European Journal of Cardio-thoracic Surgery 29 (2006) 511—516

www.elsevier.com/locate/ejcts

Serial angiographic follow-up of grafts one year and five years

after coronary artery bypass surgery
Kwang Ree Cho, Jun-Sung Kim, Jae-Sung Choi, Ki-Bong Kim *
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital,
28 Yeon-Gun Dong, Jong-Ro Gu, Seoul 110-744, South Korea

Received 27 July 2005; received in revised form 19 December 2005; accepted 21 December 2005; Available online 24 January 2006

Abstract

Objective: We studied retrospectively the patency of grafts after coronary artery bypass grafting (CABG) using serial angiographies performed
one year and five years after surgery. Methods: One hundred and nine patients who had available coronary angiographies at both one year and five
years after CABG were included. Morphologic changes of anastomotic sites and grafts were traced in the same group of patients using the
FitzGibbon grading system. Results: The arterial graft patency rate (FitzGibbon grade A + B) was significantly higher than the saphenous vein
grafts at both one year (98.0% vs 82.4%, p < 0.001) and five years (90.7% vs 80.2%, p = 0.006) after surgery, respectively. The arterial graft patency
rate was superior to vein grafts in the left anterior descending coronary artery territory at both one year (97.5% vs 82.0%, p = 0.001) and five years
(90.9% vs 78.0%, p = 0.042) postoperatively. Other territories showed similar patency rates between arterial and vein grafts. The vein graft
patency rate at five years postoperatively was lowest in the right coronary territory when compared with other territories. When the patency
pattern was compared between postoperative years 1 and 5, the proportion of FitzGibbon grade B grafts increased significantly in the vein grafts
(3.1% vs 7.5%, p = 0.002), while that of arterial grafts remained stable (8.6% vs 7.3%, p = 0.774). When the graft patency at postoperative year 5
was compared between patients with recurrent angina and those without, the patients with recurrent angina showed a higher proportion of
FitzGibbon grade B grafts (19.2% vs 4.8% in arterial grafts, p = 0.023; 20.5% vs 4.8% in vein grafts, p = 0.003) and lower grade A grafts (65.4% vs
86.4% in arterial grafts, p = 0.019; 43.6% vs 78.2% in vein grafts, p < 0.001), and a lower vein graft patency rate (64.1% vs 83.0%, p = 0.014).
Conclusions: The arterial graft patency rate was significantly higher than that of saphenous vein grafts, especially in the left anterior descending
coronary artery territory, at one year and five years postoperatively. The decreased patency rate of the vein grafts, along with insulin-dependent
diabetes mellitus, were associated with angina recurrence.
# 2006 Elsevier B.V. All rights reserved.

Keywords: Coronary artery bypass grafting (CABG); Angiography; Ischemic heart disease

1. Introduction 2. Patients and methods

Several studies have investigated the patency rates of 2.1. Patients

grafts after coronary artery bypass grafting (CABG) and
shown that arterial grafts have superior patency than vein
grafts [1—4]. However, most of these studies were cross-
sectional investigations performed at a defined point in time
after CABG. The aims of this study were (1) to compare the
patency of arterial and saphenous vein grafts in patients who
had received coronary angiography at both one year and five
years after CABG, (2) to evaluate the graft patency rates
based on target territories, and (3) to elucidate the
predictors for angina recurrence.
* Corresponding author. Tel.: +82 2 2072 3482; fax: +82 2 747 5245.
E-mail address: kimkb@snu.ac.kr (K.-B. Kim).
1010-7940/$ — see front matter # 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2005.12.026
Of the 197 patients who underwent isolated conventional
CABG between January 1995 and December 1997, 109 (55.3%)
patients who received both one year and five years follow-up
coronary angiographies were included for evaluation of the
anastomotic sites and patency of the grafts. Patients who
required concomitant cardiac operations, who had early
(<30 days) or late (>30 days) mortality after CABG, or who
did not receive both follow-up coronary angiographies were
excluded from this study. Written, informed consent was
obtained from each participating patient, and Institutional
Review Board approval was provided.
The patients were 78 males and 31 females with a
mean age of 59  9 years at the time of surgery. Preope-
rative coronary angiography revealed one-vessel disease in
5 patients, two-vessel disease in 19 patients, three-vessel
512 K.R. Cho et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 511—516

