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Ann Thorac Surg 2000;69:318
© 2000 The Society of Thoracic Surgeons

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Correspondence

New method of myocardial revascularization with the radial artery

^a Department of Cardiothoracic Surgery, Royal Brompton & Harefield NHS Trust, Sydney St, London, England SW3 6NP, United Kingdom

e-mail: william.chong{at}ic.ac.uk

To the Editor

There have been several publications on new and innovative methods of anastomosing arterial conduits to achieve total arterial revascularization with the least amount of arterial conduits [1, 2]. These techniques are technically challenging and creative, such as the recently published "horseshoe radial artery graft," allowing for complete arterial revascularization of all myocardial areas [1]. However, there are concerns regarding the effect this may have on long-term graft survival. We have no long-term patency data on any of these techniques. By creating such grafts as the "inverted T" [2] or "Y" or "horseshoe" grafts [1], the hemodynamic forces these grafts are subjected to may be adversely abnormal.

Studies on hemodynamics of flow in human arteries have shown the predilection for atherosclerotic plaque formation at areas of bifurcation ("Y" and "T" grafts), branching, and curvature (horseshoe pattern) [3]. These are areas associated with reduced flow velocity and wall shear stress, and where flow departs from a laminar unidirectional pattern. The success of the pedicled left internal thoracic artery graft has partly been attributed to the fact that it is grafted onto the left anterior descending (LAD) artery, which has the straightest course with no acute curvature in the myocardium. Long saphenous vein graft situated onto the LAD also performed substantially better than if it was grafted to other coronary arteries, with patency rates decreasing in descending order from LAD to circumflex (Cx) and right coronary (RCA) arteries [4]. The Cx and RCA both have obtuse and acute curvatures, respectively, in their course on the heart.

The formation of "Y," "T," or "horseshoe" grafts create branching, curvatures, and bifurcations, which are likely to be associated with abnormal hemodynamic forces leading to accelerated development of atherosclerotic plaques. Furthermore, arterial grafts are living conduits, and by creating such anastomoses, they are being used mainly as passive piping. It is a valid reason to perform such grafts in cases of a diseased or calcified ascending aorta, but caution must be taken when advocating the routine use of such anastomotic design until more long-term data are available.

References

1. Aguero O.R., Navia J.L., Navia J.A., Mirtzouian E. A new method of myocardial revascularization with the radial artery. Ann Thorac Surg 1999;67:1817-1818.[Abstract/Free Full Text]
2. Tashiro T., Nakamura K., Iwakuma A., et al. Inverted T graft. Ann Thorac Surg 1999;67:629-631.[Abstract/Free Full Text]
3. Glagov S., Zarius C., Giddens D.P., Ku D.N. Hemodynamics and atherosclerosis. Insights and perspective gained from studies of human arteries. Arch Pathol Lab Med 1988;112:1018-1031.[Medline]
4. Lytle B.W., Loop F.D., Cosgrove D.M., Ratliff N.B., Easley K., Taylor P.C. Long-term (5–12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248-258.[Abstract]

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