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Ann Thorac Surg 1999;68:2093-2099
© 1999 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia
b Department of Cardiac Surgery, Epworth Hospital, Richmond, University of Melbourne, Melbourne, Australia
Address reprint requests to Dr Tatoulis, Department of Cardiac Surgery, Royal Melbourne Hospital, Suite 28, Private Medical Centre, Melbourne, Victoria 3050, Australia
e-mail: james.tatoulis{at}nwhcn.org.au
Presented at the Poster Session of the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.
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Abstract |
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Methods. All 3,220 consecutive patients who had total arterial coronary revascularization from January 1988 to June 1998 were evaluated. Data were collected prospectively. The mean age was 62.2 years. Of the patients, 595 (18.8%) had diabetes; 739 (23%) had a left ventricular ejection fraction of less than 0.50; and 484 (15%) were classified unstable/urgent. The conduits included 3,140 left internal thoracic arteries, 1,224 right internal thoracic arteries, and 2,417 radial arteries, 654 of which were bilateral. A Y or T graft with the left internal thoracic artery was used in 467 patients. Patients were followed up at 1 month, 3 months, and yearly thereafter. Postoperative angiography was performed for symptoms or as part of an ethics committee–approved prospective study.
Results. The operative mortality rate was 0.7% (21 patients). Complications included stroke in 26 patients (0.8%), myocardial infarction in 27 (0.8%), sternal infection in 35 (1.1%), and reoperation for hemorrhage in 23 (0.7%). The peak level of the myocardial enzyme of creatine kinase was 16.4 ± 14.9 IU/L. Twenty-five patients (0.8%) required intraoperative or postoperative intraaortic balloon pump support. Mortality and stroke rates were higher in patients having reoperation (0.6% versus 1.8%; p = 0.11; and 0.7% versus 2.2%; p = 0.07, respectively). Postoperative angiographic patency was 97% at 5 years for the left internal thoracic artery (620 grafts), 89% at 5 years for the right internal thoracic artery (276 grafts), and 91% at 1 year for the radial artery (65 grafts).
Conclusions. Total arterial coronary revascularization can be performed safely with good patency rates in a large number of patients and may potentially avoid the sequelae of vein graft atherosclerosis.
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Introduction |
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There has been concern that myocardial revascularization based entirely on arterial grafts may not be able to support the myocardium in the short term [7], particularly in the presence of critical coronary stenoses, cardiomegaly, or left ventricular hypertrophy, and thus lead to hypoperfusion and increased mortality. It has also been thought that there might be a higher morbidity from longer operation times and from possible local ischemic complications (sternum and hand) from bilateral ITA and RA harvesting. The aim of this study was to evaluate our experience with TACR to define the perioperative risks, to establish its safety and efficacy in the perioperative and early postoperative periods, and to document the patency rates in the arterial conduits used.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Graft procurement
Each ITA was harvested as a pedicle 1.5 to 2 cm wide from its bifurcation distally to the subclavian vein proximally. Side branches were clipped and divided. Diathermy use was minimal. Each ITA was dilated by intraluminal and topical administration of papaverine hydrochloride in heparinized arterial blood. The RA was used either as a single artery or as part of a bilateral RA procedure (654 patients) with one or both ITAs. The LITA was harvested simultaneously with the left RA, followed by RITA harvest if required. Bilateral RAs were procured first, the wounds were closed, the forearms were placed beside the torso, and sternotomy was performed. Details of these techniques have been previously published [3, 6]. The conduits used are shown in Table 2.
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The majority of the proximal free arterial graft anastomoses were constructed to the ascending aorta directly. In a redo operation, the hood of an old vein graft was often used as the proximal anastomosis site. Use of a cross-clamp facilitated construction of the proximal anastomoses. Technical details have been previously published [6]. Intraoperative data are summarized in Table 3.
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Surgical strategy
Early in our experience, TACR was used for younger patients, for patients in whom vein grafts had failed and redo CABG was being done, and when there was insufficient conventional conduit. With progressive familiarity and confidence in harvesting, handling, and placing the arterial conduits, we extended the application so that all patients having CABG are considered for TACR, though sometimes it is not performed because of obesity, insulin-dependent diabetes (bilateral ITA), or RA dominance. Currently we achieve TACR in 81% of all coronary procedures.