Table 1 trunk to <50%, or a graft that was functionally impaired by

Patient preoperative characteristics and risk factors
new stenosis equivalent to >50% of the impairment before
Patient characteristics N the operation, which was proximal or distal, as relevant to
Sex (male:female) 109 (78:31)
the anastomosis site. Grade O was defined as occlusion. The
Age (years) 59  9 grade for the entire graft was determined by the lowest of
LVEF (%) 58  10 the three site grades.
Unstable:stable 83:26
Risk factors, N (%) 2.5. Statistical analysis
Smoking 56 (51.4)
Hypertension 54 (49.5) Statistical analysis was performed with the Statistical
Diabetes mellitus 32 (29.4)
Hyperlipidemia 27 (24.8)
Analysis System software package (version 11.0; SAS
Age > 70 years 9 (8.3) Institute, Cary, NC, USA). The patency rates of the arterial
LVEF < 40% 7 (6.4) and vein grafts were compared using the x2-test. The graft
Angiographic diagnosis, N (%) patency rate and the proportion of FitzGibbon grade B grafts
Three-vessel disease 64 (58.7) between the one-year and five-year coronary angiographies
Two-vessel disease 19 (17.4) were compared using the x2-test with McNemar examination.
One-vessel disease 5 (4.6) The freedom from graft occlusion during the follow-up period
LMD with or without peripheral disease 21 (19.3)
was calculated using the Kaplan—Meyer survival curve, and
LMD: left main coronary artery disease; LVEF: left ventricle ejection fraction. the factors affecting graft occlusion were analyzed using the
Cox proportional hazard model. The factors affecting angina
disease in 64 patients, and left main coronary artery disease recurrence were analyzed using the simple logistic regression
with or without peripheral coronary artery disease in 21 analysis.
patients. Eighty-three patients (76%) had unstable angina, 32 All results are expressed as mean  standard deviation; a
patients (29%) had diabetes mellitus, and 9 patients (8%) p value < 0.05 was considered significant.
were older than 70 years (Table 1).
All the operations were performed by a single surgeon (K.-
B.K.). 3. Results

