• 
• 

Three Part Question

In [patients undergoing coronary artery bypass surgery], is the use of the [cephalic vein] associated with acceptable [vein graft patency].

Clinical Scenario

You are referred a diabetic 78 yr old gentleman with left main stem disease and triple vessel disease. He has severe varicose veins in both his legs, but he has a large first diagonal artery and you would like to place 4 grafts. You would like to use the left internal mammary artery, and both radial arteries and you wonder whether you could also use a cephalic vein from his arm. You resolve to check the patency of these veins in the literature prior to proceeding.

Search Strategy

Medline 1966 to November 2006 using OVID interface,
[exp Thoracic Surgery OR Thoracic Surgery.mp OR exp Coronary Artery Bypas/ OR CABG.mp OR Cardiovascular Surgical Procedures/ ] and [upper extremity vein$.mp OR arm vein$.mp OR cephalic vein$.mp]

Search Outcome

A total of 219 papers were identified using the reported search. 7 papers documenting the patency of the cephalic vein for coronary bypass grafting and the largest series of cephalic veins for a lower extremity bypass were documented. In addition another 6 papers on lower extremity grafting with cephalic veins were briefly reviewed but not tabulated.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Licht et al, 1996, Denmark	39 patients had cephalic veins used for coronary artery bypass grafting in a 10 year period. 43 distal anastomoses. 18 had an angiographic follow up programme. Follow up 30 months (17 – 87 months)	Case series (level 4)	Cephalic Patency by Angiography at median 30 months	Patency by distal anastomoses 46%. Patency by graft 52%. In addition Intraluminal disease 39% (12/31) Mild dilatation 19% ( 6 grafts)	Small case-series 8 patients died during follow up Only 18 of 39 cephalic veins had patency assessment.
			IMA patency by angiography	100%
Wijnberg et al, 1990, Holland	40 cephalic veins in 28 patients used for coronary artery bypass grafts. (over 10 previous years) 77 distal anastomoses. 28 matched patients who had saphenous veins harvested were also compared	Case control study (level 3b)	5 year patency by digital subtraction angiography	Cephalic vein 8/17 (47%). Saphenous vein 17/22 (77%) (p=0.051)	Indication for needing arm vein 22 Varicose Veins 5 prior use 1 dwarfism Mean follow up 4.6 years. All patients were anticoagulated post-operatively.
			Symptoms	Symptomatically no difference, arm vein pts were on more anti-anginal medication (74%v/s39%)
Stoney et al, 1984, USA	56 cephalic veins from 1974 to 1982 in 28 patients used for coronary artery bypass grafts. Basilic vein from upper arm also occasionally used. Separate group of 28 patients who had saphenous vein grafts used for comparison.	Case control study (level 3b)	Patency by Angiography (Mean delay 25 months range 2mths to 9yrs)	32/56 (57%) patency of cephalic vein at 2 yrs 7 patent grafts had localised stenoses 45/57 (79%) patency of saphenous vein at mean 44mths	Poor unmatched comparison group with angiograms at a different time intervals .
			LIMA patency in same patients	15/16 (93%)
Jarvinen et al, 1984, Finland	16 cephalic vein grafts for coronary artery bypass grafts in 15 patients, performing 34 distal anastomoses. 8 male 7 females 46-77yrs Indication 13 Varicose 2 Prior use	Case series (level 4)	Patency by Angiography at mean 1.4 years post-op)	27/31(87% ) for cephalic veins. 100% LIMA patency. 3 short saphenous veins were patent	4 patients also had coronary endarterectomy.
Prieto et al, 1984, Canada	13 patients 34-66yrs Indication 13 stripping	Case series (level 4)	Patency by Angiography	24 grafts 10 patients studied 6 pts at < 9 month 9/10(90%) grafts patent 4 pts at >1yr 5/8(62%) grafts patent but additional 2 had gross stenosis	Small case-series No aspirin or anticoagulation, beta blockers in half of pts
Seifert et al, 1982, Germany	17 patients,35 grafts	Case series (level 4)	Patency by Angiography	0.3-2.1 yr mean 0.7 yr patency 23/35 66%
Faries et al, 2000, USA	520 patients who had a lower extremity bypass graft using an arm vein from 1990 to 1998. Intraoperative vein angioscopy was performed to identify and lyse valves. Fem-pop bypass grafts (33%) Popliteal-tibial (28%) 98% of operations were for limb salvage. 70% single arm vein, 30% spliced composite veins Mean follow up 25 months	Cohort study (level 2b)	Cephalic vein patency measured by continuous vein doppler	30-day = 97.0% ± 0.7%, 1-year = 80.2% ± 2.1%, 3-year = 68.9% ± 3.6%, 5-year = 54.5% ± 6.6%;	Lower limb revascularisation
Mehta et al, 1991, USA	Case study. 69 year old lady had an arteriovenous fistula formed 2 weeks prior to surgery. Short saphenous vein anastomosed to RCA and second segment to OM. In 1979	Case report (level 4)	Vein Patency	Both cephalic vein patent on angiography in 1986 and one patent in July 1990	Case report only

