An 85-year-old man presented for cardiac risk evaluation before planned femoral artery-to-distal popliteal artery bypass surgery. His medical history included ischemic cardiomyopathy (left ventricular ejection fraction, 35%), end-stage kidney disease necessitating hemodialysis, severe peripheral artery disease, and hypertension. Thirty years previously, he had undergone 4-vessel coronary artery bypass grafting.

Coronary angiograms revealed a patent saphenous vein graft (SVG) feeding 3 obtuse marginal branches (Fig. 1) and a widely patent SVG to the mid left anterior descending coronary artery (LAD) (Fig. 2). The patient had diffuse 80%-to-90% stenosis of the proximal LAD, with competitive flow suggesting severe left main disease. His mid left circumflex and proximal right coronary arteries were occluded, and his distal right coronary artery filled through left-to-right collateral vessels.

Fig. 1

Coronary angiogram shows the patent sequential saphenous vein graft (arrow) to the 1st, 2nd, and 3rd obtuse marginal (OM) branches.

Fig. 1

Coronary angiogram shows the patent sequential saphenous vein graft (arrow) to the 1st, 2nd, and 3rd obtuse marginal (OM) branches.

Fig. 2

Coronary angiograms show the A) aortotomy takeoff (arrow) of the saphenous vein graft (SVG) to the mid left anterior descending coronary artery (LAD), and B) the native LAD with the patent SVG to its mid segment. The proximal LAD has diffuse 80%-to-90% stenosis; the mid and distal segments have no substantial disease. Retrograde filling indicates severe left main disease.

Fig. 2

Coronary angiograms show the A) aortotomy takeoff (arrow) of the saphenous vein graft (SVG) to the mid left anterior descending coronary artery (LAD), and B) the native LAD with the patent SVG to its mid segment. The proximal LAD has diffuse 80%-to-90% stenosis; the mid and distal segments have no substantial disease. Retrograde filling indicates severe left main disease.

Comment

The success of coronary artery bypass grafting depends on long-term patency of the arterial and venous grafts. At 10 years, 45% to 50% of SVGs and 90% to 95% of internal mammary artery grafts remain patent.14  To our knowledge, the longest reported patency of an SVG is 33 years, in 2 separate cases.5,6  This is the 3rd case of at least 30-year patency of an SVG, and the first instance of a sequential SVG remaining patent for that length of time.

Section editor: Raymond F. Stainback, MD

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