2.2. Operation The average number of distal anastomoses per patient was
3.5  1.1. Of the 378 distal anastomoses performed, internal
Conventional CABG was performed with single-stage thoracic arteries (ITA) were used in 144 (38.1%), radial
venous cannula drainage, moderate systemic hypothermia, arteries were used in 7 (1.9%), and saphenous veins were used
and antegrade or retrograde cold-blood cardioplegic solu- in 227 (60.1%). Bilateral ITAs were used in 21 of 109 (19.3%)
tion. The patients were heparinized with an initial dose of patients. The sequential anastomotic technique was per-
heparin (3 mg/kg) and periodically supplemented with formed in 42 of 151 (27.8%) distal arterial grafts and in 77 of
additional doses to maintain an activated clotting time of 227 (33.9%) saphenous vein grafts.
>480 s. At the end of the procedure, 1 mg of protamine per
each milligram of heparin was given. 3.1. Patency of grafts at one year and five years
postoperatively (Table 2)
2.3. Postoperative follow-up
The one-year patency rate (FitzGibbon grade A + B) was
All the patients received aspirin (300 mg/day) post- 98.0% for arterial graft (including 100%, 7/7 for radial
operatively and follow-up examinations at three-month arteries) which was superior to the one-year patency rate of
intervals after discharge. Follow-up coronary angiographies 82.4% for saphenous vein grafts ( p < 0.001). The grade A
were performed at one year (14  4 months) and five years patency rate was 89.4% for arterial grafts (including 85.7%,
(64  9 months) after CABG. Patients received one year and 6/7 for radial arteries), which was also higher than the grade
five years follow-up coronary angiographies regardless of any A patency rate of 79.3% for saphenous vein grafts ( p = 0.011).
angina symptoms, but angiographies were not performed in The proportion of FitzGibbon grade B grafts was higher in the
patients with renal dysfunction or in patients who refused the
procedure. Follow-up coronary angiography included four- Table 2
Graft patency rate at one year and five years postoperatively
plane selective coronary and bypass graft angiography. One
physician initially reviewed all the coronary angiograms and FitzGibbon grade Arterial graft (%) Vein graft (%) p
consensus was reached after review. A One-year 135/151 (89.4) 180/227 (79.3) 0.011
Five-year 126/151 (83.4) 165/227 (72.7) 0.018
2.4. Grading of anastomoses
B One-year 13/151 (8.6) 7/227 (3.1) 0.032
Five-year 11/151 (7.3) 17/227 (7.5) 1.000
All of the anastomoses were reviewed and graded as
O One-year 3/151 (2.0) 40/227 (17.6) <0.001
described by FitzGibbon and associates [5] as follows. Grade Five-year 14/151 (9.3) 45/227 (19.8) 0.006
A was defined as an excellent graft with unimpaired run-off.
Patency (A + B) One-year 148/151 (98.0) 187/227 (82.4) <0.001
Grade B was defined as a graft displaying stenosis that
Five-year 137/151 (90.7) 182/227 (80.2) 0.006
reduced the caliber of the proximal or distal anastomosis or
 K.R. Cho et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 511—516
arterial graft group than in the vein graft group (8.6% vs 3.1%,
p = 0.032).
The five-year patency rate (FitzGibbon grade A + B) was
90.7% for arterial grafts (including 100%, 7/7 for the radial
arteries), which was higher than the 80.2% rate for saphenous
vein grafts ( p = 0.006). The grade A patency rate was 83.4%
for arterial grafts (including 85.7%, 6/7 for radial arteries),
which was also higher than the grade A patency rate of 72.7%
for saphenous vein grafts ( p = 0.018). The proportion of
grade B grafts was similar in both arterial and vein grafts at
five years postoperatively (7.3% vs 7.5%, p = 1.000).
3.2. Graft patency rates (Table 2)
The arterial graft patency rate decreased significantly
from one year to five years after surgery (98.0% to 90.7%,
p = 0.001) while the vein graft patency rate remained stable
(82.4% to 80.2%, p = 0.063). However, the proportion of grafts
with FitzGibbon grade B increased in vein grafts (3.1% to
7.5%, p = 0.002) while grade B arterial grafts (8.6% to 7.3%,
p = 0.774) remained stable between one year and five years.
3.3. Comparison of graft patency rates according to
target territories (Table 3)
We defined target territories as the left anterior descending
coronary artery (LAD) territory, which includes the LAD or
diagonal branches; the left circumflex coronary artery (LCX)
territory, which includes the ramus intermedius or obtuse
marginal branches; and the right coronary artery (RCA)