Distribution of grafts
The LITA was usually placed as a pedicled graft to the LAD (with a sequential anastomosis, if appropriate, to the diagonal artery) and the RITA, to the next most important artery. The RA was the most versatile and usually placed distally to the circumflex coronary artery, posterior descending coronary artery, or left ventricular branch of the right coronary artery. A total of 9,177 distal arterial anastomoses were constructed (2.9 per patient).
Follow-up, database, and analysis
All patients were followed up at 1 month, 3 months, and yearly thereafter (routine review). A shorter interval was used if symptoms occurred. Information from the last follow-up was used. Follow-up in the hospital was by daily consultation until discharge and then by office visit (surgeon, cardiologist, or family practitioner), by telephone interview, at the specially designed radial artery clinic, and by patient survey questionnaire. All data for all patients relating to the entire hospital stay and the 1-month follow-up were 100% complete. Beyond that time, follow-up was 97.2% complete, with 90 patients not available beyond 1 month. The mean follow-up was 30.4 ± 15 months (range, 1 to 124 months).
Postoperative coronary angiography was performed in response to possible cardiac symptoms or as part of an ethics committee–approved arterial conduit graft study (Royal Melbourne Hospital Research and Ethics Committee). Graft data were collected directly from the angiography laboratory. Each angiogram was independently reviewed by the cardiologist, radiologist, and surgeon. Grafts with string signs were defined as not patent.
All data were entered prospectively on a computer database program at hospital discharge, follow-up, and postoperative angiography. Values are expressed as the mean ± the standard deviation. The exact odds-ratio procedure, accompanied by exact 95% confidence intervals, was used to test for differences between primary and redo CABG by TACR (StatXact 3.1; Cytel Software Corporation, Cambridge, MA.) A p value of less than 0.05 was considered significant. The Kaplan-Meier method of actuarial survival and graft survival was used.
Event criteria and definitions
These are in accordance with the guidelines for data reporting and nomenclature of The Society of Thoracic Surgeons. Patient demographics, disease definitions, and symptom category definitions are in accordance with The Society’s database definition and fields.
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Results |
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Operative morbidity
The morbidity related to TACR was low. The results are summarized in Table 4. Twenty-six patients (0.8%) sustained a stroke, and 23 patients (0.7%) required reoperation for postoperative hemorrhage or evacuation of intrathoracic or intrapericardial clot. Thirty-five patients (1.1%) had a sternal infection, but only 2 of the total cohort of 3,220 patients required a muscle flap transfer. A perioperative acute myocardial infarction occurred in 27 patients (0.8%). The mean peak level of the creatine kinase cardiac isoenzyme was 16.4 ± 14.9 IU/L.
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Repeat CABG was associated with higher hospital mortality, more strokes, and greater use of the intraaortic balloon pump than was primary CABG. However, the differences were not significant (Table 5).
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The combined rate for all major operative complications (death, stroke, hemorrhage, sternal infection, and acute myocardial infarction) was 4.1%. The mean time to extubation was 9.0 ± 4.9 hours. The mean postoperative hospital stay was 6.9 ± 4.8 days.
Follow-up
The mean follow-up was relatively short, as most of the TACR procedures had been performed since 1995 with the introduction of liberal use of the RA. Of the patients, 97.2% were available for follow-up beyond 1 month. Mean follow-up was 30.4 ± 15 months (range, 1 to 124 months). The actuarial survival of patients at 5 years was 93.8% ± 2.5%.
Hand and forearm complications
In 2,417 patients, one or both (654) RAs were harvested. Donor forearm complications were extremely rare. There were only two instances (0.08%) of fingertip ischemia; both patients had scleroderma, and an Allen test showed ulnar collateral reperfusion of the hand in the 6- to 10-second time frame. There were nine major forearm hematomas (0.4%), one of which required drainage. Eight patients had minor erythema around the donor forearm wound. There were no major forearm infections. Functional assessment of the donor forearm has previously been reported [6]. The most common problems were forearm scar discomfort and subjective sensory abnormalities, which resolved by 6 months postoperatively.
Postoperative angiography
From 1 month to 120 months postoperatively (mean time, 42 months), 961 arterial conduits have been studied either for possible ischemic cardiac symptoms or for specific ethics committee-approved studies. Because of the symptomatic group, the angiographic results may be biased toward lower patency rates. The patency results are shown in Table 6. The LITA had the best patency rate, followed by the RITA. Angiographic data for the RA are still being accumulated. There was one instance of localized segmental spasm over a distance of 1 cm in an RA graft, which was subsequently dilated with intragraft administration of nitroglycerin. Patent arterial grafts were smooth. There were no instances of intraluminal abnormalities consistent with graft atherosclerosis.
