The no-touch vein graft for coronary artery bypass surgery preserves the left ventricular ejection fraction at 16†years postoperatively: long-term data from a longitudinal randomised trial.

OBJECTIVES: To assess the left ventricular heart function and the clinical outcome 16 years after coronary artery bypass surgery. DESIGN: In a randomised trial, the no-touch (NT) vein graft in coronary artery bypass surgery has shown a superior patency rate, a slower progression of atherosclerosis and better clinical outcome compared to the conventional (C) vein graft at 8.5 years. All patients at mean time 16 years were offered an echocardiographic and clinical examination. RESULTS: In the NT-group 34 patients and in the C-group 31 patients underwent an echocardiography examination. A significantly better left ventricle ejection fraction was seen in the NT-group compared to the C-group (57.9% vs 49.4%; p=0.011). The size of the left atrium in NT was 21.7 cm(2) compared to 23.9 cm(2) in C; p=0.034. No patient in NT had atrial fibrillation compared to five patients in C (p=0.021). Patients with a brain natriuretic peptide value (BNP) ≥150 was 30% in NT compared to 38% in C. Total mortality was 25% in NT vs 27% in C. Cardiac-related deaths were 8% and 12% in NT and C respectively. CONCLUSIONS: The NT vein graft preserves the left ventricular ejection fraction after 16 years. A smaller left atrium, a lower BNP and no atrial fibrillation indicates an improved diastolic left ventricular function in the NT-group. TRIAL REGISTRATION: The study is registered with clinicaltrials.gov (NCT01686100) and The Research and Development registry in Sweden (no. 102841).

The "no-touch" harvesting technique for vein grafts in coronary artery bypass surgery preserves an intact vasa vasorum.

OBJECTIVES: Our objective was to evaluate the impact of vein graft harvesting technique on structure and function of vasa vasorum. METHODS: Paired segments of great saphenous veins harvested either with conventional harvesting technique or no-touch technique were obtained from 9 consecutive patients undergoing coronary artery bypass grafting. Quantitative measurements, using immunohistochemistry and morphometry, were performed. Ultrastructural analyses of vasa vasorum were performed with electron microscopy. Video footage of superficial vasa vasorum in an implanted saphenous vein graft harvested with the no-touch technique was captured during a coronary bypass operation and is presented for online viewing. RESULTS: The total area of vasa vasorum in vein grafts harvested with the conventional technique was significantly reduced both in the media (P = .007) and in the adventitia (P = .014) compared with vein grafts harvested with the no-touch technique. Ultrastructural findings indicated that the no-touch technique preserved an intact vasa vasorum whereas the conventional technique did not. Video footage showed retrograde flow in the vasa vasorum in vein graft harvested with the no-touch technique. CONCLUSIONS: These findings show that the no-touch technique for saphenous vein graft harvesting for coronary bypass grafting preserves an intact vasa vasorum. This could represent one of the mechanisms underlying the improved patency of saphenous vein grafts harvested with this technique.

Slower progression of atherosclerosis in vein grafts harvested with 'no touch' technique compared with conventional harvesting technique in coronary artery bypass grafting: an angiographic and intravascular ultrasound study.

OBJECTIVES: In a long-term randomised coronary artery bypass grafting (CABG) study, the patency rate using a new 'no touch' (NT) vein-graft preparation technique was superior to the conventional (C) technique. This cineangiographic and intravascular ultrasound (IVUS) substudy examined possible mechanisms. METHODS: A total of 45 patients (118 grafts) in the NT group and 46 patients (112 grafts) in the C group had patent grafts at short-term follow-up after 18 months. Thirty-seven patients (91 grafts) in the NT group and 37 patients (77 grafts) in the C group had patent grafts at long-term follow-up after 8.5 years, and were evaluated on a scale from 0 (normal) to 2 (significant stenosis) by cineangiogram. IVUS was performed in 15 NT grafts and 14 C grafts in the short-term follow-up, and 27 NT grafts and 26 C grafts in the long-term follow-up, in grafts considered normal by the cineangiogram. The grafts were evaluated with respect to lumen volume, intimal thickness, incidence of plaque and plaque components. RESULTS: In the short-term follow-up, the cineangiogram showed more normal grafts (89.0% in the NT group compared with 75.0% in the C group), and the number of grafts with stenosis was 11.0% in the NT group compared with 25.0% in the C group (p=0.006). IVUS showed less mean intimal thickness (0.43 (0.07)mm vs 0.52 (0.08)mm; p=0.03), less grafts with considerable intimal hyperplasia (≥ 0.9 mm; 20% vs 78.6%; p=0.011) and fewer patients with considerable hyperplasia (≥ 0.9 mm; 25% vs 100%; p=0.007). In the long-term follow-up, the cineangiogram showed more normal grafts, with 91.2% in the NT group compared with 83.1% in the C group; there were fewer grafts with significant stenosis, with 7.7% in the NT group compared with 15.6% in the C group (p=0.14). IVUS showed fewer grafts containing multiple plaques (14.8% vs 50%; p=0.008), less advanced plaque with lipid (11.8% vs 63.9%; p=0.0004) and less maximal plaque thickness (1.04 (0.23)mm vs 1.32 (0.25)mm; p=0.02) in the NT group compared with the C group. CONCLUSION: The superior long-term patency rate using the NT vein-graft technique at CABG could be explained by a significantly slower progression of atherosclerosis.

No touch vein harvesting technique for CABG improves the long-term clinical outcome.

OBJECTIVES: To investigate the long-term clinical outcome, averaging 8.5 years, of two saphenous vein harvesting techniques for CABG; no touch (NT) versus conventional (C). DESIGN: In a randomized study, 49/52 in group NT and 44/52 in group conventional were evaluated for reangina, myocardial infarction, new revascularization, functional class, risk factors and medical treatment. The vein grafts and the native coronary arteries were correlated to the occurrence of reangina. RESULTS: There were significantly more patients free from angina and in NYHA class I (67.3 versus 43.2%; p =0.02) in group NT compared to group C. No cardiac death was found in group NT versus three in group C. There were trends towards fewer patients with cardiac death or myocardial infarction (3.8 vs. 13.4%; p =0.16), more patients free from angina (75.5 vs. 63.6%; p =0.26) and fewer patients with graft occlusion (24.3 vs. 43.2% (p =0.14) in group NT. CONCLUSIONS: The results of the NT-technique are encouraging with no cardiac deaths, significantly more asymptomatic patients and a trend towards impact on hard clinical endpoints compared to the conventional technique.

The no-touch technique of harvesting the saphenous vein for coronary artery bypass grafting surgery.

A new 'no-touch' (NT) technique of saphenous vein (SV) preparation for coronary artery bypass grafting (CABG) surgery was developed where the vein is harvested with a pedicle of surrounding tissue, which protects the vein from spasm therefore obviating the need for distension. The adventitial layer and the structures contained within the cushion of surrounding tissue possess both mechanical and functional properties that protect the vein from spasm and ischemia. In addition, the surrounding tissue supports excessively long vein grafts and prevents kinking. A detailed description of the technique is presented and this is the first time we publish the technique as a videoclip.

Alloimmunization in pregnancy during the years 1992-2005 in the central west region of Sweden.

OBJECTIVES: To study the incidence of red cell immunization and to evaluate the use of low-risk invasive procedures in the management of alloimmunized during pregnancy. DESIGN: A 14-year retrospective study of all immunized mothers and their newborns. Population. All reported alloimmunizations between the years 1992 and 2005 in our catchment area were examined. METHODS: Background factors, maternal antibody classification, antibody titers, anti-D quantitation, procedures and maternal treatments instituted during pregnancy, fetal outcome and treatment of the newborn were evaluated. RESULTS: There were 78,145 deliveries in the region. Alloimmunization during pregnancy was detected in 0.4% of all pregnancies, excluding ABO immunizations. A significant alloimmunization (titer level > or =8) was detected in 0.16%. Anti-D immunizations were responsible for 60% of significant immunizations followed by anti-Fy(a) in 10%, anti-c in 7% and anti-K in 4%. Maternal plasma exchange and high-dose intravenous immunoglobulin were used as low-risk invasive treatments in 12 cases. Delivery was in > or =38 weeks in 93% of cases. Twenty-nine newborns were treated with exchange transfusions (ETs) after delivery, whereof 21/29 were due to anti-D, seven due to anti-c and anti-E and in one case anti-Fy(a). No deaths occurred due to severe alloimmunization. CONCLUSION: Anti-D still accounts for the most severe immunizations and for most of the cases where ET was necessary. Low-risk invasive techniques to evaluate and treat pregnancies complicated by alloimmunization seem possible and accurate, avoiding invasive procedures that may exacerbate the immunization during pregnancy.

Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial.

OBJECTIVE: Conventional harvesting of the saphenous vein in coronary artery bypass surgery produces vessel damage that contributes to graft failure. A novel "no touch" technique provides high short- and long-term patency rates. METHOD: This randomized longitudinal trial compares graft patency of two patient groups undergoing coronary artery bypass surgery. Conventional: 52 patients had their veins stripped, distended, and stored in saline solution. No-touch: 52 patients had veins removed with surrounding tissue, not distended, and stored in heparinized blood. Angiographic assessment was performed at mean time 18 months after the operation in 46 patients in the conventional group and 45 patients in the no-touch group and repeated at mean time 8.5 years in 37 patients from both groups. RESULTS: The distribution of the grafts to the recipient coronary arteries regarding their size and quality was similar in both groups. The angiographic assessment at 18 months postoperatively showed 89% conventional versus 95% no-touch grafts were patent. Repeated angiography at 8.5 years showed a patency rate for the conventional group of 76% and 90% for the no-touch group (P = .01). The multivariate analysis showed that the most important surgical factors for graft patency were the technique of harvesting (odds ratio= 3.7, P = .007) for the no-touch versus the conventional technique and the vein quality before implantation (odds ratio = 3.2, P = .007) for veins that were of good quality. By comparison the patency of the thoracic artery grafts was 90%. CONCLUSION: Harvesting the saphenous vein with surrounding tissue provides high short- and long-term patency rates comparable to the left internal thoracic artery.

Preparation of the saphenous vein for coronary artery bypass grafting: a new technique "no touch" that maintains the vein wall integral and provides high immediate patency

OBJETIVO: O objetivo deste trabalho é apresentar uma nova técnica "no touch" de preparo da veia safena e sua importância clínica. Esta nova técnica consiste na retirada da veia safena do seu leito, juntamente com um pedículo de tecido adiposo, protegendo a veia contra espasmos e, conseqüentemente, da necessidade de distendê-la durante a operação. MÉTODO: O estudo foi realizado em dois tempos: 1) Inicialmente, foi realizado um estudo prospectivo e randomizado, envolvendo 156 pacientes que foram submetidos à operação de revascularização miocárdica. Neste estudo nós comparamos a técnica "no touch" (NT) com duas outras: a convencional (C) e a intermediária (I). Foi feita uma avaliação detalhada da morfologia endotelial, utilizando a microscopia eletrônica, enquanto que a perviabilidade das pontes foi determinada com um exame angiográfico executado num período médio de 18 meses após a operação. 2) Finalmente, a enzima óxido nítrico síntase (NOS) foi identificada com ajuda do estudo imunohistoquímico e também pela localização auto-radiográfica de (3H)-L- Nitro-Arginina (NOARG). RESULTADOS: A avaliação morfológica mostrou integridade endotelial de 97 por cento nas veias que foram tratadas pela técnica NT; enquanto quase metade da superfície endotelial das veias tratadas pelas outras duas técnicas exibiu ausência de células endoteliais. O exame angiográfico revelou perviabilidade de 95,4 por cento para as pontes do grupo NT, 88,9 por cento para as pontes do grupo (C) e 86,2 por cento para as pontes do grupo (I). O estudo imunohistoquímico revelou a presença de NOS nas três camadas que compäem a parede da veia quando, as mesmas, foram tratadas pela técnica NT. Por outro lado, foi observada uma elevada redução desta enzima nas veias que foram tratadas pela técnica (C). A análise auto-radiográfica confirmou os resultados imunohistoquímicos. CONCLUSAO: A integridade endotelial e a atividade da enzima óxido nítrico síntase foram melhor mantidas com o uso da técnica NT no preparo da veia safena. A atividade vasodilatadora e bloqueadora da agregação plaquetária causada pelo óxido nítrico (NO) pode ser a responsável pela proteção da veia contra o espasmo, como também pela alta perviabilidade imediata da mesma. Além disso, as propriedades mecânicas providas pelo tecido gorduroso em volta da veia, contribuíram para o melhor resultado desta nova técnica.

Prognostic factors for the survival of surgically treated patients for non-small cell lung cancer.