Comment(s)

Licht et al reported a series of 39 patients undergoing coronary artery bypass grafting(CABG) who had a cephalic vein. 18 had angiographic follow up (mean 31 months). 52% of grafts were patent, 39% of all veins had intraluminal disease, and 19% were dilated. Wijnberg et al compared a group of 28 patients who received a cephalic vein graft with a matched group who received saphenous vein grafts. At mean 4.6 year follow up, cephalic vein patency was 47% compared to 77%. Stoney et al assessed the patency of 56 cephalic or basilic vein grafts from 28 patients. 32/56(57%) grafts were patent at mean 25 months while 7(12.5%) of the patent grafts had localised stenoses. Jarvinen et al reported the patency of 16 cephalic veins in 15 patients. At a mean follow up of 1.4 years (1-42 months), 87% (27/31 distal anastomoses) were patent angiographically although 3 veins also had aneurysmal dilatation. Prieto et al examined ten patients at different intervals. The early patency of arm vein grafts in six patients studied less than 9 months after operation was 9 out of 10 grafts (90%). Four patients were followed for more than a year, after which time 5 out of 8 grafts (63%) were patent, 2 of them with gross abnormalities. Seifert et al studied 17 patients at 8 months follow up, out of 35 grafts only 23 (66%) were patent. There were attempts to address the issue of delicate thin wall and poor handling of arm veins by creating arterio-venous fistulae to arterialise the vein before using it for bypass grafting. Faries et al reported the cephalic vein graft patency of 520 lower limb bypass procedures up to 1998. Patency was assessed regularly using doppler ultrasound and interestingly on harvesting, half of the veins had an angioscopy performed and luminal integrity was assessed, resulting in 30% of veins being spliced to resect an abnormal section. The 3-year patency was 69%, and the 5-year patency was 55%. Mehta et al reported a case where two cephalic arterialised veins were used. One vein lasted at least 7 years and the other was patent at 11 years. We identified several other studies that documented the use of the cephalic vein for lower extremity bypass. We did not tabulate these but the patency was: Schulman in 64 patients, 5-year patency 31% for femoropopliteal bypass and 15% for femorotibial bypass; Holzenbein in 250 cephalic vein grafts, 3-year patency 52%; Harris in 67 patients, 68% at 5 years; Brochado-Neto in 35 cephalic veins : 42% 2-year patency; Harward in 43 patients, 49% at 3 years; Seston in 34 patients 40% 3-year patency.

