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Ann Thorac Surg 2002;73:131-137
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Flow dynamics in internal thoracic artery grafts 10 years after coronary artery bypass grafting

Yukio Ichikawa, MD*a, Hirokazu Kajiwara, MDb, Yasuharu Noishiki, MDa, Ichiya Yamazaki, MDa, Kenji Yamamoto, MDb, Takayuki Kosuge, MDb, Sunao Sato, MDb, Yoshinori Takanashi, MDa

a First Department of Surgery, Yokohama City University School of Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
b Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan

Accepted for publication August 6, 2001.

* Address reprint requests to Dr Ichikawa, First Department of Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Flow dynamics in internal thoracic artery grafts 10 years after surgery are not known.

Methods. Doppler examination was performed in native internal thoracic arteries as a control (n = 8) and in internal thoracic artery grafts to the left anterior descending coronary artery 6 months postoperatively (group A, n = 25), at 5 years (group B, n = 14), and at 10 years (group C, n = 11).

Results. Each graft group showed a diastolic to systolic peak velocity ratio of less than 1.0 at the proximal end, and more than 1.0 at the distal end, but the control group showed a ratio of less than 1.0 throughout the length of the artery. The diastolic peak velocity of the graft groups was significantly faster than that of the control group at the distal end (versus group A, p < 0.01; versus group B, p < 0.005; and versus group C, p < 0.05). The systolic peak velocity of the graft groups was significantly lower than that of the control at the proximal end (versus group A, p < 0.0001; versus group B, p < 0.005; and versus group C, p < 0.0005). There were no significant differences of flow velocities among the graft groups and graft diameter among the four groups.

Conclusions. Although the internal thoracic artery is systolic predominant, when native artery is used as graft, it changes its hemodynamics to diastolic predominance, especially at the distal end. Even after 10 years, graft flow dynamics are unchanged. This hemodynamic character may be one of the factors related to the superior long-term patency.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
How is the flow velocity of internal thoracic artery graft in the long term after coronary artery bypass grafting (CABG)? How does the flow velocity of the conduit relate to the patency of the graft? These are simple but important questions for cardiovascular surgeons.

The internal thoracic artery (ITA) has been shown to be the most reliable conduit for CABG. Favorable effects on mortality and morbidity are observed irrespective of age or left ventricular function and are particularly evident if the ITA is implanted into a proximally stenosed left anterior descending coronary artery (LAD), in view of the large area of myocardium subtended by this native vessel [1, 2]. There have been many anatomic and physiologic studies of the ITA, and the effects of the anatomic and physiologic properties of the ITA on its patency have been discussed [3–5]. The structural and physical properties of the ITA confer excellent resistance to atheroma [6, 7].

However, the relationship between the hemodynamic properties and patency of ITA grafts has not been determined, and the flow characteristics of native ITAs that control the results of bypass grafting have not been widely reported. Flow dynamics of internal thoracic artery grafts 10 years after CABG and flow dynamic alteration of native internal thoracic arteries as in situ grafts are not known.

To make clear the flow dynamic predominance of the ITA that might affect graft patency, blood flow velocities of native ITAs and ITA grafts 6 months, 5 years, and 10 years after CABG were measured with a 0.018-inch Doppler guidewire (FloWire, Cardiometrics, Inc, Mountain View, CA) and a velocimeter (FloMap, Cardiometrics, Inc, Mountain View, CA) after graft angiography.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient population
The study population consisted of 72 patients (58 men, 14 women) without anterior myocardial infarction who had had CABG (69 patients) or who needed coronary angiography because of angina (3 patients). Of these 72 patients, 50 patients whose ITA grafts for the graft to the left anterior descending coronary artery (LAD) were studied, and 19 patients were excluded from the study because of difficulty obtaining reliable data. Coronary angiography and Doppler examination of bypass conduits after right and left cardiac catheterization were performed. The patients who were included in this study were chosen sequentially from the cases for evaluation of coronary artery and graft patency according to our arterial revascularization protocol study as part of routine follow-up.