territory, which includes the RCA, posterior descending artery,
or posterolateral branch. Most of the arterial grafts were used
in the LAD or LCX territories. In the LAD territory, the patency
rate of vein grafts was inferior to arterial grafts at both one
year and five years (82.0% vs 97.5% at one year, p = 0.001;
78.0% vs 90.9% at five years, p = 0.042). In the LCX territory, the
patency rate of vein grafts was not statistically different from
that of arterial grafts (87.2% vs 100% at one year, p = 0.122;
87.2% vs 87.5% at five years, p = 1.000). In the RCA territory,
Table 3
Comparisons of graft patency rates according to target lesions
Target Time Arterial graft (%)
ITA (%)
LAD territory a One-year
117/120 (97.5)
Five-year
109/120 (90.8)
LCX territory b One-year
21/21 (100)
Five-year
18/21 (85.7)
RCA territory c One-year
3/3 (100)
Five-year
3/3 (100)
LAD: left anterior descending coronary artery; LCX: left circumflex coronary artery; RCA: right coronary artery.
a
LAD territory: left anterior descending artery and diagonal branches.
b
LCX territory: ramus intermedius and obtuse marginal branches.
c
RCA territory: right coronary artery, posterior descending coronary artery and posterolateral branches.
*
p = 0.023 when compared with LCX territory.
513
the patency rate was similar between the vein and arterial
grafts (77.1% vs 100% at one year, p = 0.334; 73.5% vs 100% at
five years, p = 0.330), although arterial grafting was used in
the RCA territory in only a small number of patients. The
arterial graft patency rate was similar in all territories at one
year and five years after surgery. The vein graft patency rate
was also similar in all territories at one year; but it was lowest
in the RCA territory at five years after surgery (73.5%, 61/83)
when compared with other territories (78.0% in LAD territory,
p = 0.680; 87.2% in LCX territory, p = 0.023).
3.4. Effect of grafting techniques on graft patency rate
Arterial sequential anastomoses were made in 42 (27.8%)
of the 151 distal anastomoses. The patency rate of the
sequential anastomoses at one year and five years was 97.6%
(41/42) and 90.5% (38/42), respectively. There were no
differences in patency of arterial sequential grafting
compared with individual grafting (98.2%, 107/109 at one
year, p = 1.000; and 90.8%, 99/109 at five years, p = 1.000).
The patency rates of sequentially grafted veins were also
similar to those of individual grafts (87.0%, 67/77 vs 80.0%,
120/150 at one year, p = 0.204; 84.4%, 65/77 vs 78.0%, 117/
150 at five years, p = 0.294).
In 46 of 151 (30.5%) distal anastomoses using arterial
grafts, proximal inflow was supplied by an arterial Y-
composite graft. Composite vein grafts for proximal inflow
were used in 6 of 227 distal anastomoses. The patency rates
of the distal anastomoses in the composite graft groups were
similar to those of non-composite graft groups at both one
year and five years after surgery.
3.5. Fate of FitzGibbon grade B grafts
There were 13 FitzGibbon grade B arterial grafts at one
year postoperatively. Eleven of the grafts were found to be
slender and the other two showed anastomotic stenosis.
Seven of 13 became occluded while six remained grade B at
five years postoperatively. Six of the seven occluded arterial
Vein graft (%) p
RA (%)
118/121 (97.5) 41/50 (82.0) 0.001
1/1 (100)
110/121 (90.9) 39/50 (78.0) 0.042
1/1 (100)
24/24 (100) 82/94 (87.2) 0.122
3/3 (100)
21/24 (87.5) 82/94 (87.2) 1.000
3/3 (100)
6/6 (100) 64/83 (77.1) 0.334
3/3 (100)
*
6/6 (100) 61/83 (73.5) 0.330
3/3 (100)
514 K.R. Cho et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 511—516
Table 4
Graft patency at five years postoperatively in patients with recurrent angina
Graft Grade Angina (+), N = 20 Angina ( ), N = 89
Arterial A 17/26 (65.4) 108/125 (86.4)
graft (%) B 5/26 (19.2) 6/125 (4.8)
O 4/26 (15.4) 11/125 (8.8)
A+B 22/26 (84.6) 114/125 (91.2)
Vein A 17/39 (43.6) 147/188 (78.2)
graft (%) B 8/39 (20.5) 9/188 (4.8)
O 14/39 (35.9) 32/188 (17.0)
A+B 25/39 (64.1) 156/188 (83.0)
grafts (grade O) were associated with moderate stenosis
(<80%) of the native vessel. Four newly occluded arterial
grafts at five years postoperatively were all associated with
moderate stenosis of the native vessel.
There were seven FitzGibbon grade B vein grafts at one
year postoperatively. All seven demonstrated segmental
narrowing in the trunk of the vein grafts. All seven remained
as grade B grafts at five years postoperatively; however, two
