[19] Additionally, diseased grafts represent an increasing proportion of culprit lesions and acute graft occlusion may cause acute coronary syndromes (ACS). They installed stents in the 2 grafts, and I have had no further problems in the ensuing 4 years. Reported intraoperative mortality rates are 5.8-9.6%. The concept of surgical revascularization for coronary artery disease (CAD) originated in the early 20th century. [103] However, in a smaller randomized trial, moderate-intensity oral anticoagulation alone or combined with low-dose aspirin was not superior to low-dose aspirin in the prevention of recurrent ischemic events in patients with non-ST-elevation ACS and previous CABG. The use of the SVG, arterial grafts or both during CABG is largely depending on the site of anatomic obstruction, the availability of good quality conduits, patient preferences, and the clinical condition of the patient. In the much larger retrospective observational study from the Cleveland Clinic of 2191 patients with prior CABG who underwent multivessel revascularization between 1995 and 2000 were evaluated. Finally, in patients with SVG failure treated with PCI, prehospital use of antiplatelet therapy compared with patients not using antiplatelets was associated with lower occurrence of major adverse cardiac events after SVG intervention. CABG may be performed in one of three ways. Fractional flow reserve (FFR) measurement to assess the significance of stenosis in a bypass graft can be performed in a similar fashion as in a native coronary vessel and guide decision making. PCI with BA should be restricted to the early postoperative period during which spasm is difficult to exclude. Do such patients have a less positive prognosis than bypass patients who do not experience complications? [8] In his physiologic approach in the surgical management of coronary artery disease, Favaloro and his team initially used a saphenous vein autograft to bypass a stenosis of the right coronary artery. Other structures at risk for injury during sternal re-entry include perforation of the right ventricle, and innominate vein. In patients with previous CABG, simvastatine 80 mg compared to simvastatine 10 mg, was significantly more effective in reducing the rate of a combined cardiovascular endpoint at a median follow-up of 4.9 years (9.7% versus 13.0%). The Proxis embolic protection system (St. Jude Medical, Maple Groves, Minnesota), a proximal balloon occlusion device, employs a distal balloon to seals the SVG while a proximal balloon seals the inside of the guiding catheter. For the surgery, clinicians remove or redirect blood vessels from other areas of the body and then reroute blood flow to … [67,82] However, the degree of stenosis in the native vessel is a major predictor of IMA graft patency. Its presence is associated with graft success, and its absence with graft failure. Purpose: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation. About 40 percent of vein grafts experience such a failure within 18 months of the operation. [10] Arguably, the first successful IMA – coronary artery anastomosis was already performed 4 years earlier by the Russian surgeon Vasilii Kolesov. [13,77] Two types of vasoconstrictors are found to be important spasmogens in arterial grafts. The FilterWire EX (Boston Scientific) and the FilterWire EX (Boston Scientific) both showed noninferiority to distal balloon occlusion devices. Specific reasons for not to use the RIMA may include additional time to harvest, concerns over deep sternal wound infection, myocardial hypoperfusion, and unfamiliarity. Early IMA graft failure is attributed to technical errors and distal anastomosis. Cardiologists frequently treat blockages in coronary arteries with coronary artery bypass graft (CABG) surgery. At 10 years, there was no significant difference in mortality between groups (redo CABG 74% vs. PCI 68%). In asymptomatic patients, redo CABG or PCI should only be considered if the graft or coronary artery is of good size, severely narrowed and supplies a large territory of myocardium. In a retrospective study, outomes after BMS and DES treatment in IMA grafts were evaluated. Submitted: July 10th 2012Reviewed: November 7th 2012Published: March 13th 2013. [227-229] Bleeding is associated with an increased morbidity and mortality. However, disadvantages are: 1) the need to cross the lesion before adequate protection, possibly liberating friable material before balloon occlusion; 2) temporary cessation of blood flow leading to ischemia and possible hemodynamic instability, as well as limiting visualization making accurate stent placement difficult; 3) inability to obtain full evacuation, especially near the occlusion balloon; 4) possible traumatic injury to the SVG during balloon occlusion, and 5) the need for a relatively disease-free landing zone of approximately 3 cm distal to the lesion for placement of the occlusion