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Comment |
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The logical extension has been to use both ITAs to further extend the benefits seen with the LITA. This strategy has been successful in many units [3, 4, 9–11]. However, patency results for the RITA (85% to 95% at 5 years) are inferior to those for the LITA. This may be related to technical issues or to the placement of the RITA grafts to more distal, less favorable anastomotic targets [3, 4]. Others have failed to find evidence that multiple arterial grafts (including bilateral ITA grafts) provide further clinical benefits. This may be because the additional arterial grafts were often to secondary vessels, such as a diagonal or intermediate artery [12]. Although bilateral ITA grafts could sometimes accomplish TACR, in general this was limited, particularly if the heart was large. Extensive arterial revascularization can be achieved by using the RITA as a free graft with multiple sequential anastomoses or a LITA–RITA T graft [13, 14].
The revival of use of the RA [5] prompted us to try it to achieve TACR. The ease of procurement and the excellent size, length, and handling characteristics make the RA a versatile arterial conduit allowing an uncompromised distal anastomosis beyond any stenosis, particularly on the inferolateral wall [6, 15]. The RA can be used in combination with one or both ITAs. Both RAs are often used with the LITA. Total arterial coronary revascularization has also been reported using the LITA and the RA as a pedicled Y graft [16, 17]. Although there are issues associated with use of the RA, such as occasional calcification, RA dominance, spasm, and potential forearm and hand complications, they can be overcome with appropriate preoperative assessment and intraoperative strategies.
Despite evidence of the potential benefits of multiple arterial grafting, the standard coronary operation remains the LITA to the LAD and vein grafts to the other vessels. This study addresses three major concerns of cardiac surgeons with TACR—infection, arterial graft spasm, and perioperative myocardial hypoperfusion.
Infection is a major concern. We avoid bilateral ITAs in obese patients with insulin-dependent diabetes. We use an ITA retractor that is placed only on the sternum (not on the side bars of the operating table), judicious use of cautery, meticulous hemostasis, closing and draining of each pleural space, and closing of the pericardium, except the most inferior 2 cm, along with a 24-hour regimen of prophylactic antibiotics (floxacillin and gentamicin sulfate or cephalothin sodium) beginning with induction of anesthesia. Use of the RA avoids donor-site wound infections.
Arterial graft spasm is managed by intraluminal administration of warm papaverine (neutral pH by addition of heparinized blood), topical papaverine, avoidance of conduit trauma by harvesting with a no-touch technique, and allowing adequate time for dilation (
15 minutes). The most distal portions of the ITA are smaller and more prone to spasm, and if there is sufficient conduit length, these distal segments are discarded, facilitating construction of the anastomosis and reducing the tendency for spasm [3]. Topical cardiac cooling and pericardial ice slush are avoided, as the cold stimulus can induce arterial graft spasm. Occasionally spasm is seen in the distal LITA after construction of the LITA–LAD anastomosis; this is managed by further topical papaverine in warm (37°C) heparinized blood and high perfusion pressures (mean > 80 mm Hg) on full cardiopulmonary bypass for 10 to 15 minutes. If there is still concern, another aortocoronary free arterial or vein graft could be placed to the LAD.
We have used infusions of nitroglycerin or milrinone from the time of release of the cross-clamp for 24 hours to further protect against arterial conduit and coronary artery spasm, to maximally dilate the coronary bed to enhance graft flows, and to favorably adjust preload and afterload conditions for the heart. Both are powerful vasodilators, and infusion allows their facile use. We have not used diltiazem hydrochloride infusions (not available in Australia). Recent reports indicate that nitroglycerin may be a more appropriate vasodilator [18]. A calcium-channel blocker (amlodipine) was given empirically for 6 months on the basis of the documented occurrence of isolated and transient segmental RA spasm in postoperative angiograms [5].
Perioperative myocardial hypoperfusion has been documented and is of concern [7]. It may be related to arterial conduit or arterial graft spasm, or to technical errors such as inadequate conduit length, tension, kinking, or technical problems with the anastomosis. Hypoperfusion can occur where a previously functioning stenotic vein graft has been interrupted and replaced with an ITA graft. We meticulously avoid the patent diseased vein graft, leaving it in situ, and place the new arterial graft more distally. Cardiac dysfunction after bypass can also be related to primary myocardial dysfunction (low baseline ejection fraction), prolonged operation and inadequate myocardial protection, the possibility of atheromatous embolization from old patent diseased vein grafts, and the state of the distal vessels.
