Propofol partially attenuates complete freund's adjuvant-induced neuroinflammation through inhibition of the ERK1/2/NF-κB pathway.

Peripheral inflammation in male C57BL/6 mice was induced by intraplantar injection of 20 µL complete freund's adjuvant (CFA) in the left hind paw. Mice were randomly divided into three groups: Sham, CFA, and propofol+CFA. Mechanical allodynia was assessed by von Frey analysis, and heat hyperalgesia was detected by exposure of the plantar surface to a beam of radiant heat. Propofol significantly attenuated the severity and duration of CFA-induced pain hypersensitivity, heat hyperalgesia, and paw edema. Propofol inhibited CFA-induced microglia activation, and markedly decreased CFA-induced ionized calcium binding adapter molecule 1 (IBA-1) expression. Propofol inhibited CFA-induced expression of p-extracellular signal-regulated kinase1/2 (p-ERK1/2) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) p65, as demonstrated by Western blot analysis. In addition, 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide assays indicated that propofol had no cytotoxic effect on BV2 microglia cells. Reverse transcription-quantitative-polymerase chain reaction and enzyme-linked immunosorbent assay results demonstrated that propofol attenuates CFA-induced tumor necrosis factor-α (TNF-α), interleukin (IL)-6, and IL-1ß production in the spinal cord as well as in BV2 cells. Taken together, these results demonstrate that propofol attenuates CFA-induced neuroinflammation (TNF-α, IL-6, and IL-1ß expression) through a mechanism that involves activation of ERK1/2/NF-κB signaling pathway.

One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery.

BACKGROUND: To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. METHODS: Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass. RESULTS: No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75-64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3). CONCLUSIONS: Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

Oral hygiene and periodontal conditions in the Chinese patients with aortic aneurysm.

BACKGROUND: This cross-sectional study aims to evaluate the association of periodontal conditions and oral hygiene habits in the Chinese patients with an aortic aneurysm (AA). METHODS: A questionnaire and periodontal examinations were carried out in the AA patients and non-AA volunteers recruited from the Center for Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University between August 2011 and June 2016. General information (e.g., height and weight), history of systemic diseases, and oral hygiene habits (e.g., brushing methods and regular oral examinations) were collected in the self-reported survey. Periodontal examinations, such as plaque index and bleeding index, were conducted in all the subjects. The correlation between periodontal indices and AA was further explored using univariate and multivariate analyses. RESULTS: Our analyses revealed that 87.6% of AA patients have chronic periodontitis, which is significantly higher than that of the non-AA patients (55.8%). In addition, AA patients demonstrated more severe periodontal damages with 69.3% moderate and severe periodontitis, compared to only 16.0% in the non-AA group. Using AA as the dependent variable and all the potential risk factors as covariates (e.g., gender, age, smoking, obesity, diabetes, hypertension, and hyperlipidemia), a logistic regression analysis was performed to show clinical attachment loss (CAL) being an independent risk factor for AA (OR = 2.309, 95% CI: 1.623-3.284, p = 0.000). In comparison with the non-AA patients, more AA patients have poor oral hygiene habits and don't have regular dental appointments for supra-gingival cleaning. CONCLUSION: Poor periodontal condition and dental hygiene were identified in the AA patients, suggesting that periodontitis-induced CAL may play a role in AA disease mechanisms.

Aorta-Iliac Bypass in Thoracoabdominal Aortic Aneurysm Repair in Young Chinese Patients.

BACKGROUND: Many surgical methods of thoracoabdominal aortic aneurysm repair (TAAAR) have been introduced over the past several decades, with varying degrees of success. We developed an aorta-iliac bypass technique to treat thoracoabdominal aortic aneurysm (TAAA) in young Chinese patients. The aim of this study is to evaluate the results of this technique intraoperatively and postoperatively. METHODS: From June 2014 to March 2015, 28 patients underwent TAAAR using aorta-iliac bypass technique. A four-branched tetrafurcate graft was used. Two branches of the graft are sutured to bilateral common iliac arteries in an end-to-side fashion. The trunk of the graft was sutured to the proximal descending aorta in an end-to-end fashion. Then aorta-iliac bypass was established, and the lower extremities, viscera organ and spinal cord (SC) obtained perfusion from proximal descending aorta via the bypass graft. The thoracic and abdominal aorta were clamped in a staged fashion. The patent segmental arteries (SAs), and visceral arteries (coeliac trunk, superior mesenteric arteries, and renal arteries) were reattached sequentially. Evoked potential (EP) monitoring was adopted to assess the SC ischaemia throughout the procedure. The postoperative outcomes and follow-up results of this technique were evaluated. RESULTS: There was no in-hospital mortality. Complications included acute kidney dysfunction and pulmonary haemorrhage in one case (3.6%) each. The SAs were reattached in all cases. The EP wave disappeared after proximal descending aorta was clamped, and gradually recovered after the patent SAs reattached. The median follow-up after operation was eight months (range, 1-10 months). There was no delayed neurologic deficit or late death. CONCLUSIONS: Thoracoabdominal aortic aneurysm repair using aorta-iliac bypass may be a simple and safe choice for young Chinese patients with thoracoabdominal aortic aneurysms.