of them required percutaneous interventions because of
recurrent angina. Five newly occluded vein grafts at five
years postoperatively were grade A grafts at one year
postoperatively.
3.6. Freedom from graft occlusion
Freedom from arterial graft occlusion at one year, three
years, and five years postoperatively were 99.1%, 96.2%, and
94.8%, respectively. Freedom from SVG occlusion at one year,
three years, and five years postoperatively were 90.3%,
65.6%, and 64.3%, respectively. Cox proportional hazard
model failed to define any risk factors for graft occlusion in
both arterial and vein grafts.
3.7. Recurrence of angina and graft patency (Table 4)
During the follow-up period, 20 patients experienced the
recurrence of angina. When graft patency was compared
between patients with recurrent angina and those without, the
main differences were higher FitzGibbon grade B grafts (19.2%
vs 4.8% in arterial grafts, p = 0.023; 20.5% vs 4.8% in vein grafts,
p = 0.003) and lower grade A grafts (65.4% vs 86.4% in arterial
grafts, p = 0.019; 43.6% vs 78.2% in vein grafts, p <0.001), and
a lower vein graft patency rate (64.1% vs 83.0%, p = 0.014). Of
the 20 patients with recurrent angina, 5 underwent percuta-
neous interventions (two for new native lesions, two for vein
graft lesions, and one for LAD with occluded ITA). One patient
without recurrent angina underwent percutaneous interven-
tion for a progressed native coronary lesion. When the
predicators for angina recurrence were analyzed, multivariate
analysis identified insulin-dependent diabetes mellitus as the
only predictor for angina recurrence (odds ratio: 14.278,
p = 0.007) among the patient variables.
4. Discussion
This study demonstrated four main findings. First, the
patency rates were significantly higher in arterial grafts than
in vein grafts at both one year and five years after CABG.
Second, the benefit of using arterial grafts was most
p prominent in the LAD territory at one year and five years
0.019
after surgery. Third, the decreased patency rate of the vein
0.023 grafts, along with insulin-dependent diabetes mellitus, were
0.293 associated with angina recurrence. Fourth, most of the
0.293 decrease in patency of arterial grafts was associated with
<0.001 moderate stenosis of the native coronary artery and most of
0.003 the decrease in patency of vein grafts was associated with
0.014 graft disease itself.
0.014
The lower graft patency rate of the saphenous vein than
with the ITA has prompted surgeons to use arterial grafts in
CABG to improve the long-term outcome of myocardial
revascularization. However, the saphenous vein is still
being utilized frequently as a graft in CABG. In addition to
immediate postoperative graft failure caused by throm-
bosis, the long-term patency of the saphenous vein graft
can be affected by fibro-intimal hyperplasia during the first
year after surgery [6] and by atherosclerosis beyond the
fifth postoperative year [7,8]. In contrast to most of the
previous studies investigating the patency of grafts by
cross-sectional study at a specific time point, we per-
formed coronary angiography in all of the 109 patients at
both one year and five years after CABG to trace the
changes of the anastomoses and grafts in the same patient
population.
The ITA has demonstrated higher intermediate and late
patency rates than saphenous vein grafts and has a >90%
patency rate five years after CABG [2,9,10]. The present
study demonstrated that both the overall (grade A + B) and
grade A patency rates were significantly higher in the arterial
grafts than in the saphenous vein grafts at one year and five
years after surgery. However, the patency rate of arterial
grafts decreased significantly between one year and five
years after surgery (98.0% to 90.7%, p = 0.001), when
analyzed using the x2-test with McNemar examination. We
used the x2-test with McNemar examination, instead of the
simple x2-test, because the present study analyzed the
morphologic change of anastomotic sites in the same patients
group.
One study found no difference in the adjusted risk of
one-year occlusion rates between these two grafts [11].
The authors suggested that this difference in one-year
occlusion rates could be attributed to a difference in the
distribution of graft characteristics related to the target
coronary arteries rather than to the graft material. We
found that the vein graft patency rates in the LCX and RCA
territories were comparable with those of arterial grafts