Clinical Bottom Line

The patency rate seems to be in the order of 50% at around 3 years for cephalic veins used for coronary bypass grafting, and this was variable. In addition we identified only 181 cephalic veins used for coronary bypass grafting in the literature. In lower extremity bypass procedures over 900 uses of the cephalic vein have been documented but again patency seems to be around 50% at 3 to 5 years. Arterialisation of the vein using an arteriovenous fistula, and angioscopy have both been used as an attempt to improve patency in some papers. In addition, a large proportion of the reported cephalic veins for coronary grafting were used for sequential bypass grafting which may have affected patency rates. Thus in summary the patency of the cephalic vein used for coronary arterial bypass grafting is around 50% at 3 years.

References

1. Licht P, Jacobsen E, Lerbjerg G, Andersen PE, Alstrup P. Cephalic veins in coronary artery bypass surgery. European Journal of Cardio-Thoracic Surgery 1996;10(5):327-30.
2. Wijnberg DS, Boeve WJ, Ebels T, van G, I, van den Toren EW, Lie KI, Homan van der Heide JN. Patency of arm vein grafts used in aorto-coronary bypass surgery. European Journal of Cardio-Thoracic Surgery 1990;4(9):510-3.
3. Stoney WS, Alford WC, Jr., Burrus GR, Glassford DM, Jr., Petracek MR, Thomas CS, Jr. The fate of arm veins used for aorta-coronary bypass grafts. Journal of Thoracic & Cardiovascular Surgery 1984:88(4):522-6.
4. Jarvinen A, Harjula A, Mattila S, Valle M, Harjola PT. Experience with arm veins as aorto-coronary bypass grafts. Journal of Cardiovascular Surgery 1984:25(4):344-7.
5. Prieto I, Basile F, Abdulnour E. Upper extremity vein graft for aortocoronary bypass. Annals of Thoracic Surgery 1984:37(3):218-21.
6. Seifert D, Bircks W, Jehle J, Schulte HD. Aorto-coronary bypass grafts using cephalic veins. Thoracic & Cardiovascular Surgeon 1982;30(Supplement):15-6.
7. Faries PL, Arora S, Pomposelli FB, Jr., Pulling MC, Smakowski P, Rohan DI, Gibbons GW, Akbari CM, Campbell DR, LoGerfo FW. The use of arm vein in lower-extremity revascularization: results of 520 procedures performed in eight years. Journal of Vascular Surgery 2000:31(1 Pt 1):50-9.
8. Mehta S, Levine S, Margolis JR, Martin JC, Krauthamer D, Traad E. Long-term patency of arterialized cephalic vein used as a conduit for coronary artery bypass grafting. Catheterization & Cardiovascular Diagnosis 1991;23(3):208-10.
9. Schulman ML, Badhey MR. Late results and angiographic evaluation of arm veins as long bypass grafts. Surgery 1982:92(6):1032-41.
10. Holzenbein TJ, Pomposelli FB, Jr., Miller A, Contreras MA, Gibbons GW, Campbell DR, Freeman DV, LoGerfo FW. Results of a policy with arm veins used as the first alternative to an unavailable ipsilateral greater saphenous vein for infrainguinal bypass. Journal of Vascular Surgery 1996;23(1):130-40.
11. Harris RW, Andros G, Dulawa LB, Oblath RW, Salles-Cunha SX, Apyan R. Large-vessel arterial occlusive disease in symptomatic upper extremity. Archives of Surgery 1984;119(11):1277-82.
12. Brochado-Neto FC, Albers M, Pereira CA, Gonzalez J, Cinelli M, Jr. Prospective comparison of arm veins and greater saphenous veins as infrageniculate bypass grafts. European Journal of Vascular & Endovascular Surgery 2001;22(2):146-51.
13. Harward TR, Coe D, Flynn TC, Seeger JM. The use of arm vein conduits during infrageniculate arterial bypass. Journal of Vascular Surgery 1992;16(3):420-6; discussion 426-7.
14. Sesto ME, Sullivan TM, Hertzer NR, Krajewski LP, O'Hara PJ, Beven EG. Cephalic vein grafts for lower extremity revascularization. Journal of Vascular Surgery 1992;15(3):543-9.