One of the aims of this study was to address the concern of the potential inability of arterial conduits alone to support the myocardium in the perioperative period, with a resultant potential increase in perioperative low cardiac output, perioperative infarction, and mortality. However, the incidence of these complications has been extremely low and comparable to that in series where conventional grafting strategies (LITA and vein grafts) were used. Others [19] have shown that patients receiving multiple arterial grafts have a lower incidence of low cardiac output, perioperative infarction, and perioperative mortality and have a survival benefit especially if there are preoperative comorbid conditions [9–11, 19, 20]. Even in the context of major left main stenosis (12.3% of patients), the TACR grafting strategy was capable of supporting the myocardium.
The optimal deployment of arterial conduits remains controversial. We use the LITA to the LAD/diagonal system, the RITA (in younger patients) to the next most important artery, and then the RA, with only a modest reliance on sequential anastomoses. Free grafts were predominantly anastomosed to the ascending aorta proximally in a facile manner with the single cross-clamp technique. Most (85%) of our patients had two or more separate graft inflows. Others [14, 16, 17] believe the LITA alone is capable of providing the required inflow for the graft circulation and have advocated use of a LITA–RITA or LITA–RA Y or T graft. Arguments for this technique are that it more closely reproduces the physiology of the arterial conduit as a third-order branch, may safeguard against development of intimal hyperplasia (though this benefit is not proven), preserve arterial conduits (as only two are required), reduce operating times, require fewer incisions, and minimize ascending aorta manipulation. We have a modest experience (467 patients in this series) with this technique. It is used routinely by one of us (A.G.R.) or for specific indications such as inadequate conduit availability or length or to avoid proximal anastomoses on an atheromatous ascending aorta. The early results of the Y graft technique are good [16], and if long-term angiographic studies are favorable, there will be substantial support for expansion of its use.
Postoperatively, 961 arterial conduits were studied. The angiographic follow-up on ITA grafts was longer, as they were in use from the beginning of this study. The RA grafts were introduced in 1995. The patency of the LITA grafts was superior (97% at 5 years), which is in accordance with previously published series. The patency rate for the RITA was excellent (89% at 5 years), though inferior to that of the LITA. Published RITA graft patencies range from 75% to 94.5%, and these values may reflect the effect of placement to more distant, smaller, and less ideal coronary vessels, as seen in the inferior patency rates of vein grafts placed to vessels other than the LAD. In addition, technical factors such as tension and compromised anastomotic sites may be relevant. In our experience [21], the patency of pedicled RITA grafts was slightly superior to that of the free RITA. However, pedicled grafts are more frequently attached proximally to larger coronary arteries in contrast to free grafts anastomosed more distally; hence patency rates may reflect these differences in graft distribution.
The RA patency rate of 91% at 1 year was excellent but inferior to the rates for the ITA. Early RA patency rates (less than 3 months) have been reported to range between 96% and 100% and the rate at 1 year to 2 years, between 84% and 100% [6, 16, 22]. These results also suggest the RA may have an inferior patency to the ITA. The reasons for this are not defined; the lower rate may be due to the biological behavior of the graft, its placement to distal smaller coronary arteries, and the issue of the proximal anastomosis. The importance of string signs, particularly in free ITA and RA grafts, is unknown and controversial. Do they represent a physiologic response—autoregulation of flow in a conduit placed to a large coronary artery with a noncritical stenosis—and if present for a substantial period, do they become a permanent change?
Theoretically there are no strict contraindications to TACR. However, we would avoid total revascularization with a LITA–RA composite graft where the LITA was small with a poor flow or where the RA was dominant or calcified. One could also question the wisdom of harvesting and placing an arterial graft to an occluded coronary artery that supplied an old infarct.
In conclusion, TACR is safe, having a low operative mortality and morbidity, and can be used in a substantial number of patients requiring CABG. The patency of the arterial conduits is excellent, particularly for the ITAs, and is extremely promising for the RA. Importantly, no atheromatous changes were noted in the arterial grafts, and this potentially may lead to fewer reoperations in patients undergoing TACR.
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