until five years after surgery. However, the patency rates of
arterial grafts were superior to vein grafts in the LAD
territory at both time points (97.5% vs 82.0% at one-year,
p = 0.001; 90.9% vs 78.0% at five-year, p = 0.042). Excellent
arterial graft patency rates regardless of target territories
in the present study correlated with previous studies
[12,13]. Although previous studies [14,15] demonstrated a
lower patency rate of RITA in the RCA territory, we did not
observed the finding in our small number of arterial grafts in
the RCA territory.
The patency of sequential vein grafting has been
demonstrated to be superior to individual grafting if the
most distally located anastomosis had good quality and
 K.R. Cho et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 511—516
diameter [16]. In the present study, we failed to identify a
difference between sequential and individual vein grafting at
one year and five years after surgery. The excellent patency
rate of arterial sequential anastomoses (97.6% at one year
and 90.5% at five years) in the present study correlated with
the previous reports [12,17].
Although the occlusion rate of saphenous vein grafts has
been reported to be 2—2.5% per year between the first and
fifth postoperative years [18], the patency of vein grafts
remained stable in the present study (82.4% to 80.2%,
p = 0.063). This study supports the idea that very little
change occurs between one year and five years in the
overall patency rate of saphenous vein grafts [19,20].
Instead, the proportion of FitzGibbon grade B grafts
increased in vein grafts (3.1%, 7/227 to 7.5%, 17/227,
p = 0.002) while the proportion of grade B arterial grafts
(8.6%, 13/151 to 7.3%, 11/151, p = 0.774) remained stable
during the four-year interval. Interestingly, most of the
decreased patency of arterial grafts in the present study
seemed to be associated with the status of the native
coronary artery. Of the 11 occluded arterial grafts after one
year, 10 (90.9%) were associated with moderate stenosis
native disease (<80% stenosis). Only 1 of 11 occluded
arterial grafts needed a percutaneous intervention in the
native coronary artery because of angina recurrence. The
decrease in vein graft patency was associated with disease
in the graft itself, demonstrated by segmental narrowing
in the vein graft trunks. Although all seven of the grade
B vein grafts at one year remained as grade B, two
needed percutaneous interventions because of progressive
stenosis and recurrent angina at five years. The increase in
the FitzGibbon grade B and grade O vein grafts and
decrease in the grade A vein grafts were associated with
angina recurrence in the present study. However, multi-
variate analysis failed to correlate the graft occlusion to
angina recurrence. Only the insulin-dependent diabetes
mellitus predicted the angina recurrence. Its deleterious
effect on the progression of native coronary artery disease
as well as grafts could be a possible explanation for this.
When the predicators for angina recurrence were analyzed
according to the patient variables, multivariate analysis
identified insulin-dependent diabetes mellitus as the only
predictor for angina recurrence (odds ratio: 14.278,
p = 0.007).
There are limitations to the present study that must be
recognized. First, the present study was not performed in a
randomized manner with regard to the type of conduits and
the target vessels because randomized controlled trials with
regard to this type of study are often unrealistic and
impractical. Second, this study had a relatively small sample
size, which might be insufficient to compare the fate of
grafts. Third, we might have overestimated the patency rates
by selecting the patients who survived and had angiographies
performed at one year and five years after surgery. Eight
saphenous vein grafts (four in patients with inadequate left
ITA flow, three in emergent cases, and one additional vein
graft to the LAD in a patient with cardiopulmonary bypass
weaning difficulty) were used to revascularize the LAD
whereas nearly 100% of LAD grafts are arterial grafts in most
current practice. These might serve as confounding vari-
ables. Fourth, the present study included a low risk group of
515
patients with young age and good left ventricular function.
Consequently, the conclusions of this study should be applied
for those patients undergoing conventional CABG with
comparable risks.
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