balloon. Consideration should be given to preoperative antiplatelet therapy including aspirin and clopidogrel. In a recently published retrospective study, in which patients were prescribed aggressive dual antiplatelet therapy, 287 consecutive patients with graft failure were assigned by the heart-team to PCI or redo CABG. [168] Whether specific stent platforms, polymers or drugs are more appropriate in SVG and arterial graft lesions has not been addressed at this time. [17] Arterial grafts were used in 75% of redo CABG procedures and stents in 54% of PCI (approximately one-half with BMS). Invasive versus non-invasive treatment in ACS and prior CABG was evaluated in the GRACE (Global Registry of Acute Coronary Events), and 6-month mortality was lower in patients revascularized versus those treated medically by univariate but not by multivariable analysis. [83] In addition, the target vessel for the IEA must be one that is completely occluded or severely stenotic, with low coronary resistance, and in territories not totally infarcted to avoid “string sign” (conduit <1 mm diameter). Evaluation for ischemia is as in other patients with stable angina without prior CABG. [162] These results needs to be confirmed in a prospective randomized trial. [139-141] Rapid identification of early graft failure after CABG and diagnostic discrimination from other causes enables an adequate reintervention strategy for re-revascularization, i.e. [220,221] Periodic deflating of the lungs will help prevent injury to the pulmonary parenchyme during re-entry. [192] The PercuSurge GuardWire (Medtronic, Minneapolis, Minnesota) and the TriActiv embolic protection system (Kensey Nash Corporation, Exton, Pennsylvania) both demonstrated a significant decrease the incidence of no-reflow and improved 30-day clinical outcome but the latter was associated with more vascular complications and the need for blood transfusion. The likelihood of MACE was higher in SVG vs. native culprits in patients with small to modest troponin elevations. No difference was observed in 30-day mortality with redo CABG compared to PCI (2.8% vs. 1.7%) but as expected periprocedural Q wave MI occurred more often after redo CABG (1.4% vs. 0.3%). Patient selection was present as patients undergoing PCI more frequently presented with STEMI, multivessel disease, SVG failure, a history of MI, and shorter time-to-graft failure. At 4.5 years, 1 RA graft was occluded due to competitive flow from the native coronary vessel and 2 RA restenoses following BA were treated by stenting. [103] Similar findings were observed in a post hoc analysis from the TNT trial. Redo CABG for coronary bypass graft failure is not favoured by cardiologists and surgeons alike, due to the higher morbidity and mortality compared with primary CABG. In a propensity analysis of long-term survival after redo CABG or PCI in patients with multivessel disease and high-risk features, short-term outcome was very favourable, with nearly identical survival at 1 and 5 years. The primary endpoint of death, MI, target vessel revascularization at 5-year follow-up was 65.9% in the BMS group and 43.4% in the DES group, this difference did not reach statistical significance. The incidence of atherosclerosis in native arteries in the in situ position in the four major arterial grafts is low, especially in the IMA. In such a way, the entire myocardium is provided with continuous, cold cardioplegic solution through coronary sinus perfusion. The routine use of beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, or nitrates post CABG is not supported by data, however, many of these patients require beta blockers and ACE inhibitors for preexistent heart failure or MI according to the ACC/AHA guideline recommendations. RA graft stenosis treated by percutaneous intervention was evaluated in a small study including 18 patients. In diabetic patients with post-CABG angina, the outcomes after repeat revascularization were evaluated in an observational study in which 1123 such patients underwent PCI (75% BA, 25% stent palcement) and 598 underwent redo CABG. In arterial graft failure, ostial stenoses are the least common and the pathogenesis of ostial stenoses may be affected by its proximity to the aorta and potential extension of atherosclerosis from that vessel. Finally, the RIMA may go behind the aorta through the transverse sinus to reach the marginal branches of the Cx artery, which is very far away from the sternal re-entry area and poses therefore minimal risk for potential injury. Most patients presented with ACS and the most common cause of graft failure was occlusion or thrombosis. Stenting showed excellent and durable results and is preferred in most cases. Redo CABG has a two- to four-fold higher mortality than the first procedure which is mainly driven by comorbidity and less by the re-operation itself. The first challenge, safe sternal re-entry without