[Significance of intraoperative precise management on intracavitary treatment for pulmonary thromboembolism].

OBJECTIVE: To compare cardiac adverse events, clinical outcomes and mid-and-long-term effects among massive and sub-massive pulmonary embolism (PE) patients under different periodswho received thrombus fragmentation by pigtail catheter. METHODS: Two groups of patients who receivedthrombusfragmentation bypigtail catheter in different periods were analyzed retrospectively. Group E: 38 cases received therapy from July 2004 to October 2009 with local anesthesia; Group P: 64 cases with general anesthesia from March 2010 to December 2014. All patients were confirmedPEby CT and angiography. Parts of patients with deep vein thrombosis (DVT) received inferior vena cava filter placement 3 days later. The patients were followed up for 6-24 months after discharge. Cardiac adverse events, clinical outcomes during the thrombusfragmentation process, and mid-and-long-term effects were compared between the two groups. RESULTS: There were no significant differences in preoperative clinical data betweenthe two groups (P>0.05). Compared with group E, clinical warning events were significantly improved in group P (odds ratio(OR): 1.24, 98.3, 1.45, 2.50; P<0.05). Within group P, there were significant differences inarterial oxygen partial pressure (PaO2) [(98.3±8.7)vs(81.3±7.1)], mean pulmonary artery pressure (mPAP) [(25.3±7.9)vs(37.2±7.6)], heart rate (HR) [(94.3±7)vs(122±9)], airway resistance [(16.7±1.6)vs (22.5±2.1)] and mean arterial pressure (MAP) [(53.4±7)vs(42.5±6)] before and after thrombus fragmentationtreatment (P<0.05). The incidence of congestive heart failure and pulmonary arterial hypertension associated with chronic pulmonary thromboembolism (CPEPH) during follow-up were significantly different between group P andgroup E (P<0.05). CONCLUSION: Thrombus fragmentation by pigtail catheter with intraoperativeprecise management under general anesthesia can reduce cardiac adverse events andimprove the mid-and-long-term effects among PE patients.

[Effect of aorta-iliac bypass total thoracoabdominal aorta aneurysm repair to spinal cord function].

OBJECTIVE: To evaluate the effect of aorta-iliac bypass total thoracoabdominal aorta aneurysm repair to spinal cord function. METHODS: This was a prospective study. From June 2014 to April 2015, 31 patients underwent total thoracoabdominal aorta aneurysm repair were treated with aorta-iliac bypass technique. There were 23 male and 8 female patients with a mean age of (36±12) years. A 4-branched tetrafurcate graft was used. The aorta-iliac bypass was established, then distal descending aorta was perfused in a retrograde fashion via bypass graft. Thoracic and abdominal aorta were replaced in a staged fashion. Evoked potentials (EP) monitoring was adopted to assess the spinal cord ischemia throughout the procedure. The intraoperative evoked potentials results, clinical outcomes and follow-up results of this technique were evaluated. RESULTS: The EP wave disappeared after proximal descending aorta clamped and gradually recovered after the patent segmental arteries reattached. Motor evoked potentials disappeared for (56±18) minutes, somatosensory evoked potentials disappeared for (50±19) minutes. The EP wave was restored to normal at the end of operation in all cases. The somatosensory evoked potentials remained unchanged in 2 cases (false negative). One case died after operation. There were acute kidney dysfunction in 3 cases, and pulmonary haemorrhage in 1 case. No spinal cord injure occurred. The median follow-up after operation was 8 months (ranging from 1 to 11 months). There was no delayed neurologic deficit or relative death. CONCLUSIONS: There is a transient function loss of spinal cord during the aorta-iliac bypass total thoracoabdominal aorta aneurysm repair. But the process is reversible. The technique of the aorta-iliac bypass is practicable.

Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection?

BACKGROUND: The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. METHODS: Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. RESULTS: The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). CONCLUSIONS: PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.

Identification and surgical repair of familial thoracic aortic aneurysm and dissection caused by TGFBR1 mutation.

BACKGROUND: This study aimed at exploring the causative gene and summarizing the clinical characteristics in a Chinese thoracic aortic aneurysm and dissection (TAAD) family. METHODS: Family members were examined for features of syndromic genetic diseases by clinician and geneticist. Genomic DNA was extracted from 2 distantly related members with definite TAAD for exome sequencing. RESULTS: A pathogenic mutation (rs111426349, c.1459C >T) of transforming growth factor ß receptor 1 (TGFBR1) was confirmed, which result in the amino acid substitution p.R487W. Fourteen TGFBR1 mutation carriers were detected among 39 tested members in this family. The average age at diagnosis of aortic root dilatation or aneurysm was 23.2 ± 12.6 years (range 3-37 years). Early onset of aortic root dilatation was significant in this family without reported phenotypes. The David procedure was performed prophylactically in 3 carriers of this family. CONCLUSIONS: Familial TAAD caused by TGFBR1 mutation (c.1459C >T) was confirmed in a large Chinese Han ethnic family using exome sequencing. Aggressively prophylactic David procedure may be not necessary at a smaller aortic size in familial TAAD patients with TGFBR1 mutation and further observation is warranted.

Can EuroSCORE II predict the mortality and length of intensive care unit stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey type I aortic dissection?

BACKGROUND: EuroSCORE is a widely used objective risk scoring model. OBJECTIVE: The aim of this study was to evaluate the validation of EuroSCORE II for predicting in-hospital mortality and length of intensive care unit (ICU) stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey Type I aortic dissection. PATIENTS AND METHODS: Between February 2009 and February 2012, data from 384 consecutive patients, who underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation, were collected retrospectively. EuroSCORE II was applied to predict mortality and length of ICU stay. The C-statistic was used to test discrimination of the model. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: The in-hospital mortality was 8.07%. The mean length of ICU stay was 3.06 days. A total of 75 patients remained at ICU for 5 days or more and 42 patients for 7 days or more. EuroSCORE II did not show good discriminatory ability in predicting mortality and length of ICU stay. The C-statistic of predicting mortality, ICU stay for 5 days or more, and ICU stay for 7 days or more were 0.49, 0.56, and 0.52, respectively. The calibration was poor for predicting mortality (p < 0.001), ICU stay for 5 days or more (p < 0.001), and ICU stay for 7 days or more (p < 0.001). CONCLUSION: Although EuroSCORE II is the newest risk model for cardiac surgery, it is not accurate when it is applied for thoracic aortic surgery. A new risk evaluating system specially designed for aortic surgery should be developed in the future.

One-stage repair for stanford type B aortic dissection concomitant with cardiac diseases: open stented elephant trunk technique combined with cardiac operation.

BACKGROUND: We evaluated an open stented elephant trunk (sET) technique combined with cardiac operations for a one-stage treatment of patients with complicated Stanford type B aortic dissection (AoD) and cardiac diseases. METHODS: Between April 2007 and March 2010, 16 patients with Stanford B AoD and cardiac diseases (mean age 49.75 ± 13.42 years) underwent sET combined with cardiac operations. Under deep hypothermic cardiac arrest (DHCA), a stented graft was directly delivered via the incision of aortic arch and the proximal graft was sutured on the normal distal aortic arch wall in a continuous circumferential full-thickness fashion. The combined cardiac operations (Bentall procedure, etc.) were performed before sET implantation while cooling. RESULTS: Average time of cardiopulmonary bypass, aortic cross clamping durance, and DHCA was 131.62 ± 23.85, 64.69 ± 9.72, and 21.94 ± 3.60 minutes, respectively. There were no early deaths and no neurological complications. During a follow-up of 18.69 ± 9.94 months, computed tomographic angiography was performed in all patients. Neither endoleak nor stent shifting was observed. Retrograde type A AoD was not found during follow-up. Thrombus was formed in the false lumen from the proximal descending aorta to the diaphragmatic section. CONCLUSIONS: The open sET technique combined cardiac procedures can reliably treat Stanford type B AoD concomitant with surgical cardiac disease in a single stage.