The patients were classified into the following four groups. The control group consisted of 7 patients with native ITA (six men, one woman; four right ITAs, four left ITAs); 3 patients were preoperative and the other 4 patients had had CABG but had at least one native internal thoracic artery (one member of the control group was also used for group C measurements). Group A consisted of 25 patients (19 men, six women; nine right ITAs, 16 left ITAs) assessed 6 months postoperatively; group B consisted of 14 patients (11 men, three women; eight right ITAs, six left ITAs) 5 years postoperatively; group C consisted of 11 patients (10 men, one woman; two right ITAs, nine left ITAs) 10 years postoperatively.

The Human Subjects Committee of the Kanagawa Cardiovascular and Respiratory Center Review Board approved the study and written consent was obtained before the study.

Grafts for flow velocity measurement
We selected pedicled ITA grafts to LADs that had stenotic lesions in more than 75% and were free of significant distal coronary stenosis. The ITAs had no angiographic evidence of significant luminal stenosis.

Cardiac catheterization and angiography
All patients received intravenous heparin (2000 U) before examination. Right and left heart catheterization was done by the femoral approach using Judkins’ technique with 0.5% lidocaine local anesthesia. Left ventriculography was done after right and left heart pressure data were obtained, and cardiac output was measured by the thermodilution method. Selective coronary angiography, native ITA angiography, and graft angiography were performed after oral spray of isosorbide dinitrate (0.6 mg).

To measure the diameter of the graft at the position corresponding to the tip of the Doppler guide wire where flow velocity was obtained, graft angiography was analyzed quantitatively by videodensitometry (INTEGRIS H/HM/BH/V3000, Philips Medical Systems International BV, Best, The Netherlands). During catheterization, a 12-lead surface electrocardiogram was monitored continuously.

Blood flow velocity measurements
Blood flow velocities were obtained in the proximal and distal ends of the native ITA and ITA graft with a 0.018-inch Doppler guide wire (FloWire, Cardiometrics, Inc, Mountain View, CA) and a velocimeter (FloMap, Cardiometrics, Inc, Mountain View, CA) after selective coronary angiography. The Doppler guide wire was advanced into the native ITA or the bypass graft through a 5F coronary angiography catheter (Goodtec, Goodman, Inc, Nagoya, Aichi, Japan). Flow velocities of the ITA were obtained in the proximal end 10 to 20 mm from the conduit ostium and in the distal end 10 to 20 mm from bifurcation of the ITA or graft anastomosis, as determined by the angiographic images. An optimal Doppler signal was obtained by moving the guide wire slightly within the artery and adjusting the range gate control. During the Doppler study, a 12-lead surface electrocardiogram and a pressure waveform at the tip of the guiding catheter were monitored continuously. Frequency analysis of the Doppler signals was performed in real time by fast-Fourier transform using a velocimeter [8, 9]. Doppler signals were recorded at rest on videotape and by a video printer at a sweep speed of 100 mm/second; the electrocardiogram and aortic pressure tracing also were recorded. Systolic peak velocity (SPV), diastolic peak velocity (DPV), mean velocity (MV), and the ratio of diastolic to systolic peak velocity (DSVR) were measured from the phasic coronary flow velocity recording as previously reported [8, 9].

Data were acquired from eight native internal thoracic arteries (seven proximal and eight distal recordings) and 50 ITA grafts (49 proximal and 45 distal recordings). None of the patients had complications related to conduit cannulation or Doppler guide wire instrumentation.

Statistical analysis
Continuous values were expressed as mean ± standard deviation (SD). Comparisons of variables between the control group and ITA graft groups were performed using one-way analysis of variance and Scheffé F test, and between two different sites within each group using a paired t test for factor analysis. Statistical differences were considered significant at a value of p less than 0.05 (two sided).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Patient characteristics
There were no significant differences among the four groups with regard to mean pulmonary artery pressure, mean pulmonary capillary wedge pressure, mean aortic pressure, left ventricular end-diastolic pressure, cardiac index, left ventricular ejection fraction, pulse rate or body surface area. Patient characteristics are summarized in Table 1.


