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Ann Thorac Surg 1997;64:1263-1268
© 1997 The Society of Thoracic Surgeons
Department of Cardiac Surgery, Royal Melbourne and Epworth Hospitals, University of Melbourne, Melbourne, Australia
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. From 1986 to 1995, 1,454 patients had a FRITA graft. Preoperative characteristics included mean age, 58.8 years (range 29 to 84 years); non–insulin-dependent diabetes, 116 (8%); insulin-dependent diabetes, 7 (0.5%); left ventricular ejection fraction from 0.30 to 0.40, 159 (11%); left ventricular ejection fraction less than 0.30, 14 (1%); and unstable angina, 144 (9.9%). In 11 patients the FRITA was the only graft, in 1,443 a left internal thoracic graft was also used and revascularization completed with additional arterial and vein grafts. There were 3.3 ± 1.1 distal anastomoses per patient, the aortic clamp time was 49 ± 12 minutes, and bypass time was 69 ± 16 minutes. The FRITA was used to reach the circumflex marginal arteries in 718 patients (49.5%), posterior descending artery in 286 (19.7%), diagonal or intermediate in 172 (11.8%), left anterior descending artery in 119 (8.1%), right coronary artery in 115 (7.9%), and left ventricular branch of right coronary artery in 44 (3%). The proximal anastomosis was directly on the aorta in 1,441, other arterial graft in 8, and vein graft in 5.
Results. Operative mortality was 13 patients (0.9%); stroke occurred in 14 patients (1%) and myocardial infarction in 19 (1.3%). The peak creatine kinase myocardial isoenzyme serum level was 20.6 ± 13.6 IU/L. Complications included sternal infection in 18 patients (1.2%) and reoperation for hemorrhage in 23 (1.6%). Survival at 5 and 7 years, respectively, was 96% ± 2.1% and 94% ± 2.5%. In 71 patients with a FRITA studied at a mean of 41.5 ± 14 months postoperatively for recurrent symptoms, 67 FRITA grafts were widely patent (94.5%), 3 displayed a string sign, and 1 was totally occluded.
Conclusions. Use of the right internal thoracic artery as a free graft is safe and effective and allows greater flexibility in arterial coronary revascularization.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Encouraged by favorable reports on the performance of the internal thoracic artery (ITA) for coronary grafting [1–3], we commenced routine use of the left internal thoracic artery (LITA) for grafting to predominantly the left anterior descending artery (LAD) in 1984. Our experience was favorable and we expanded the use of the ITA by the liberal use of bilateral ITA to coronary grafting in 1985, especially in younger people. This practice was based on reports of excellent long-term patency of the ITA [4] and that it appeared to be relatively free of atheroma [4, 5].
Although we could place the pedicled right internal thoracic artery (RITA) to the circumflex marginal vessels through the transverse sinus, the LAD or diagonal (anterior to the aorta), or to the right coronary artery (RCA), we often found that the pedicled RITA graft was limiting in not being able to reach the more distal circumflex marginal arteries. Also, in the right coronary distribution, the intended point of anastomosis at or near the acute margin, though patent, frequently had extensive wall disease, and alternative surgical strategies were required (division of the endothoracic fascia or converting a "stretched" pedicled graft to a free graft) to create the coronary anastomosis more distally where the wall was normal.
To overcome the anatomic limitations of the pedicled RITA graft, we decided to use the RITA graft electively and routinely as a free graft, thus markedly expanding its application, particularly in being able to comfortably reach the posterior descending or left ventricular branches of the RCA, or the distal circumflex marginal system. Reports in 1986 [4] of favorable results in the use of free ITA grafts encouraged us to continue this practice.
This report examines our experience during a 10-year period in 1,454 consecutive patients that had a planned free RITA to coronary artery graft as part of the coronary revascularization, and in particular addresses late angiographic patency.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In 1,443 patients (99%) the FRITA was part of a bilateral ITA procedure. In only 11 instances was the FRITA used without an additional LITA, particularly when only the distal RCA system required revascularization. All patients had primary coronary revascularization procedures only. Reoperations, combined operations with valves, and other operations are not considered in this report, to enable the studied population to be as homogeneous as possible. The patient demographics are summarized in Table 1
. Complete myocardial revascularization was achieved by the use of additional vein grafts or other arterial grafts (inferior epigastric, radial).
