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Ann Thorac Surg 1998;66:S2-S5
© 1998 The Society of Thoracic Surgeons

Arterial grafting: techniques and conduits

^a Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, St. Louis, Missouri, USA

Address reprint requests to Dr Barner, Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Suite 3108 Queeny Tower, St. Louis, MO 63110

Presented at "Risk Management in CABG: Significant Surgical Considerations," New Orleans, LA, Jan 24, 1998.

	Abstract

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
The superior long-term patency and survival of the internal thoracic artery in coronary artery bypass grafting, compared with saphenous vein, established the internal thoracic artery as the conduit of choice for myocardial revascularization. Use of the internal thoracic artery has expanded, and the possibility of similar performance by other arteries has motivated surgeons to investigate alternative arterial conduits (eg, the gastroepiploic artery, inferior epigastric artery, and radial artery). Although these grafts have become more technically feasible and have shown benefits, more follow-up data are needed to determine the long-term patency, freedom from arteriosclerosis, and efficacy of alternative conduits.

	Introduction

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
More than three decades have elapsed since the advent of coronary artery bypass grafting (CABG). In the beginning, the saphenous vein (SV) served as the principal conduit. By the mid-1980s, however, accumulating data showed the clinical advantage of an 85% to 90% 10-year patency rate for the internal thoracic artery (ITA) compared with a 50% patency rate for the SV [1]. Since then, increasing interest in arterial conduits has led to expanded use of the ITA and also use of the so-called alternative arterial conduits—namely, the gastroepiploic artery (GEA), inferior epigastric artery (IEA), and radial artery (RA)—primarily as supplements to both the right and left ITA.

Surgeons have sought to build on the demonstrated benefit of the ITA by using both ITAs and, when appropriate, by using them in a complex manner (eg, free grafts, sequential anastomosis, and conduit-to-conduit anastomosis). Problems related to the complex use of ITA grafts, in contrast with the SV, are that arterial conduits are more difficult to harvest, more easily damaged, more demanding to anastomose owing to fragility and small size, and more compromised by spasm or technical error, which can result in graft closure (occlusion) or myocardial hypoperfusion (patent graft but inadequate flow).

Technical refinement gained from greater experience has improved early results. Each arterial conduit has its own associated "learning curve," and early graft patency is related to technical considerations associated with harvesting, handling, routing, and anastomosis. Recent data encourage the continued use and evaluation of arterial conduits to achieve complete revascularization of the heart in bypass procedures.

	Internal thoracic artery

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
Although use of the left ITA for the left anterior descending (LAD) coronary artery became firmly established in the mid-1980s, it has taken more than a decade for use of the right ITA to become well established. Tatoulis and colleagues [2] reported routine use of the right ITA as a free graft from the aorta in 1,454 patients having bilateral ITA harvesting. This series is the largest reported to date. Morbidity and mortality were low when patients were younger and the incidence of diabetes low. Patency for the free right ITA was 89% ± 8.5% to 5 years and 96% ± 1.5% (p = not significant) for the in situ left ITA. Verhelst and associates [3] have reported global patency of 86.4% for the free ITA and 100% for the in situ ITA. Clearly, the patency of free grafts is diminished by 5% to 8% compared with pedicle grafts, whereas anastomosis to a SV hood achieves a nonsignificant improvement in patency compared with direct aortic anastomosis (Table 1).

I elect to place the right ITA to the second most important coronary artery (other than the LAD) in terms of size of the artery itself and the amount of healthy muscle supplied by that artery. Because I am reluctant to cross the anterior midline with the right ITA, I use the right ITA as a free graft for the left side of the heart; if used for the right coronary system, I frequently use it as a free graft to reach the posterior descending artery, although this is not necessary in all patients. Five-year patency of 93.7% for transverse sinus routing of the in situ right ITA has been reported by Gerola and coworkers [6]. I am reluctant to harvest both ITAs in the insulin-dependent patient because of the increased risk of mediastinal infection.

Tector and associates [7] have championed an expanded role for the ITAs, based on the initial experiences of Mills [8] and Sauvage and coworkers [9]. Anastomosis of the right ITA to the posterior aspect of the left ITA T-graft allows it to reach the circumflex system and the distal branches of the right coronary artery in most patients. In the experience of Tector and colleagues [7], patency for T-anastomoses has been 91.2% (31 of 34); for right ITA anastomoses, 86.5% (77 of 89); and 98.3% (59 of 60) for left ITA anastomoses. The sternal infection rate was high at 3.1% (15 of 486), but 9 of the 15 patients with such infection had diabetes.

The so-called T-graft (Fig 1) is technically complex, and many surgeons would not be comfortable with this aspect of the operation. Others have concern about the adequacy of inflow through a single source and would prefer three or more conduits with one or, at most, two distal anastomoses per conduit. In the study by Tector and associates [7] of 486 patients receiving T-grafts, 4 (<1%) required supplemental vein grafting intraoperatively, and an additional 5 (1%), 2 of whom had cardiac arrest and 3 had low cardiac output, were returned to the operating room for supplemental vein grafting.

View larger version (34K): [in this window] [in a new window]   Fig 1. Internal thoracic artery T-graft (left), which uses a true right-angle anastomosis, and radial artery T-graft (right), which uses more of a traditional Y anastomosis. (Reprinted from Barner HB. Techniques of myocardial revascularization. In: Edmunds LH Jr, ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:481–534, by permission of McGraw-Hill, New York, NY.)