A rare case of severe tricuspid regurgitation caused by detached stent falling into the right ventricle after transjugular intrahepatic portosystemic shunt.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is an important method to alleviate cirrhotic portal hypertension. But the falling and fracture of the stent which detaches into the heart is a potentially fatal threat. CASE PRESENTATION: We present a case of severe tricuspid regurgitation caused by detached stent falling into the right ventricle after transjugular intrahepatic portosystemic shunt. CONCLUSION: Great attention should be paid to the serious complication of stent fracture after TIPS especially when the dual stent technique is used in TIPS.

Repair of extensive thoracoabdominal aortic aneurysm with a tetrafurcate graft: midterm results of 63 cases.

OBJECTIVE: The objective is to present a method for maintaining the spinal cord blood supply and our midterm results for using a tetrafurcate graft in extensive thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: From August 2003 to October 2007, we used a tetrafurcate graft to perform repairs to TAAAs of Crawford extent II in 63 consecutive patients. The mean age of this group of patients was 39.98 +/- 10.62 years, and 46 (73%) of them were male. All of the procedures were performed under profound hypothermia with a short interval of circulatory arrest. T6 to T12 intercostal arteries were reconstructed as a "neo-intercostal artery" (N-IA) and were connected to an 8-mm sidearm of the graft to maintain the spinal cord blood supply. Visceral arteries were joined into a patch and were anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8-mm sidearm or joined to the patch. The other 10-mm sidearms were anastomosed to iliac arteries. RESULTS: With 100% follow-up, the early-mortality rate was 7.94%. The incidence of cerebral complications was 9.52%. Temporary paraplegia was observed in 2 patients, and paraparesis occurred in 1 patient. Pulmonary complication was the most common morbidity in this group (25.40%). Two patients with Marfan syndrome had N-IA artery pseudoaneurysms during follow-up. The mean survival time of this group was 50.64 +/- 2.13 months, with survival rates of 92.06% after 1 year, 88.38% after 2 years, and 86.11% after 3 years. CONCLUSION: The N-IA may play an important role in spinal cord protection, and N-IA pseudoaneurysm should be avoided in Marfan syndrome patients. The use of a tetrafurcate graft is a reliable method for TAAA repair, with satisfactory midterm results.

Massive calcification of giant left atrium in a rheumatic mitral stenosis patient: A case report.

Giant left atrium is a condition characterized by an extreme enlargement of the left atrium with a diameter more than 80 mm and it is usually associated with long standing rheumatic mitral valve disease. We present a case of giant left atrium with massive calcification in a female patient who had a history of rheumatic heart disease, severe mitral stenosis, permanent atrial fibrillation, and cerebral infarctions.

Facile synthesis of cleistetroside-2, a partially acetylated oligorhamnoside from Cleistopholis glauca and patens.

A tetrasaccharide, dodecanyl 4-O-acetyl-alpha-l-rhamnopyranosyl-(1-->3)-2,4-di-O-acetyl-alpha-l-rhamnopyranosyl-(1-->3)-4-O-acetyl-alpha-l-rhamnopyranosyl-(1-->4)-alpha-l-rhamnopyranoside (cleistetroside-2), was synthesized via '2+2' convergent strategy. Sequential regioselective 3-O-glycosylation of isopropyl 1-thio-alpha-l-rhamnopyranoside (4) with 4-O-acetyl-2,3-O-isopropylidene-alpha-l-rhamnopyranosyl trichloroacetimidate (8), and isopropyl 4-O-acetyl-2,3-O-isopropylidene-alpha-l-rhamnopyranosyl-(1-->3)-2,4-di-O-acetyl-alpha-l-1-thio-rhamnopyranoside (10) with dodecanyl 4-O-acetyl-alpha-l-rhamnopyranosyl-(1-->4)-2,3-O-isopropylidene-alpha-l-rhamnopyranoside (12), greatly facilitate the target availability.

Synthesis of a fluorescence-labeled K30 antigen repeating unit using click chemistry.

An N-dansyl-labeled K30 antigen repeating unit, [4-[5-(N,N'-dimethylamino)naphthalene-1-sulfonamine]-1H-1,2,3-triazol-1-yl]hexyl beta-D-glucopyranosyluronate-(1-->3)-alpha-D-galactopyranosyl-alpha-D-mannopyranosyl-(1-->3)-beta-D-galactopyranoside, was synthesized using click chemistry, the copper(I)-catalyzed 1,3-dipolar cycloaddition reaction of an azide and an alkyne. The target compound could further facilitate the studies of interactions among K30 oligosaccharides and proteins.