The survival and outcome rates of 284 patients who underwent surgical treatment for non-small cell lung cancer were assessed retrospectively. Resectability rate was 94.1%, hospital mortality 3.9% (n = 11) and the mortality rates in patients who underwent pneumonectomy or lobectomy were 8.9% and 0.6%, respectively. The overall 5-year survival was 43.6%. Female gender, earlier stages of disease and a complete resection were strongly predictive for a long-term survival. Women in stage IA disease had a 5-year survival rate of 92.7%. The 5-year survival rate for patients in stages IIIA and N2 disease who underwent a complete resection was 21.9%, and 9% for those who did not undergo a complete resection. It is concluded that the best surgical results were observed in women who were operated on at an early stage of disease. A complete resection also contributed to a better outcome, even for patients in stage IIIA and N2 disease.

Improved patency in vein grafts harvested with surrounding tissue: results of a randomized study using three harvesting techniques.

BACKGROUND: The technique of harvesting the saphenous vein for coronary artery bypass grafting influences the fate of vein grafts. The patency rate of a novel "no-touch" technique in which the vein is harvested with a pedicle of surrounding tissue and not distended was compared with two other techniques. METHODS: One hundred fifty-six patients who underwent coronary artery bypass grafting were randomized to three saphenous vein harvesting groups: group C (conventional)--the vein was stripped, distended, and stored in saline; group I (intermediate)--the vein was stripped, local application of papaverine was used instead of distention, and the vessel was then stored in heparinized blood; and group NT (no-touch)--the vein was harvested with surrounding tissue, not distended, and stored in heparinized blood. Surgical and clinical factors that might influence graft occlusion were recorded. One hundred twenty-seven vein grafts in group C, 116 in group I, and 124 in group NT, as well as 118 left internal mammary artery grafts, were angiographically assessed at 18 months mean follow-up time. RESULTS: The vein graft patency was 88.9% in group C, 86.2% in group I, and 95.4% in group NT. There was a statistically significant difference between the patency of the single-vein grafts in NT and the other two groups (p = 0.025). The higher the flow, the better the patency irrespective of the technique used. A higher attrition rate was found in vein segments taken from the knee area in group I. Poor vein quality affected patency in all groups. Forty-seven of all 51 sequential grafts (92.2%) were patent. The patency of left internal mammary artery grafts was 108 of 118 (91.5%). CONCLUSIONS: We conclude that preservation of the surrounding tissue of the saphenous vein using this no-touch technique abolishes venospasm intraoperatively and plays an important role in maintaining vein graft function and patency.

Localization of nitric oxide synthase in saphenous vein grafts harvested with a novel "no-touch" technique: potential role of nitric oxide contribution to improved early graft patency rates.

OBJECTIVE: The use of the saphenous vein in coronary artery bypass graft surgery is associated with high 1-year occlusion rates of as much as 30%. A new "no-touch" technique of saphenous vein harvesting in which the vein is harvested with a pedicle of surrounding tissue and not distended may result in improved early patency rates. We hypothesize that nitric oxide synthase is better preserved with the no-touch technique, and the aim of this study was the investigation of whether nitric oxide synthase distribution and quantity in saphenous veins harvested with the no-touch technique differ from those veins harvested with the conventional technique. The separate contribution of perivascular tissue removal and distension to alterations in nitric oxide synthase was also studied. METHODS: Segments of 10 saphenous veins were harvested from 10 patients who underwent coronary artery bypass grafting surgery with the no-touch and conventional techniques. Samples were also taken from segments that were stripped of surrounding tissue but not distended. Nitric oxide synthase distribution was studied with reduced nicotinamide adenine dinucleotide phosphate--diaphorase histochemistry, and staining was quantified with image analysis. Immunohistochemistry was used for the identification of specific nitric oxide synthase isoforms, and immunomarkers were used for the identification of associated cell types. RESULTS: Nitric oxide synthase content was higher in no-touch vessels as compared with conventionally harvested vessels (35.5%; P <.05, with analysis of variance). This content was associated with endothelial nitric oxide synthase on the lumen while all three isoforms were present in the media. In the intact adventitia of no-touch vessels, all three isoforms of nitric oxide synthase were also present, associated with microvessels and perivascular nerves. Perivascular tissue stripping and venous distension both contribute to the reduced nitric oxide synthase in conventionally harvested veins. CONCLUSION: The new no-touch technique of saphenous vein harvesting preserves nitric oxide synthase, which suggests that improved nitric oxide availability may be an important mechanism in the success of this technique.