Vein Graft Preservation During Coronary Artery Bypass Graft Surgery: Operative Techniques, Biomaterials and Advances from Tissue Engineering

The failure of saphenous vein grafts following coronary artery bypass grafting (CABG) remains a significant issue, as it limits the durability of vein-based surgical revascularisation compared to arterial conduits. Venous graft disease is a dynamic process that begins early in the perioperative period as a consequence of harvesting trauma, ex vivo preservation, and the sudden exposure of the conduit to the arterial haemodynamic environment. This narrative review summarises the available evidence on local graft protection strategies, focusing on intraoperative and perioperative approaches aimed at preserving endothelial integrity, attenuating initial inflammation, and limiting maladaptive remodelling. Specifically, the review analyses the role of endothelium-protective preservation solutions, external support devices, biodegradable drug-eluting biomaterials, and locally targeted RNA therapies. Preclinical and early clinical evidence suggests that local graft protection is biologically plausible and may reduce intimal hyperplasia, luminal irregularity and adverse graft remodelling. However, its impact on long-term clinical outcomes remains uncertain. An integrated approach combining harvest optimisation, conduit preservation, mechanical support, and local delivery of drugs or regulatory molecules may represent a promising framework for improving vein graft biology; however, its ability to translate into durable patency gains and improved clinical outcomes after CABG requires further clinical validation.