damaging coronary bypass grafts and other retrosternal structures, has been described to be safely performed when using an oscillating or micro-oscillating saw. MY GUY had 5 bypasses (quintuple?) [100,101] In patients undergoing coronary bypass surgery with a coronary stent in situ implanted within 1 year, clopidogrel should be continued if the stented vessel has not been grafted. [33] As it has been demonstrated that intimal hyperplasia does not occur in vein-to-vein isografts, it can be stated that pathologic changes seen in SVG in the arterial circulation are predominantly caused by hemodynamic and physiochemical changes. IF your arteries are *gradually* occluding, the build -up in pressure apparently stimulates the growth of your inbuilt bypasses, and even generation of more. In the third scenario, the RIMA graft is used and comes in front of the aorta across the midline and reaches the LAD. [19,41]. After the intervention, a retrieval catheter is advanced over the guidewire to collapse the filter and remove it along with retained contents. What is the average time grafts take to get re-blocked after a bypass surgery? Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. Also one bypass has failed. In a recently published retrospective analysis, the outcomes after PCI with BMS or DES for ACS due to graft failure were evaluated. Contact our London head office or media team here. Patients who underwent stenting had a target lesion revascularization rate of 15.4% and those who underwent BA had a rate of 5.4%. Neurological complications and bleedings are common following redo CABG. Contrastingly, 2 small studies did not show improved clinical impact of DES compared to BMS. The most common cause of graft failure is movement, which dissociates any new blood vessel growth (neovascularization) into the graft, depriving it of oxygen and nutrients. Both registries showed that patients with graft failure can undergo PCI with a relatively low risk for in-hospital mortality or nonfatal major complications. Regarding the type of bypass graft, LIMA graft failure may be responsible for acute ischemic complications after CABG in at least a third up to half of the cases. [132] Moreover, patients with graft intervention often have a higher generalized atherosclerotic burden and more comorbidities. No significant differences were present in in-hospital and 1- or 6-month outcomes between the 2 groups, including target lesion revascularization with DES (DES 3.33% vs. BMS 10%). However, early diagnostic angiography is suggested as the different anatomic possibilities, i.e. In the GUSTO-1 (Global Utilization of Streptokinase and TPA for Occluded Arteries I) trial a significantly increase in 30-day mortality was observed following reperfusion with tissue-type plasminogen activator in prior CABG patients compared to those without prior CABG (10.7% vs. 6.7%). Failed grafts after bypass surgery. However, on rare occasions, focal stenoses of the RA graft can occur. I was walking 5 miles a day and starting to jog a little until late February, 2010 when all of a sudden I couldn't walk for 3 minutes without gasping for breath. [1] Later, Beck also developed another revascularization technique by anastomosis between the aorta and the coronary sinus. [205] Compared to patient without prior CABG, patients with prior CABG presenting with ACS are older, have more cardiovascular risk factors, more frequent comorbidities, higher TIMI risk score, lower left ventricular ejection fraction, had higher prevalence of previous treatment with evidence-based medications, were less likely to have ST-segment deviation or positive cardiac biomarker on presentation. [123]. Although all arterial grafts may develop vasospasm, it develops more frequently in the GEA and RA, than the IMA and IEA. In the presence of degenerative old vein grafts, delivery of cardioplegia solution is considered safer through retrograde coronary sinus perfusion than anterograde delivery of cardioplegic solution because of the risk of atheromatous embolization from atherosclerotic vein grafts which can lead to acute occlusion of coronary artery branches. [81], Atherosclerosis in arterial grafts can develop before coronary grafting when the graft is in the in situ native position, or after. A decrease. The DCRI’s Renato Lopes, MD, PhD, (pictured) was the lead author. [96] Although, the largest risk reduction was observed when aspirin was given at 1 h after operation, there was a non-significant increase in the rate of re-operation in this group. [41], Midterm SVG failure is mainly caused by fibrointimal hyperplasia as it serves as the foundation for subsequent graft atheroma leading to occlusive stenosis. [226] Soft flow aortic cannulae, heparin-coated circuits, and administration of adenosine have proposed as techniques to lower neurological complications, but adequate studies and therefore evidence are lacking. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. [218,219] To help decrease the risks associated with redo CABG, a number of technical advances have been introduced in the surgical arena. Whether clopidogrel given in addition of aspirin to high-risk patients after CABG would reduce thrombotic complications was evaluated in several studies. [200] Recently, an adjustment was suggested to this score to include left main disease as well as the protective properties of patent bypass grafts, the modified Duke jeopardy score (Figure 1). Thick plaque build-up and calcified coronary artery branches as well as calcification of the aortic arch make distal and proximal anastomosis of coronary bypass grafts hard and increase the chances of graft failure. [104] Currently, the American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines recommended that oral anticoagulation in addition to aspirin can be considered only when it is indicated for other reasons. By making research easy to access, and puts the academic needs of the researchers before the business interests of publishers. Moreover, after encountering arterial flow patterns increased levels of intracellular adhesion molecule-1, vascular cell adhesion molecule-1, and monocyte chemotactic protein-1 will facilitate leukocyte-endothelial interactions so that leukocyte infiltration of the lesions will ensue. [191] Distal balloon systems provide occlusion beyond the lesion securing the blood and may prevent plaque embolization into the myocardial bed. Methods: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. Target lesion revascularization was 21.3% after PCI, and 3.2% following redo CABG. Patients with a SVG culprit also suffered higher rates of mortality at 30 days (14.3% vs. 8.4%) and MACE at 1 year (36.8% vs. 24.5%). Adenosine is an endogenous purine nucleoside, a vasodilator of arteries and arterioles, and inhibits platelet activation and aggregation. Studies have demonstrated that there are differences between arterial and venous grafts: 1) arterial grafts are less susceptible to vasoactive substances then veins [63]; 2) the arterial wall is supplied by the vaso vasorum and in addition through the lumen, whereas the veins are only supplied by the vaso vasorum [64]; 3) the endothelium of the arteries may secrete more endothelium-derived relaxing factor [65]; 4) the structure of the artery is subject to high pressure, whereas the vein is subjected to low pressure. Warfarin – Conflicting evidence is reported whether warfarin in addition to aspirin is beneficial in patients post CABG. Regarding the type of bypass graft, LIMA graft failure may be responsible for acute ischemic complications after CABG in at least a third up to half of the cases. Several intrinsic and extrinsic factors may play a role in the mechanism of SVG failure. Potential consequences of graft failure (loss of patency) include the development of angina, myocardial infarction, or cardiac death. It’s based on principles of collaboration, unobstructed discovery, and, most importantly, scientific progression. During EndoMT, many of the endothelial cells that line the inner surface of the vein … Following graft revascularization, patients remain at very high risk for subsequent clinical events. [215]. The proximity of vein grafts to the sternum varies significantly due to the large number of options for proximal as well as distal anastomosis sites. [166,167] Sexe also appeared to be a predictor as women have a significantly higher 30-day cumulative mortality rate compared with men (4.4% vs. 1.9%), a higher incidence of vascular complications (12% vs. 7.3%), and postprocedural acute renal failure (8.1% vs. 4%). In a retrospective analysis patients undergoing BMS implantation for the treatment of IMA graft stenosis were compared to patients treated with BA. Given the large amount of atherosclerotic material and thrombus burden with limited runoff found in occluded SVG, it is suggested that reperfusion success rate is reduced. In another study, factors that predict the late progression of SVG atherosclerosis were evaluated in 1248 patients in the Post-CABG trial. In contrast to the long-term results of the RRISC study, at a median follow-up of 35 months PES treated-patients had a significantly lower incidence of MI (17% vs. 46%), target lesion revascularization (10% vs. 41%), and target vessel failure (34% vs. 72%) as well as a trend toward less definite or probable stent thrombosis (2% vs. 15%). [130] In another study, outcomes of 192 patients with acute MI from a SVG culprit undergoing PCI were compared to patients with a native culprit. Although, the IMA is the most used conduit to restore the blood flow to the LAD, it is less easy to use because of its complicated preparation and postoperative complications. prior open-heart surgery, age >70 years, left ventricular ejection fraction <35%, MI within seven days or intraaortic balloon pump