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Ann Thorac Surg 2000;69:498-500
© 2000 The Society of Thoracic Surgeons

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Original Articles

Complete myocardial revascularization with bilateral internal thoracic artery T graft

^a Department of Cardiac Surgery, Centre Hospitalier Universitaire de Charleroi, Jumet, Belgium

Address reprint requests to Dr El Nakadi, Department of Cardiac Surgery, CHU de Charleroi, 73 rue de Gosselies, 6040 Jumet, Belgium
e-mail: badih.el.nakadi{at}village.uvnet.be

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The internal thoracic artery is widely recognized as the ideal graft for coronary artery bypass procedures. However, because of the inadequate length of the conduit, use of bilateral internal thoracic artery grafting was not suitable for complete revascularization. To overcome this limitation, the T graft was introduced in the 1990s. We decided to prospectively assess the safety of this technique.

Methods. One hundred six patients with a mean age of 51.5 years underwent complete revascularization with an internal thoracic artery T graft. Mean left ventricular ejection fraction was 0.60 (range, 0.22 to 0.85).

Results. No patient required reexploration for bleeding, and no patient died within 30 days after operation. On the basis of electrocardiographic changes, 3 patients sustained a perioperative myocardial infarction. One patient had a sternal wound infection. Mean follow-up was 35 months (range, 15 to 61 months). The actuarial survival rate was 99% ± 1% at 5 years. No myocardial infarctions were reported during the follow-up. Seven patients had recurrent angina. Eighty patients (76%) underwent postoperative stress tests, and 90% had negative results.

Conclusions. Complete myocardial revascularization with the T graft is a safe and reliable technique with excellent midterm results.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
In the 1980s, several studies [1–3] clearly demonstrated a significant improvement in long-term survival when the left anterior descending coronary artery (LAD) was bypassed with the attached left internal thoracic artery (LITA). This conduit was widely recognized as the ideal graft for coronary artery bypass procedures even in comparison to other arterial grafts [4, 5]. However, the use of bilateral ITA grafting was not considered suitable for complete revascularization because of the inadequate length of the conduit. To overcome this limitation, Tector and associates [6] introduced the T graft, constructed by anastomosis of the free right ITA (RITA) to the attached LITA, thereby adding an extra 10 cm of length to the RITA. We decided to prospectively assess the safety of the technique in a select population and report here the early and midterm results.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between January 1994 and September 1997, all patients who had three-vessel disease and were younger than 60 years old as well as older patients without available vein graft were totally revascularized with an ITA T graft. Patients with insulin-dependent diabetes and severe obesity (body mass index > 33 kg/m²) or with severe obstructive lung disease were excluded.

All patients received a standardized anesthesia procedure including Swan-Ganz catheter monitoring. Operation was performed through a median sternotomy. We used a 3.5 power magnification and a Pittman retractor (Omni-Tract; Surgical Division of Minnesota Scientific, Inc, Minneapolis, MN). Before heparinization, the ITAs were harvested with cautery of and titanium clips on the branches. They were dissected with a pedicle of muscle and fascia to minimize arterial wall damage and to prevent graft twisting. After heparin administration, the LITA was prepared with careful and gentle intraluminal injection of a papaverine hydrochloride solution. The artery was clamped at its distal end, thus allowing the blood pressure to achieve maximum vessel distention. The RITA was then taken down, and papaverine solution was gently injected into its proximal end. It was not used beyond its bifurcation.

Classic cardiopulmonary bypass and antegrade cold crystalloid cardioplegia were used. The first anastomosis was placed on the posterior descending artery in an end-to-side perpendicular fashion, using the distal end of the RITA. Posterolateral anastomoses were performed in a side-to-side diamond-shaped fashion. After each suture completion, 100 mL of crystalloid cardioplegia was injected into the proximal end of the RITA, and the pedicle was sutured to the epicardium. A 1-cm parallel arteriotomy was made on the posterior wall of the LITA. The T anastomosis between the two ITAs was performed in an end-to-side perpendicular fashion. The pedicles were sutured together to prevent twisting. The anterior wall anastomoses were then performed.

Cardiac enzyme analysis and electrocardiography were done on all patients immediately after operation and 8 hours postoperatively as well as 24 hours, 2 days, 5 days, and 8 days after grafting. Surgical follow-up was performed at approximately 6 weeks, and routine follow-up including stress testing was carried out by the referring cardiologists.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
One hundred six patients with a mean age of 51.5 years (range, 35 to 69 years) were included in the study. Preoperative characteristics are listed in Table 1. Fifty-eight patients (55%) underwent stress testing with positive results in 90%. Left ventricular ejection fraction ranged from 0.22 to 0.85 with a mean of 0.60. Eight patients had previously undergone coronary artery bypass grafting.