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Operative Procedures
Sternotomy was followed by harvesting of the LITA and then the RITA, initially using a Favaloro retractor (Pilling, Durham, NC), but more recently (since 1991) the Delacroix-Chevalier (Paris, France) retractor. When each ITA was harvested the pleura was routinely opened, significant branches were clipped beside the ITA, and either cautery used on the chest wall side or, if the branches were large, they were clipped on both sides and divided by scissors. The dissection extended from the subclavian vein above to the ITA bifurcation below. The internal thoracic veins and adjacent tissues were taken with the pedicle such that the pedicle was approximately 2 cm wide. Each ITA had an intraluminal injection using a blunt-ended 1-mm vascular needle of 3 mL of a 1% papaverine solution of heparinized blood and Ringer's lactate solution (pH 7.2). Additionally 1% papaverine in Ringer's lactate solution was sprayed on the external surface of the ITA. The distal end was clipped, and the ITA pedicle was wrapped in a papaverine-soaked gauze, temporarily placed between the medial surface of each lung and the mediastinum, and allowed to pulsate in that position.
Preparations for cardiopulmonary bypass were then made with ascending aortic and right atrial cannulation. Before the commencement of cardiopulmonary bypass the RITA was checked, its distal end divided just proximal to the occluding hemostatic clip (Weck, Durham, NC), and the flow checked. The large right internal thoracic vein, which lies very medially superiorly, was divided between medium hemoclips, and then the proximal part of the RITA was clipped twice and divided. The free RITA graft was then prepared for anastomosis by shaping the distal and proximal ends appropriately. The graft was then stored in a heparinized blood solution with 1% papaverine.
Cardiopulmonary bypass was conducted at 28°C (between 1986 and 1990), but subsequently at 32°C. Initially only antegrade blood cardioplegia was used at intervals of approximately 20 minutes to perform the distal anastomoses (cardioplegia at 15°C and heart temperature 20°C), and the proximal anastomoses were constructed using a side-biting clamp. Since 1991 combined antegrade and retrograde blood cardioplegia at 20°C has been employed together with the use of a single cross-clamp for all distal and proximal anastomoses and the myocardial temperature kept at 20° to 25°C. Additional doses of retrograde blood cardioplegia were given after the completion of each anastomosis. The heart was vented through the aortic root. Vein grafts were usually placed first, next any other arterial grafts (inferior epigastric or radial), the FRITA graft was placed next, and finally the LITA graft was placed to the LAD artery. Intravenous nitroglycerin infusions were commenced immediately after the release of the cross-clamp. The thymus and pericardium were routinely closed, drains placed into each pleural cavity and behind the sternum, and since 1992 we have routinely reconstituted the pleural cavities by picking up the pleural edges with the sternal wire sutures. Intraoperative variables are detailed in Table 2.
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. When the LAD was occluded and the distal circumflex also required grafting, the FRITA was anastomosed to the LAD (119 times) and the LITA was placed to the circumflex marginal system.
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After distal anastomosis the pedicle was secured with four interrupted 6-0 polypropylene sutures to maintain orientation. The FRITA was predominantly used as a single graft with 27 grafts having sequential distal anastomoses, those being in the circumflex marginal system.
The ITA was used to construct 2,963 (61.8%) of all anastomoses (1,454 FRITA plus 27 sequential, 1,443 LITA plus 39 sequential). Other arterial anastomoses were 75 radial and 11 inferior epigastric. Total arterial anastomoses were 3,049 (63.6%), and vein grafts were 1,749 (36.4%).
The proximal anastomoses were almost always constructed directly on to the ascending aorta (1,441). This was done with continuous 7-0 polypropylene. If the aorta was thick or atheromatous or if the length was not adequate to reach the aorta (from a distal circumflex marginal artery), then the proximal anastomosis was constructed directly onto a saphenous vein graft in 5 or onto the proximal LITA as a Y graft in 8. A vein patch on the aorta was not used in any case. When cardiopulmonary bypass was discontinued, systolic pressure was kept at more than 110 mm Hg, a mean arterial pressure of more than 80 mm Hg, and the cardiac index more than 2.5 L • min-1 • m-2. The systemic vascular resistance was maintained at 800 to 1,000 units.
