Disruption of Graft Endothelium Correlates With Early Failure After Off-Pump Coronary Artery Bypass Surgery Jeffrey V. Manchio, BS, Junyan Gu, MD, Linda.

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Disruption of Graft Endothelium Correlates With Early Failure After Off-Pump Coronary Artery Bypass Surgery Jeffrey V. Manchio, BS, Junyan Gu, MD, Linda Romar, RN, James Brown, MD, James Gammie, MD, Richard N. Pierson, MD, Bartley Griffith, MD, Robert S. Poston, MD The Annals of Thoracic Surgery Volume 79, Issue 6, Pages 1991-1998 (June 2005) DOI: 10.1016/j.athoracsur.2004.12.054 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Endothelial assessment: Surplus segments of each saphenous vein conduit were procured intraoperatively, after vein harvest but before the completion of grafting. (Left) After sectioning, portions of the vein biopsies with endothelial disruption were identified using immunohistochemical analysis of the endothelial marker, CD3. (Right) The percentage of vessel circumference that maintained endothelial integrity was then determined using image analysis software. The Annals of Thoracic Surgery 2005 79, 1991-1998DOI: (10.1016/j.athoracsur.2004.12.054) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Coagulation testing: Blood samples were collected from each study patient immediately preoperative and postoperatively (PostCAB), on postoperative days (POD) 1 and 3. Each sample was analyzed for ex vivo platelet function using whole blood aggregometry, thrombelastography, hemostatus, and flow cytometry, and by in vitro testing of the coagulation cascade (fibrionogen, d-dimer, and INR). As illustrated by the data for whole blood aggregometry (top) and thromboelastography (bottom), no hematologic test was significantly different between patients with grafts that were all patent versus those with at least one thrombosed graft at any time point. Open bars = grafts patent (n = 106 patients); solid bars = graft failed (n = 10 patients). (TEG-MA = TEG analyzer maximum amplitude.) The Annals of Thoracic Surgery 2005 79, 1991-1998DOI: (10.1016/j.athoracsur.2004.12.054) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Status of bypass grafts: The large diameter and predictable course of the venous bypass graft offsets many of the technical obstacles encountered with native coronary imaging using multiple detector-row cardiac computed tomography (Philips Medical). Given a high level of patient acceptance, we obtained follow-up for 85% of venous bypass grafts before hospital discharge. Early graft thrombosis was detected by a proximal stump as illustrated in this representative example or by the lack of contrast in a region known to contain a bypass graft. The Annals of Thoracic Surgery 2005 79, 1991-1998DOI: (10.1016/j.athoracsur.2004.12.054) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Study population: In this study, we performed a prospective analysis of 125 patients treated with acetylsalicylic acid (325 mg orally every day) as the only antiplatelet agent after receiving a total of 390 grafts. We focused our patency analysis on the 217 vein grafts evaluated for patency. Arterial grafts and the 42 grafts were not evaluated by postoperative computed tomography angiography were excluded from this analysis. Most of these 217 vein grafts were harvested endoscopically. (CTA = computed tomography angiography; Intraop = intraoperative.) The Annals of Thoracic Surgery 2005 79, 1991-1998DOI: (10.1016/j.athoracsur.2004.12.054) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Endothelial integrity versus thrombosis: Percentage of endothelial integrity was 10.75% ± 17.56 % in the 10 vein grafts that failed compared with 51.45% ± 36.29% in grafts that remained patent on postoperative day 5 (p < 0.01). Eight of the 10 patients found to develop early vein graft thrombosis had additional vein(s) that were patent. In these eight patients, vein grafts that were patent (n = 9) were compared with the thrombosed grafts (n = 8) and endothelial integrity found to be significantly higher (43.83% ± 32.68% versus 10.75% ± 17.56%, p < 0.03). Open bars = patent vein grafts; solid bars = thrombosed vein grafts. The Annals of Thoracic Surgery 2005 79, 1991-1998DOI: (10.1016/j.athoracsur.2004.12.054) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions