Preferred Vein Sources for CABG

Primary Conduit Hierarchy

The American College of Cardiology recommends using the left internal mammary artery (LIMA) to the LAD as the gold standard, with >90% patency at 10-15 years 1, 2, 3
The American College of Cardiology recommends using the radial artery over the saphenous vein for the second most important non-LAD vessel, with superior patency rates of 89% versus 65-80% at 4-5 years 1, 2, 3

The American College of Cardiology suggests using the endoscopic saphenous vein harvest technique in patients at risk of wound complications to reduce leg wound infection rates from 20-26% to 4-7% 1
The American College of Cardiology recommends using the no-touch saphenous vein harvest technique in patients at low risk of wound complications, as endoscopic harvesting has been associated with reduced long-term graft patency 1, 4

The American College of Cardiology recommends considering saphenous vein grafting instead of arterial grafts in patients with chronic kidney disease likely to progress to hemodialysis, to preserve radial arteries for dialysis access 1, 2

The American College of Cardiology recommends objectively assessing palmar arch completeness and ulnar compensation before harvesting the radial artery 1, 2
The American College of Cardiology suggests avoiding radial artery after transradial catheterization 1, 2
The American College of Cardiology recommends using radial artery grafts only for vessels with significant stenosis (>70% left-sided, >90% right-sided) 2, 3
The American College of Cardiology recommends prescribing oral calcium channel blockers for the first postoperative year to prevent vasospasm 1, 2

The American Heart Association notes that prosthetic material (PTFE, polyester) can be used for above-knee popliteal bypasses when no autogenous vein is available, but patency is significantly inferior (47% at 5 years for above-knee, 33% for below-knee) 5

The radial artery demonstrates superior graft patency compared to saphenous vein grafts, with 5-year functional occlusion rates of 12.0% versus 19.7% (P=0.03) and complete occlusion rates of 8.9% versus 18.6% (P=0.002) 6, 7
Saphenous vein grafts have declining patency: 10-25% occlude within 1 year, additional 1-2% per year during years 1-5, and 4-5% per year during years 6-10 8
Only 50-60% of saphenous vein grafts remain patent at 10 years, with half showing atherosclerotic changes 8

Patient with significant stenosis (>70% for left-sided vessels, >90% for right coronary artery) may benefit from radial artery, which performs best with severe stenoses 6, 7
Target vessel with severe stenosis (>90%) may benefit from RIMA to prevent graft atrophy 8
Use of saphenous vein grafts may be considered when target vessel has moderate stenosis (<70%) where arterial grafts may develop string sign 6, 7

Radial artery should be used preferentially for left-sided coronary arteries with ≥70% stenosis 8
The radial artery is a muscular artery susceptible to spasm and atrophy when grafting moderately stenotic vessels 8
Consider skeletonized harvesting technique to reduce sternal complications when using RIMA 6, 7
Administer perioperative aspirin and dipyridamole to improve early and 1-year patency when using saphenous vein grafts 8

Do not use radial artery for moderately stenotic vessels - the string sign occurs more frequently (3.4% vs 0%, P=0.01) 6, 7
Recognize that only 9% of CABG procedures in the US use radial artery despite superior outcomes 6, 7