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REVIEW article

Front. Cardiovasc. Med.

Sec. Cardiovascular Surgery

This article is part of the Research TopicSurgical Revascularization of the Ischemic Myocardium in the third millenniumView all 7 articles

Saphenous Vein Graft and Nitric Oxide: Strategies to Prevent Graft Failure and Enhance Patency in Coronary Artery Bypass Grafting

Provisionally accepted
Michele Dell'AquilaMichele Dell'Aquila1*Sotirios PrapasSotirios Prapas2Giorgia FalcoGiorgia Falco3Ignazio CondelloIgnazio Condello4Meher ChallagallaMeher Challagalla1Shadi AbdallaShadi Abdalla5Joshua NewmanJoshua Newman1Omar JarralOmar Jarral1Stevan PupovacStevan Pupovac1Branden TejadaBranden Tejada1Ameerah AliAmeerah Ali1Konstantinos KatsavriasKonstantinos Katsavrias2Augusto D'OnofrioAugusto D'Onofrio6Vincenzo LabriolaVincenzo Labriola6Carlo ZebeleCarlo Zebele7Antonio TotaroAntonio Totaro8Tulio CaldonazoTulio Caldonazo9Hristo KirovHristo Kirov9Antonino Di FrancoAntonino Di Franco3Jordan LeithJordan Leith3Mohamed Rahouma, MD, PhD, MSc, MSMohamed Rahouma, MD, PhD, MSc, MS3Lisa RongLisa Rong3Derek BrinsterDerek Brinster1Alexander IribarneAlexander Iribarne1Frank ManettaFrank Manetta1Nirav PatelNirav Patel1Robert KalimiRobert Kalimi1Mario GaudinoMario Gaudino3Antonio Maria CalafioreAntonio Maria Calafiore2
  • 1Northwell Health, New York, United States
  • 21st Division of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
  • 3Weill Cornell Medicine, New York, United States
  • 4Universita degli Studi dell'Insubria Dipartimento di Medicina e Chirurgia, Varese, Italy
  • 5Weill Cornell Medicine - Qatar, Doha, Qatar
  • 6Universita degli Studi di Roma Tor Vergata, Rome, Italy
  • 7Department of Cardiac Surgery, Clinica Montevergine, Mercogliano, Italy
  • 8Universita degli Studi del Molise Dipartimento di Medicina e Scienze della Salute Vincenzo Tiberio, Campobasso, Italy
  • 9Friedrich-Schiller-Universitat Jena, Jena, Germany

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Nitric oxide (NO) is a central regulator of vascular homeostasis and a key determinant of saphenous vein graft (SVG) outcomes in coronary artery bypass grafting (CABG). Endothelial dysfunction, driven by altered shear stress, oxidative stress, and cardiovascular risk factors, impairs NO production and release, contributing to SVG thrombosis, intimal hyperplasia, and atherosclerosis. SVG harvesting technique, storage, and intraoperative handling affects endothelial integrity, inflammatory response, and vascular remodeling, influencing arterialization, long-term patency, and clinical outcomes. Preservation of perivascular adipose tissue (PVAT) during vein harvesting enhances NO bioavailability, reduces inflammation and oxidative stress, and supports graft adaptation. Internal thoracic artery (ITA) grafts provide durable patency, survival benefit, and NO-mediated vasoprotection, improving SVG function and mitigating maladaptive remodeling. Graft configuration further determines SVG adaptation. ITA-composite SVGs confer continuous NO exposure, promote arterial-like remodeling, and attenuate low shear stress. Optimal secondary prevention, including antiplatelet therapy, statins and lifestyle modifications further preserves endothelial function and reduces SVG failure. Targeting NO through surgical technique, graft configuration, and pharmacologic intervention represents a unifying strategy to enhance SVG performance, arterialization, and long-term outcomes, addressing the current limitation of SVG in CABG.

Keywords: Composite graft, Coronary artery bypass graft (CABG), endothelial dysfunction, Graft failure, Graft patency, nitric oxide (NO), perivascular adipose tissue (PVAT), Saphenous vein graft (SVG)

Received: 12 Nov 2025; Accepted: 09 Dec 2025.

Copyright: © 2025 Dell'Aquila, Prapas, Falco, Condello, Challagalla, Abdalla, Newman, Jarral, Pupovac, Tejada, Ali, Katsavrias, D'Onofrio, Labriola, Zebele, Totaro, Caldonazo, Kirov, Di Franco, Leith, Rahouma, MD, PhD, MSc, MS, Rong, Brinster, Iribarne, Manetta, Patel, Kalimi, Gaudino and Calafiore. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Michele Dell'Aquila

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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