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Ann Thorac Surg 2000;69:65-69
© 2000 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kamakura, Japan
Address reprint requests to Dr Sato, 1202-1 Yamazaki, Kamakura, Kanagawa 247-8533, Japan
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Abstract |
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Methods. Between July 1997 and June 1998, 13 patients received CABG with GEA (larger caliber than 2.0 mm) composite graft. We have assessed the early results.
Results. There was no postoperative death or major morbidity. Postoperative angiogram was performed in 11 patients and all conduits were patent. Postoperative exercise stress test was done in 13 cases and showed no ischemia.
Conclusions. Multiple CABG with arterial conduit can be performed by this procedure. The free RA functioned from secondary branches derived from proximal GEA. In conclusion, this procedure seems to be safe and effective, and both long-term patency and better quality of life may be expected.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Patient selection
The composite AG were selected because the target coronary artery showed small-caliber or severe stenosis or total occlusion at the preoperative angiogram. The following conditions are also considered as the reason for the selection: 1) multiple revascularization of more than three distal anastomoses; 2) avoidance of the use of bilateral ITA because of severe diabetes; and 3) use of the RA in patients with negative Allen test. The patients who had chronic renal dysfunction (serum creatinine > 2.0 mg/dL) and elderly patients over 70 years were excluded.
Operative technique
Graft harvest
Through a median sternotomy, left ITA (LITA) was harvested in semi-skeletonized fashion [3] as described previously. Simultaneously, RA was harvested using the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) [4] as described previously. After total mobilization, the artery was cannulated and kept in the heparinized blood with papaverine until its use [5]. Unilateral fasciotomy was performed before use. In 2 cases, the Allen test was positive, and a free right ITA (RITA) was used in 1 and an inferior epigastric artery (IEA) was used in the other to create the composite graft.
After harvesting ITA, skin incision was extended 1 to 2 inches distally and the GEA was harvested by using the Harmonic Scalpel [4].
After general heparinization, the distal ends of the LITA and GEA were cut, and 1 to 2 mL of diluted papaverine solution (20 mg in 20 mL normal saline) was inserted into each graft. After the injection of the diluted papaverine, the GEA was indicated as an inflow of the composite graft when the distal size of the GEA was larger than 2.0 mm in diameter.
Coronary revascularization
Normothermic cardiopulmonary bypass (CPB) and antegrade intermittent warm blood cardioplegia [6] were used. During preparation for the distal anastomosis, to prevent the graft spasms, free RA was dilated under perfusion pressure to connect to the side tube of inflow line of the CPB circuit. The graft was kept pulsatile until its use. Under cardioplegic heart arrest, coronary revascularization was performed first with the free RA to the target LCX branches, such as the obtuse marginal branch (OM) and/or posterolateral branch (PL), then to the RCA branches, such as the posterior ascending branch (PDA) or atrioventricular nodal branch (AV), with 8-0 polypropylene suture using sequential anastomosis technique; for example, distal free RA end to obtuse marginal branch, free RA side to posterolateral branch, and proximal RA end to posterior descending branch. The GEA was then anastomosed to 1 to 2 cm distal from the proximal RA end in an end-to-side fashion with 8-0 polypropylene suture as an inflow of the free RA. Finally, LITA was anastomosed to LAD with 8-0 polypropylene suture (Fig 1).
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The types of conduits and the grafted coronary arteries are shown in Table 1. LITA was anastomosed to LAD in all cases. Free grafts such as RA, RITA, and IEA were secured to the coronary arteries with occlusion or tight stenosis depending upon the GEA flow competition [8].
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Early postoperative examination
The exercise stress test with 201T1 myocardial scintigraphy was done in all cases, and postoperative angiogram was performed in 11 cases (85%).
Follow-up
Follow-up information on the patients was collected through direct patient contact, from responses to telephone interview. The following postoperative cardiac events were also recorded during follow-up: new MI on electrocardiogram, recurrent angina, postoperative intervention such as percutaneous transluminal coronary angioplasty (PTCA) or reoperation, and noncardiac death. Mean follow-up period was 11.5 ± 3.7 months (range 6 to 17 months). Repeated angiogram after more than 6 months was performed in 2 patients.
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Results |
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Mortality and morbidity
There was no early postoperative mortality. All patients except 1 were successfully weaned from the CPB uneventfully. A hypoperfusion occurred in 1 case before coming off pump. The cause was suspected to be low flow of the LITA anastomosed to the LAD, judging from the transesophageal echocardiographic finding. The CPB was easily weaned after immediate supported saphenous vein grafting to the distal LAD without any mechanical supports. The postoperative course was uneventful and the postoperative angiogram showed fully patent grafts including LITA to proximal LAD. Swan-Ganz catheter was installed in all patients and, including this case, there was no low-output syndrome, perioperative MI, or any other morbidities. Reexploration for postoperative bleeding from ITA branches was performed in 1 case.
