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Ann Thorac Surg 1998;66:1288
© 1998 The Society of Thoracic Surgeons

Original articles: cardiovascular

Invited commentary

Hendrick B. Barner, MDa

a Division of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 3108, St. Louis, MO 63110, USA


   Invited commentary
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This detailed analysis of factors influencing patency of coronary grafts unfortunately lumps venous and arterial conduits together. It is well known that venous grafts have a higher failure rate than in situ arterial grafts at all intervals of follow-up but particularly early and late. It is also well known that venous graft failure is associated with conduit flow of less than 40 mL/min as a consequence of a small coronary artery (1.5 mm or less) or a larger coronary artery with distal atherosclerosis or not supplying viable muscle [1]. Reduced flow velocity in a relatively large conduit combined with endothelial injury leads to progressive thrombus formation and graft failure. Some of these facts have been confirmed by Louagie and associates. However, clinical flow measurements are not particularly helpful in managing vein grafts, which have greater potential for failure, because the circum-stances for reduced flow are usually obvious and frequently there is little that can be done to improve the situation (except to replace a vein graft with an arterial conduit, which will remain patent with low flow because velocity is greater and endothelial injury less).

Arterial conduit flow is frequently reduced by competitive coronary flow, but this uncommonly influences patency, although it is one cause of string sign. Again the pragmatic value of flow observations is limited in this situation [2],

The obvious value of flow measurements in clinical decision making is in the setting of zero or greatly reduced flow (when more is expected) as a result of a technical error that can then be corrected. With increasing experience these situations become fewer and the surgeon frequently recognizes the problem without flow measurement and corrects it.


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  1. Marco J.D., Barner H.B., Kaiser A.C., et al. Operative flow measurements and coronary bypass graft patency. J Thorac Cardiovasc Surg 1976;71:545-547.[Abstract]
  2. Barner H.B., Mudd J.G., Mark A.L., et al. Patency of internal mammary–coronary grafts. Circulation 1976;54(Suppl 3):70-73.




This Article
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