Stereoselective synthesis of jaspine B from D-xylose.

The natural cytotoxic marine compound, jaspine B, is stereoselectively synthesized from D-xylose in 11 linear steps with a 23.9% overall yield. The key step in the synthesis involves an iodine-induced debenzylation of a primary alcohol and the subsequent 2,5-cyclization to fit the required configuration of jaspine B. A preliminary bioassay shows strong inhibition activities against human MDA231, Hela, and CNE cell lines, indicating potential usage in various cancer treatments.

A Successful Three-Stage Surgical Treatment for Aortoesophageal Fistula After Thoracic Endovascular Aortic Repair and Esophageal Stent Repair.

A 39-year-old man with Stanford B aortic dissection was treated by thoracic endovascular aortic repair (TEVAR) and experienced an aortoesophageal fistula (AEF). After repeated TEVAR and esophageal stent implantation, the hematemesis did not cease although the whole thoracic descending aorta was covered by stents. A three-stage operation was performed, and an AEF 9 cm long was found during the operation. To our knowledge, this may be the largest AEF ever reported. The patient survived without adverse events.

Hyperoxia management during deep hypothermia for cerebral protection in circulatory arrest rabbit model.

As a brain protection strategy, antegrade selective cerebral perfusion (ASCP) is widely used in thoracic aorta surgery with deep hypothermic circulatory arrest (DHCA), yet the oxygen management for ASCP has never been standardized. The aim of this study was to investigate the possible neuroprotective effects of hyperoxia management during deep hyperthermia for ASCP combined with DHCA in a rabbit model. Rabbits were assigned into four groups: sham group, without cardiopulmonary bypass (CPB); DHCA group, DHCA for 80 minutes; ASCP group, ASCP combined with DHCA; and SH group, hyperoxia management combined with ASCP and DHCA. Hyperoxia management was performed when the nasopharyngeal temperature was below 22°C. Deep hypothermic circulatory arrest was initiated when nasopharyngeal temperature reached 16-18°C. Blood samples were withdrawn to determine blood gas indexes and neurobiochemical markers of damage, and brain tissues were stored for biochemical analysis. Cerebral oxygen balance was performed better in the SH group compared with the DHCA group and the ASCP group. Hyperoxia management did not increase lipid peroxidation with lower malondialdehyde levels in the SH group compared with the DHCA group and the ASCP group (p < 0.05). S100 calcium binding protein B in the SH group was lower compared with the DHCA group and the ASCP group (p < 0.05). There was no significant difference of neuron-specific enolase in the SH group compared with the sham group. Hyperoxia management during deep hypothermia provided substantial dissolved oxygen and demonstrated better cerebral protection over normoxia management.

The patency of sequential and individual vein coronary bypass grafts: a systematic review.

BACKGROUND: Saphenous vein grafts continue to be the backbone of daily coronary revascularization practice, but controversy still exists about whether to use them as an individual or sequential graft. We undertook a systematic review and meta-analysis of cohort studies to compare the midterm or long-term patency of sequential vein coronary bypass grafts with those of vein grafts. METHODS: A comprehensive search strategy was run in PubMed, Embase, the Cochrane Library, and the Chinese Biomedical Literature Database. Inclusion criteria were the following: (1) two cohorts of patients received sequential and single saphenous vein coronary bypass grafting, respectively; (2) prospective or retrospective cohort design; and (3) graft patency examined by angiography or ultrafast computed tomography. Two researchers independently performed the literature search, data extraction, and quality assessment. RESULTS: We identified 1,385 titles, reviewed 38 articles for inclusion criteria, and included 12 studies in the meta-analysis. The risk of occlusion in sequential grafts was lower (risk ratio [RR] = 0.67, 95% confidence interval [CI] 0.60 to 0.74) than that in single grafts. The risk of occlusion in side-to-side anastomoses was lower (RR = 0.52; 95% CI, 0.34 to 0.80) than that of end-to-side anastomoses for sequential vein grafts. There was no difference in occlusion between the distal end-to-side anastomoses of sequential vein grafts and those of single vein grafts (RR = 0.85; 95% CI, 0.68 to 1.06). CONCLUSIONS: The midterm and long-term patency of sequential vein grafts appears to be better than that of single vein grafts and the patency of side-to-side anastomoses appears to be better than that of end-to-side anastomoses for sequential vein grafts.