There was no postoperative ischemia noted by exercise stress test. In postoperative angiogram, the LITA, free RA, and free RITA grafts were all patent (Figs 2, 3) without any spasms or stenosis.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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The RA was first used for CABG by Carpentier and associates [9] in 1973; however, soon its use was abandoned because of its strong tendency to spasm. At the beginning of 1990s, Acar and colleagues [10] reported revival of this graft with a 93.5% patency rate at 9.2 months due to the adjunct of calcium-channel blockers in the postoperative period. Since then, RA has been advocated as an alternative to the SV for CABG because of the high patency rates and superior flow characteristics [11]. While the site of the proximal anastomosis of RA was the ascending aorta in all cases in Acar and associates’ report [10], Calafiore and coworkers [12] reported RA was always proximally anastomosed to an in situ ITA for several reasons. They thought the proximal site of anastomosis could be the main reason of graft failure; therefore, they avoid a proximal anastomosis to the ascending aorta. They emphasized that because RA is the third aortic branch, the rate of rise of left ventricular pressure in its natural position is different from that in the aorta-coronary artery position and the modified wall stress could be the basis of early or late graft failure.
In this report, we used RA in composite graft because the diameter is as large as a vein graft and easily anastomosed to the coronary artery. We selected in situ GEA as the inflow of the RA because, as in our previous report [1, 2], the GEA was larger in diameter than that of ITA. The LAD was always revascularized with in situ LITA. In this procedure, the coronary artery was always anastomosed by in situ AG, and no anastomosis was placed in the ascending aorta. Therefore, it may be also useful in case of a difficult aorta to avoid neurological complication [13].
The choice of the target coronary branch for the RA was also one of the important issues. As Calafiore and associates [12] described, the RA was a conduit with enough length in comparison with other free AG, and it is suitable for multiple sequential anastomosis. However, regarding the sequential grafting with AG, the flow distribution seems to be a major problem. In 1990, Kesler and associates [14] reported the excellent results of sequential LITA grafting to the LAD system, and if after pharmacological dilation, the ITA diameter is smaller than 2.0 mm, they would most likely select not to use the conduit for sequential bypass, especially if either the LAD or the diagonal arteries were quite large (2.5 mm). Therefore, we expected the conduits with larger caliber to achieve superior long-term patency after sequential CABG, and the RA seemed to be a more suitable conduit for this technique rather than other AG with smaller diameter, such as IEA or ITA. As an inflow of this graft, the GEA larger than 2 mm in distal diameter was thought to be suitable to obtain efficient flow of the sequential grafting with RA. In situ GEA was the most favorable arterial graft to revascularize to the posterolateral or diaphagmatic wall. In the present report, the proximal side of the free RA graft was anastomosed to the PL or RCA distal branch; therefore, in situ GEA seemed to reach easily 1 to 2 cm distal from the proximal RA end, so we could anastomose the proximal GEA.
Several investigators have reported flow competition [8] between the native coronary artery and the GEA. However, in our patients, we had no experience of hypoperfusion in the posterolateral or inferior area, and postoperative angiography revealed widely patent RAs without any flow insufficiency. Therefore, we consider the GEA composite graft to be favorably used to revascularize both LCX and RCA areas.
In conclusion, multiple CABG with only arterial conduit can be performed by this procedure, in which free arterial conduits such as RA and RITA functioned as secondary arterial branches derived from proximal GEA. No proximal anastomosis was required, and LAD was revascularized by in situ LITA without any composite branches. It seems to be safe and effective to use this procedure, and long-term patency and better improvement after CABG may be expected.
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References |
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This article has been cited by other articles:
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  T. Fukui, S. Takanashi, Y. Hosoda, and S. Suehiro Total Arterial Myocardial Revascularization Using Composite and Sequential Grafting With the Off-Pump Technique Ann. Thorac. Surg., August 1, 2005; 80(2): 579 - 585. [Abstract] [Full Text] [PDF]
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K. Tsunemi, S. Takai, M. Nishimoto, A. Yuda, D. Jin, M. Sakaguchi, Y. Sawada, K. Asada, K. Kondo, S. Sasaki, et al. Lengthy suppression of vascular proliferation by a chymase inhibitor in dog grafted veins J. Thorac. Cardiovasc. Surg., September 1, 2002; 124(3): 621 - 625. [Full Text] [PDF]
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