Management during reoperation of aortocoronary saphenous vein grafts with minimal atherosclerosis by angiography.

The proper management of saphenous vein grafts showing minimal angiographic evidence of atherosclerosis at the time of reoperation for progressive atherosclerosis in the native coronary circulation or for severe atherosclerosis in other saphenous vein grafts is uncertain. Following the occlusion of vein grafts in 2 patients 7 and 12 years after operation but only 2 years after arteriography demonstrated no major abnormalities in the grafts, we adopted a policy of elective replacement of all saphenous vein grafts, irrespective of angiographic findings, when reoperation was necessary 5 or more years after the initial operation. Between July, 1984, and May, 1985, 16 patients had repeat coronary artery bypass grafting 6 to 13 years (mean, 9 years) after the initial procedure. Complete revascularization was carried out in all patients. In each, it included replacement of at least 1 saphenous vein graft showing no severe obstruction (less than 30% of the luminal diameter) and no (5 patients), minimal (8), or moderate (3) luminal irregularities by angiography. By pathological examination, 3 of the grafts had minimal, 5 had moderate, and 8 had severe atherosclerotic changes present. These changes were generally more diffuse than those observed by angiography. Because angiography underestimates the severity of the atherosclerotic degeneration in saphenous vein grafts and because of the propensity of the atherosclerotic disease to progress at an unpredictable rate, we recommend routine replacement of all saphenous vein grafts at the time of reoperation if done 5 or more years after the initial procedure.