Bilateral ITA grafts were generally avoided in obese patients, those with insulin-dependent diabetes, and those with severe pulmonary emphysema.
Follow-up and Analysis
Clinical follow-up was conducted by an office visit (surgeon, cardiologist, or family practitioner) and by telephone interview. Postoperative coronary and graft angiography was usually performed in response to possible symptoms or cardiac events. Postoperative coronary and graft angiogram data were collected directly from the cardiologist and angiography laboratory, and each angiogram of a FRITA was independently reviewed by a cardiologist, radiologist, and surgeon.
All data were placed on a computer database program and analyzed using the Statistical Package for Social Sciences (SPSS/PC+). The 
2 test was used to determine the significance for discrete variables. Values were expressed as mean ± standard deviation. The Kaplan-Meier method of actuarial survival and graft survival was used. Values of p less than 0.05 were considered significant.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Perioperative Morbidity
Fourteen patients (1%) experienced a stroke, defined as any clinically detectable neurologic abnormality producing a motor, speech, or sensory deficit. Twenty-three patients (1.6%) required reoperation for excessive bleeding postoperatively. There was no instance in which the bleeding came from the proximal or distal ITA stumps. Eighteen patients (1.2%) developed a significant sternal wound infection. This was defined as any sternal infection with purulent discharge, requiring intravenous antibiotics, or requiring reoperation on the sternum. Eight patients (0.6%) required sternal debridement and rewiring. One patient required pectoral muscle flap transfer.
Nineteen patients (1.2%) had a perioperative myocardial infarction, indicated as new Q waves or creatine kinase-MB level of twice the upper limit of normal (our laboratory normal values, 0 to 25 IU/L). Plasma creatine kinase-MB levels were taken routinely at 24 hours postoperatively on all patients. The mean peak creatine kinase-MB level was 20.6 ± 13.6 IU/L (range, 3 to 91 IU/L).
Follow-up
The follow-up was 98.7% complete, with only 18 patients being lost to follow-up. The minimum follow-up was 3 months, the mean follow-up was 47.6 ± 8 months (range, 3 to 122 months). There were 21 deaths in the follow-up interval. The actuarial survival of patients at 5 years was 96% ± 2.1% and at 7 years 94% ± 2.5% (Fig 2).
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One occlusion and two string signs occurred in the first 12 months, and the other string sign was noted at 57 months postoperatively. In each instance the nonfunctioning FRITA went to a large vessel with only a moderate stenosis. Twenty-four of 27 FRITA grafts (89%) studied in the first 12 months postoperatively were widely patent whereas 43 of 44 (97.7%) grafts studied beyond 12 months were widely patent (Fig 3).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The most frequent problem encountered was when the pedicled RITA graft was used to bypass the RCA. Though the RCA may have been widely patent at or near the acute margin, there was often significant wall disease. To manage this either an anastomosis was constructed in a segment of artery that was not ideal, or the graft was "stretched" and "lengthened" by dividing the endothoracic fascia to reach further down, or when it was apparent that the graft would be too short and compromised to adequately reach distally (particularly when the heart was full), the proximal part of the pedicle required transection and implantation of the RITA into the ascending aorta in an unplanned semiurgent fashion. The conversion of a stretched RITA graft semiurgently into a FRITA graft may have been associated with technical difficulties and may account for the reported relatively low early patency for FRITA grafts [4, 9]. Furthermore later angiographic studies have shown progression of disease in the RCA system beyond a patent graft, particularly in the area between the acute margin and the crux. Hence, we and others [9, 10] would recommend preferentially grafting the RCA beyond the crux or in the posterior descending artery routinely to avoid this problem. To do this comfortably with the RITA it must be used as a free graft.
Based on the above we believe that the RITA is best used as a free graft, allowing it to reach more distally in the right coronary or circumflex distribution without tension or compromise. By its use as a free graft, the most distal segment of the RITA is often not required. This allows for a larger diameter distal RITA, facilitating the distal anastomosis, and the vessel is less prone to spasm by comparison with the more distal portion of the ITA near the bifurcation [11]. By routinely using intraluminal papaverine in heparinized blood and Ringer's lactate solution, significant ITA dilation and avoidance of spasm was achieved. We did not recognize any instance of spasm in the FRITA at operation or postoperatively.
