derivative of prostacyclin, 6-keto-PGF1 alpha, were measured by radioimmunoassay. Scanning as well as transmission electron microscopy was also performed. In particular, the efficacy of local vein treatment with papaverine, a phosphodiesterase inhibitor, was evaluated. We found that levels of 6-keto-PGF1 alpha in venous effluent showed a biphasic response with initial elevation followed by a relative depression after papaverine exposure. There were no such changes observed in veins subjected to a balanced electrolyte solution (Plasma-Lyte). In addition, levels of the platelet-inhibitory substance 6-keto-PGF1 alpha in venous tissue were less in papaverine-treated veins than those found in veins treated only with the balanced electrolyte solution (Plasma-Lyte). Furthermore, evidence for ultrastructural damage was also somewhat greater in the papaverine-treated group. An alternative method of dilating the saphenous vein after harvesting, which involves the creation of the proximal aorta-coronary anastomosis first and gentle finger manipulation subsequently, appeared to minimize venous injury. Under present clinical conditions, it appears that some amount of injury is inevitable during harvesting and suturing of the human saphenous vein during coronary bypass grafting.