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  		Table 1. Patient Characteristics

 
Native internal thoracic arteries
The MV, SPV, and DPV of the native ITAs at the distal end were 0.50 to 0.59 times that at the proximal end (proximal flow velocity > distal flow velocity) (p < 0.0001, p = 0.0001 and p = 0.0042, respectively) (Figs 1, 2, and 3).



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  		Fig 1. Comparison of mean velocity (MV) in native internal thoracic arteries among all four groups. There were no significant differences among the groups at the proximal or distal ends. *Proximal versus distal, p < 0.0001

 


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  		Fig 2. Comparison of diastolic peak velocity (DPV) in native internal thoracic arteries among all four groups. *Proximal versus distal, p = 0.0042. {dagger}Native internal thoracic arteries versus internal thoracic artery grafts at the distal end. Group A, p = 0.007; group B, p = 0.002; group C, p = 0.046.

 


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  		Fig 3. Comparison of systolic peak velocity (SPV) in native internal thoracic arteries among all four groups. *Proximal versus distal: control group, p = 0.0001; group A, p = 0.0008; group B, p = 0.001; group C, p = 0.005. {dagger}Native internal thoracic arteries versus internal thoracic artery grafts at proximal end: group A, p less than 0.0001; group B, p = 0.003; group C, p = 0.0004. {ddagger}Native internal thoracic arteries versus internal thoracic artery grafts at distal end: group A, p = 0.001.

 
The diastolic peak velocity of the native ITAs was 0.54 times and 0.59 times the mean velocity at the proximal and distal end, respectively. And the systolic peak velocity of the native ITAs was 1.93 times and 1.80 times the mean velocity at the proximal and distal ends, respectively (SPV > MV > DPV). Diastolic-systolic peak velocity ratio was 0.3 at both the proximal and distal ends of the native ITAs (Fig 4). Flow velocity data are shown in Table 2.



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  		Fig 4. Diastolic-systolic velocity ratio (DSVR). *Native internal thoracic artery versus internal thoracic artery grafts at proximal and distal ends: group A, p = 0.0001, p < 0.0001, respectively; group B, p = 0.004, p = 0.0007, respectively. {dagger}Native internal thoracic artery versus internal thoracic artery grafts at proximal end: group C, p = 0.016.

 

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  		Table 2. Flow Velocity Data

 
Internal thoracic artery grafts
The mean velocity of the ITA grafts at the distal end was 0.86 to 0.91 times that at the proximal end of the ITA grafts. There were no significant differences in the mean velocity between the native ITAs and ITA grafts at the proximal and distal ends.

The DPV at the distal end of the ITA grafts was 1.06 to 1.15 times that at the proximal end. The DPV/MV ratio of the ITA grafts was 0.91 to 0.95 and 1.07 to 1.20 at the proximal and distal ends, respectively. There was no significant difference in the DPV between the native ITAs and ITA grafts at the proximal end. But at the distal end, the DPV differed significantly between the native ITAs and ITA grafts at 6 months, 5 years, and 10 years after operation (p = 0.007, p = 0.002, and p = 0.046, respectively) (Fig 2).

The systolic peak velocity at the distal end of the ITA grafts was 0.51 to 0.65 times that at the proximal end of the ITA grafts (proximal flow velocity > distal flow velocity). There were significant differences in the systolic peak velocity between both sides of the grafts at 6 months, 5 years, and 10 years postoperatively (p = 0.0008, p = 0.001, and p = 0.005, respectively) (Fig 3).

The SPV/MV ratio of the ITA grafts was 1.10 to 1.19 and 0.63 to 0.85 at the proximal and distal ends, respectively. The SPV differed significantly between the native ITAs and ITA grafts at 6 months, 5 years, and 10 years postoperatively at the proximal end (p < 0.0001, p = 0.003, and p = 0.0004, respectively). At the distal end there was a significant difference in the SPV between the native ITAs and ITA grafts at 6 months postoperatively (p = 0.001).

The SPV was higher than MV which was higher than DPV at the proximal end, and DPV was higher than MV which was higher than SPV at the distal end in the ITA grafts.