The ITA was always harvested with the adjacent veins and accompanying soft tissues as a pedicle 1.5 to 2 cm wide, both to avoid injury to the vessel but also not to interfere with the vascular supply to the ITA wall by its own branches and vasa vasorum. The retention of the vasa vasorum is significant in maintaining wall function, integrity, and prostacylin release [12]. We contend that use of the RITA as a free graft is not deleterious to the conduit.
The incidence of atherosclerosis in the ITA is low [5] and, in our experience, only 3 of the last 200 ITAs harvested were not used because of chronic changes (2 atheroma, 1 chronic dissection from prior motor vehicle chest trauma).
The construction of the proximal anastomosis to the aorta was usually straightforward. The proximal end of the ITA graft is between 3 and 3.5 mm in diameter. A 3.5-mm aortic punch was used to create the aortic anastomotic site. In the last 5 years all distal and proximal anastomoses have been constructed during the one period of cross-clamping and this has further facilitated the construction of the proximal anastomosis in a quiet field, without the sides of the aorta being opposed by a side-biting clamp.
As the use of a second ITA graft was seen to be of possible prognostic value, generally the patients who received an FRITA graft in addition to an LITA graft were younger, had better left ventricular function, and were more stable [13]. The operative mortality and the perioperative morbidity were low and not significantly different from our series with an LITA graft only, and similar to or better than a series reported in the literature [14], despite a slightly longer operative time to harvest the second ITA.
Sternal infection is always a concern with bilateral ITA harvesting. Our infection rate was low, possibly attributed to controlled use of low-energy electrocautery, liberal use of clips and sharp division of branches, meticulous hemostasis, and relatively quick operating times. Closing the pericardium and reconstituting the pleura may also have been helpful in closing all potential spaces behind the sternum. Obese patients with insulin-dependent diabetes were avoided because of the reported high rates of sternal infection, dehiscence, and mediastinitis [15]. The long-term survival of patients was excellent, similar to other reported series [10, 16], and possibly better than those patients having a single ITA graft [7].
Postoperative angiograms were not performed routinely but were usually indicated for investigation of chest pain or other possible cardiac symptoms. The overall patency of 94.5% for the FRITA at a mean interval of 41.5 months was encouraging and similar to the patency of those LITA grafts studied at a similar time interval. This higher patency by comparison with earlier reports [4, 9] may reflect the advantage of using the FRITA graft in an elective planned way, using the more proximal portions of the vessel, and more facile performance of the proximal aortic anastomosis in a "floppy" aorta proximal to the cross-clamp. Nevertheless three of our failures occurred early. It appears that once the free ITA graft is functioning well, it is likely to stay patent, and remain free of atherosclerotic changes (as determined by angiography). This has been previously proposed [4] and is further supported by our current results. The one occlusion and three "string" signs that occurred were all in patients in whom the FRITA was placed to a large but only moderately stenotic RCA. This is still a controversial issue, but competitive flow is believed to be a significant factor [17], although technical factors related to a diseased RCA may also be at fault.
Reports also indicate that excellent (95% plus) patency rates are being achieved using free arterial grafts, with construction of the proximal anastomosis to the LITA [18, 19] to more closely approximate the characteristics in flow and pressure of third-generation arteries rather than coming directly from the aorta. It is not clear how important this practical concern is. However, once a free ITA graft is in place and functioning in the coronary circulation beyond 12 months, it is very likely to remain patent in the long term.
In conclusion, the RITA can be used a free graft, as part of a myocardial revascularization procedure, especially together with the LITA and other arterial grafts (eg, radial). This can be done safely with short- and long-term clinical results similar to or better than those for use of a single ITA only. The use of the FRITA in a planned elective fashion markedly expands the possibilities of grafting more vessels—more distally if required—allows greater versatility of arterial to coronary reconstruction, and potentially allows the use of the larger, more proximal segments of the RITA. The long-term patency at 5 years is similar to that achieved with pedicled LITA grafts.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Tatoulis, Royal Melbourne Hospital, Suite 28, Private Medical Centre, Melbourne, Australia 3050 (e-mail: jamest{at}cardiology.medrmh.unimelb.edu.au).
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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|
|
|
|
|
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|
|
|
|
|
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