required) amandable for either PCI or redo CABG were randomized. Pulling back and looking at it could cause it to become uncovered. Adequate arterial conduits are not always available, in contrast SVG are usually of good quality and calibre and are easily harvested, and are thus commonly used as conduits. Also known as coronary artery bypass graft surgery, it’s sometimes necessary to prevent heart failure. About 40% of vein grafts fail within 18 months of the operation. For the surgery, clinicians remove or redirect blood vessels from other areas of the body and then reroute blood flow to the heart through those grafted blood vessels. After the intervention, the blood with the debris can be aspirated with a suction catheter before deflating the balloon. [169] These lesions were more commonly treated with BA (91%), whereas lesions located at the ostium (8%) were more frequently treated with stents (69%). [195]. [103,106-110] Besides the lipid lowering effect, statins also exert a number of pleiotropic effects on the vascular wall which may effect SVG in a similar way. A skin graft can fail if the blood vessels fail to grow into it. What happens to velocities if the graft is starting to fail. After the saphenous vein bypass procedure was extended to include the left arterial system by Johnson [9], the use of the IMA for bypass grafting was performed by Bailey and Hirose in 1968. Moreover, the role of various surgical techniques for graft revascularization, such as off-pump and minimal invasive CABG also remain unclear. This is a reasonable option in selected patients and the primary choice in those with poor targets, conduit, or excess surgical risk. [133,138,142], Recurrent angina during the early postoperative period is usually due to a technical problem with a graft or with early graft closure and there is an indication for prompt coronary angiography with percutaneous revascularization. Percutaneous intervention in SVG lesions was evaluated in several randomized studies. [23,24] Moreover, the quality of the saphenous vein can have significant clinical consequences. Joined : Feb 2011. The results were published in the February 14 issue of Circulation. [185-187] Similarly, no reduction in MACE at 30 days was observed in a post hoc analysis when glycoprotein IIb/IIIa antagonists were used in conjunction with filter-based embolic protection, although there was a trend toward improved procedural success. The early patency of a LIMA anastomosed to the left anterior descending (LAD) is reported to be almost 99%. One is 100% closed but the doctor said somehow veins have formed around the closure so blood is flowing. [54-56], In a later stage atherosclerotic lesions may be complicated by aneurysmal dilatation which is found to correlate with thrombosed SVG. Like the other dentist said, it will take weeks or months to look normal and it will continue to remodel for months. [184] The location of the RA stenosis was proximal (n = 2), shaft (n = 11) or distal anastomosis (n = 5). Inadequate myocardial protection is an important cause of failure to wean patients off cardiopulmonary bypass. [105]. Due to the high rate of graft failure, the researchers stressed the importance of improving the length of time that grafted veins remain unblocked by selecting good-quality conduits and preventing injury to the veins when they are initially removed. Initial studies evaluating BA versus CABG noted comparable long-term results except for a much higher rate of repeat revascularization in the BA group (BA 64% vs. redo CABG 8%). Stable patients with recurrence of angina following CABG can be treated medically for their symptoms and risk factor reduction. The optimal timing of the first dose of aspirin for patients after CABG was investigated in a meta-analysis of 12 studies and found that the benefit of aspirin was optimal if started at 6 h after surgery. Noteworthy, the available comparative studies were, however, conducted before the use of aggressive dual antiplatelet therapy with aspirin and clopidogrel after PCI with stenting and aggressive lipid-lowering with statins for secondary prevention. Finally, in the APEX-AMI trial, STEMI patients with prior CABG exhibited a smaller baseline territory at risk as measured by 12-lead ECG and had less myocardial necrosis. It was the 2 vein grafts that were partially blocked, the lima was fine. [74] Arterial grafts are not uniform in their biological characteristics and difference in the perioperative behaviour and in the long-term patency may be related to different characteristics. In the randomized Post CABG trial, patients who had undergone bypass surgery 1 to 11 years before base line with elevated serum LDL-cholesterol concentrations (130 to 175 mg/dL / 3.4 to 4.5 mmol/L) were assigned to receive either aggressive lipid lowering therapy with lovastatin and, if needed, cholestyramine (target LDL-cholesterol <100 mg/dL / 2.6 mmol/L) or