	Gastroepiploic artery

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

Reports of 8- and 10-year experience with the GEA by Suma [10] and Pym and coworkers [11], respectively, have described intermediate patency of 92% to 97%. Harvesting complications have been only rarely reported. Use of the GEA for off-pump bypass has been reported with an epigastric incision and limited sternotomy or excision of the xiphoid and resection of the adjacent sternum. When used as a free graft from the aorta, patency is 80% [10, 12].

	Inferior epigastric artery

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
Experience with the IEA is much less than with the GEA. In the only reported large series, Buche and Dion [13] found inferior patency (Table 2) compared with that of other arterial conduits. Both IEAs can be harvested through the same midline incision; more commonly, one IEA is harvested through a paramedian incision with a lateral approach to the rectus muscle, which is retracted medially. Use of this artery is limited by its short length, which is caused by variability in its size and the fact that it may divide and become too small or enter the rectus muscle, making dissection exceedingly difficult.

	Radial artery

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
The RA was transiently used in the early seventies [16] and was reintroduced by the same group in 1992 [17]. Harvesting this conduit necessitates prior assessment of collateral circulation to the hand. We use the Allen test [16], with visual assessment of return of capillary circulation to the skin of the palm and digits. The radial and ulnar arteries are occluded at the wrist, and the hand is opened and closed 20 times vigorously, followed by release of the ulnar artery. Capillary refilling occurs in 2 to 10 seconds; if more than 10 seconds, the test is considered positive and the RA is not harvested. If the palmar skin is heavily pigmented so that the capillary filling cannot be visually assessed, a digital pulse oximeter can be used to determine return of capillary flow. In our experience with 528 patients, 4.4% had a bilaterally positive test and 11.9% had a unilaterally positive test (unpublished data).

The RA is usually harvested from the nondominant arm, but in 65 patients the RA was harvested from the dominant arm. Hypoperfusion of the hand or claudication has not been recognized by us or by others. Sensory loss owing to injury to the lateral antebrachial cutaneous nerve or to the superficial radial nerve has occurred in about 5% of patients, but is frequently reversible and has not been particularly bothersome or disabling.

The artery is anastomosed proximally to the aorta if the latter is healthy, using a 4- to 5-mm punch and 7-0 polypropylene suture. Alternatively, the artery can be anastomosed to the hood of an associated vein graft or to a pericardial patch placed in the aortic wall. Calafiore and associates [14, 15] have anastomosed the RA to an in situ arterial conduit (usually the left ITA) with a single distal anastomosis. Influenced by this approach as well as by the ITA T-graft [7], we have chosen to attach the radial to the left ITA in a Y configuration and direct it to the circumflex and right coronary arteries.

Most surgeons using the RA have used perioperative diltiazem and have then switched to oral calcium channel-blocking agents for 3 to 12 months. We do not use calcium-channel–blocking agents. We do treat the conduit with intraluminal papaverine (2 mg/mL of heparinized blood) placed in the conduit after the proximal anastomosis is performed, allowing the conduit to dilate for 10 minutes while exposed to arterial pressure.

Five-year RA patency has been reported by Acar and coworkers [18] as 84.2% (n = 57) at a mean of 5.6 years. Brodman and associates [19] have reported an RA patency of 95.7% (n = 94) at a mean of 3 months, and Calafiore and colleagues [14] have reported a patency of 94.3% (n = 35) at a mean of 21 months when the RA was anastomosed to another arterial conduit. In our experience, patency for the RA T-anastomosis is 94% (17 of 18); for RA anastomosis, 86% (30 of 35); and for the left ITA directed to the LAD system, 100% (25 of 25) (unpublished data).

The RA T-graft (Fig 1) has the same limitations as the ITA T-graft; that is, technical complexity and a single-source inflow that increases risk of hypoperfusion. Hypoperfusion occurred in 3 (0.5%) of 570 patients having an RA T-graft. The RA T-graft’s advantage over the ITA T-graft is that conduits are harvested simultaneously in the former and there is decreased risk of mediastinal infection. The RA is longer and larger than the ITA and does not taper significantly, which provides greater distal flow capacity. Additionally, the RA is less fragile and does not have the potential to dissect.

In our experience with 620 patients in whom the RA was used (unpublished data), one death occurred in 540 patients having an elective operation and three deaths in 80 patients having reoperative coronary bypass (total mortality = 0.7%). Four (<1%) of 620 patients had a mediastinal wound infection, and 1 of these 4 had diabetes. Thus, in this group of patients, morbidity and mortality have been at very acceptable rates.

	Summary

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 
Complete revascularization with arterial conduits is gradually becoming easier and its benefits are becoming more demonstrable. It can be achieved with both ITAs and one or more alternative arterial conduits, or with both ITAs in a T-graft configuration. The T-graft is highly complex, and its use is not advisable unless the surgeon is extremely skilled and experienced. In patients with insulin-dependent diabetes, it is appropriate to avoid the increased risk of mediastinal wound infection associated with bilateral ITA grafts by using the left ITA and one or two alternative conduits. Further clinical data are needed to determine the long-term clinical value of the GEA, IEA, and RA when interposed into the coronary circulation.

	References

Top Abstract Introduction Internal thoracic artery Gastroepiploic artery Inferior epigastric artery Radial artery Summary References

 

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