There were no deaths within 30 days after operation. Postoperative complications included myocardial infarction in 3 patients (3%), transitory ST-segment elevation in 12 (11%), and sternal wound infection in 1 patient (0.9%). None of the patients with transitory ST-segment elevation sustained a myocardial infarction. The patient with a sternal wound infection was not obese or diabetic. No patient had bleeding postoperatively.

One patient was lost to follow-up. Data for the remaining 105 patients were collected from cardiologist reports and telephone interviews. Mean follow-up was 35 months (range, 15 to 61 months). The actuarial survival rate was 99% ± 1% at 5 years. The patient who needed an intraaortic balloon pump died 22 months after operation.

No myocardial infarctions were reported during follow-up. Seven patients, all in Canadian Heart Association class 2, experienced recurrent angina. Five of them became asymptomatic under medical treatment. Eighty patients (76%) underwent postoperative stress testing, 72 (90%) of whom showed no evidence of residual ischemia. Two of the 8 patients with a positive result were symptomatic and underwent coronary angiography. One had an occlusion of the portion of the RITA between the LITA and the anastomosis to the first circumflex branch; the remainder of the RITA was patent. The other had an occlusion of the LITA–LAD bypass graft. One of the remaining 6 patients obtained a negative stress test result with the use of ß-blockers. The 5 other asymptomatic patients, who were in Canadian Heart Association class 2 or 3 before operation, refused angiography. Elective angiography was performed in only 3 patients because the other patients or their cardiologists refused this postoperative control. All T grafts were patent. One anastomosis to the LAD was occluded.

Two patients had sternal instability and required surgical repair.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The ITA is now widely recognized as the best graft for coronary artery bypass procedures. Its high rate of long-term patency [1–3] is due to the low risk of intimal thickening and to the freedom from major atheromatous disease in this elastic conduit [4, 5]. Several studies [7–9] showed a reduction in ischemic events and improved long-term survival when bilateral ITA grafting was used. However, the inadequate length of the in situ or free RITA necessitated the use of other arterial or venous grafts in patients with three-vessel disease.

In 1994, Tector and co-workers [6] introduced the T graft technique, allowing the RITA to reach the posterior circumflex and the right coronary artery branches while preserving the principle of bypassing the LAD with the attached LITA. Our technique differs slightly in the timing of heparin administration and in the sequence of anastomoses. Indeed, we found it easier to begin the posterior anastomoses with the RITA before performing the T anastomosis during cardiac arrest, instead of performing it on a beating heart.

With the extended use of bilateral ITA grafting, its operative mortality became almost equal to that of single ITA grafting [7–10]. The mortality rate reported with the T (or Y) graft technique ranges between 0% and 3.7% [6, 11, 12]. There were no hospital deaths.

One of the major concerns about bilateral ITA grafting is sternal wound infection. The reported incidence ranges between 0% and 7% [8–10]. In the study of Kouchoukos and associates [13], bilateral ITA harvesting was the strongest predictor of the development of sternal complications. Associated significant risk factors were obesity, diabetes, and prolonged mechanical ventilation. In our series, the only patient requiring a muscle flap had none of these risk factors.

In a 5-year follow-up study, Green and colleagues [8] found a significant decrease in the incidence of postoperative angina when comparing the results of a single ITA anastomosis with the results of multiple anastomoses (32.5% versus 10.5%). Seven percent of our patients had recurrent angina, but none sustained a myocardial infarction. Of the 12 patients in whom transient ST-segment elevation developed within the first hours after operation, 4 had positive postoperative stress test results. Two of them were symptomatic. Control angiography showed a segmental occlusion of one of the ITAs. Even when there are no hemodynamic or late resting electrocardiographic changes, we believe that transient ST-segment elevation could result from kinking or stretching of the T graft, leading to occlusion. These 4 patients were operated on early in our experience, when the T anastomosis was constructed as proximally as possible on the LITA. Since then, the RITA has been sutured more distally on the LITA, 1 to 2 cm distal to its point of entry in the pericardial space.

Elective postoperative angiography was performed in 3% of patients without ischemic symptoms. Patients who gave their consent preoperatively were reluctant to undergo the control at 1 year. Some groups [6, 12] had a better rate of patency control. The patency of the LITA ranged from 93% to 100%, which was similar to that of the LITA when used as a single graft to the LAD. The patency of the free RITA ranged from 88% to 91%, which was similar to or slightly higher than the patency of aorto-coronary free ITA grafts [14, 15].

The findings in the group of patients who required reoperation were comparable to those seen in our general population with respect to the incidence of morbidity, mortality, length of hospital stay, and midterm results.

This technique appeared safe in our select population, and we are currently performing it in older patients, although selectively. This method has the advantage of eliminating the morbidity of harvesting other conduits. Longer follow-up is required to evaluate the long-term results and to confirm its theoretical advantage in decreasing recurrent ischemic events.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Badih El Nakadi Marc Joris Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by El Nakadi, B. Articles by Joris, M. Search for Related Content PubMed PubMed Citation Articles by El Nakadi, B. Articles by Joris, M.