to moderate therapy (target LDL-cholesterol of approximately 134 mg/dL / 3.5 mmol/L). [202-204] Although primary PCI is the preferred strategy for STEMI patients, current guidelines do not provide specific recommendations on the optimal reperfusion strategy in patients with prior CABG. To prevent distal embolization form friable atheroemboli, and in addition may serve as a smooth-muscle cell barrier to decrease restenosis, stents covered with a mesh, most commonly polytetrafluorethylene (PTFE), were evaluated. The PREVENT IV trial, including almost 3,000 patients that underwent CABG, demonstrated that rates of use of secondary prevention medications in patients with ideal indications for these therapies are high for antiplatelet agents and lipid-lowering therapy, but suboptimal for beta-blockers and ACE inhibitors or ARBs. [97] Practically, Aspirin should be commenced within 24 h of CABG. I had a triple by-pass three years ago. Noteworthy, the clinical impact of SVG failure is still debated. Work up might include a new hearing test to look at the eustachian tube and a ct scan to look at the middle ear. If the periodontist did the donated tissue, it MUST stay 100% covered or it will fail. The researchers also noted that patients who had graft failures typically had more co-existing health conditions and were more likely to have their veins removed via an endoscopic procedure. [217,223] Following redo CABG, survival is 75–90% and 55–75% at 5- and 10-year follow-up, respectively. Long-term clinical follow-up of ACS patients with prior CABG treated with PCI has been assessed in several studies. At 30 days, there was a similar effect on the primary end point of death or MI in the eptifibatide group versus the placebo group in prior CABG patients and in patients without a history of CABG. [71] Differences are observed between territory grafted, the 10 year LIMA patency to the LAD is reported to be 96% and to the circumflex (Cx) 89%. What happens to the index if the graft is failing? In the PERSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy) trial the efficacy of eptifibatide, a Glycoprotein IIb/IIIa antagonist, in patients with ACS was compared in patients with or without prior CABG. [159] In a meta-analysis including 29 studies (3 randomized controlled trials (RCT)) involving over 7500 patients, the authors stated that DES may decrease TVR rate in treatment of SVG stenoses but no differences in reinfarction rate, stent thrombosis or mortality was found between the DES and BMS groups in the RCT’s. He began having chest pains about two months after the surgery and went to the cardiologist. [154-157] The RRISC, SOS and ISAR CABG all compared first-generation DES to BMS. Implantation of coronary stents has become the preferred revascularization strategy for treatment of graft lesions, because redo CABG is associated with an increased morbidity and mortality. [219] Additionally, the lack of satisfactory bypass conduits is common, because many patients undergoing redo CABG have very thin and dilated varicose veins, and small and calcified radial arteries. [34], SVG failure can be divided into three temporal categories: early (0 to 30 days), midterm (30 days to 1 year) or late (after 1 year). [179] At a median follow-up of 29.2 months (interquartile range, 11.1-77.7 months) target lesion revascularization was 47.8% with SES and 7.1% with BMS. In the PCI group, BMS was associated with significantly higher rates of target lesion revascularization (24.8% vs. 7.6%), but the rate of death or MI compared with DES was similar. [19,35-37] It occurs in 15% to 18% of VG during the 1st month. [118] However, in the AWESOME RCT and registry the overall in-hospital mortality was higher in the redo CABG group compared to the PCI group. The intima is composed of a continuous layer of endothelial cells on the luminal surface of the vessel. [137,138] Nongraft-related causes for myocardial ischemia after CABG are surgery-related possibly due to surgical manipulation on pre-existing microembolizing and disintegrating unstable plaque and include inadequate cardioplegic perfusion and myocardial protection, incomplete revascularization, or distal coronary microembolization. In patients whom underwent CABG for ACS subgroup analyses of the CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) and CURE (Clopidogrel in Unstable angina to prevent Recurrent Events) study provides supportive evidence to prescribe clopidogrel for 9 to 12 months in addition to aspirin. [21], The concept of the ‘failing graft’ is one of a patent graft whose patency is threatened by a hemodynamically significant lesion in the inflow or outflow tracts or within the body of the graft. 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Mar ; 63 ( 3 ):323-32. doi: 10.1097/00006534-197903000-00005 more blockages, one right below a bypass and percent...
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