The DSVR of the ITA grafts was 0.8 to 0.9 and 1.3 to 2.1 at the proximal and distal ends, respectively. The DSVR of the ITA grafts was significantly higher than that of the native ITAs at 6 months, 5 years, and 10 years postoperatively at the proximal end (p = 0.0001, p = 0.004, p = 0.016, respectively). At the distal end, there were significant differences between the native ITAs and ITA grafts at 6 months and 5 years after operation (p < 0.0001 and p = 0.0007, respectively), although there was no significant difference in the DSVR at 10 years. The DSVR value of native ITAs was less than 1.0, and the DSVR value of ITA grafts was more than 1.0 (Fig 4).

There were no significant differences in the MV, DPV, SPV, or DSVR among the graft groups at the proximal and distal ends. Figure 5 shows flow velocity spectrums. Flow velocity data are shown in Table 2.



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  		Fig 5. Phasic flow velocity patterns of a native internal thoracic artery and an internal thoracic artery graft. The flow in the native internal thoracic artery had a high systolic peak velocity throughout its length, but the flow in the internal thoracic artery grafts had a high diastolic peak velocity throughout its length.

 
Diameters of native internal thoracic arteries and internal thoracic artery grafts
Angiography confirmed that ITA conduits have a trend toward tapering gradually. There were no significant differences in diameter among the four groups at either the proximal or distal end. There were significant differences in diameters between the proximal and distal end of each vessel in all the groups (Fig 6). Vessel diameters are shown in Table 3.



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  		Fig 6. Proximal versus distal diameter of the native internal thoracic artery versus internal thoracic artery grafts. Proximal versus distal diameter of the internal thoracic artery: control, *p = 0.008; group A, *p < 0.0001; group B, *p = 0.03; group C, *p = 0.04.

 

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  		Table 3. Diameters in Native Internal Thoracic Arteries and Internal Thoracic Artery Graftsa

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Native internal thoracic arteries
Native ITAs showed a pattern of phasic blood flow with systolic-predominant peak flow velocity throughout the entire length. Native ITA primarily supplies blood to the tissue at systolic phase.

A previous study on coronary velocity dynamics found that normal coronary artery had a diastolic-predominant pattern in both proximal and distal segments [10] (Fig 7). Thus, the hemodynamic properties of the native ITA are different from those of the coronary artery.



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  		Fig 7. Flow velocity patterns in normal left anterior descending coronary artery.

 
Internal thoracic artery grafts
When the ITA was used as a graft for coronary artery bypass, the graft showed a different pattern of phasic blood flow, with a transition from systolic-predominant proximal peak flow velocity to diastolic-predominant distal peak flow, as described by Bach and associates in 1993 [9]. This result suggests that the pattern of phasic blood flow in the ITA graft is affected by blood flow in the native coronary artery, especially strongly at the distal end. Moreover, even at the proximal end, systolic predominance of the ITA grafts was weaker than in native ITAs. In some cases, the ITA grafts showed a pattern of phasic blood flow with diastolic-predominant peak flow velocity throughout the entire length, like the coronary artery (Fig 5).

The ITA grafts were characterized by predominance of diastolic peak flow velocity over systolic peak flow velocity at the distal end of the graft and reduction of systolic flow velocity at the proximal end of the graft. Because there were no significant differences in the values of individual flow velocities and the relation of MV, SPV, and DPV among the graft groups, flow dynamics of the ITA grafts might be unchanged for a long time if there is no proximal graft stenosis or new distal coronary disease.

Hemodynamic predominance of internal thoracic artery grafts
A previous study showed that the incidence of arteriosclerosis in the native ITA is low [11]. Although the reason for this is not known, one of the unique benefits of ITA grafting is the striking resistance of this conduit to atheroma [1]. The structural and physical properties of the ITA might confer this resistance to atheroma.

There have been several studies on the predominance of the ITA graft [12–15], but most of those studies reported from a histologic point of view. There have been no studies that evaluated the patency of ITA grafts by flow velocity dynamics at long periods after CABG. Therefore, we investigated the flow velocity dynamics of ITA grafts compared with dynamics of native ITAs, which might influence long-term reliability.

It has been reported that intraoperative basal blood flow is related directly to patency; lower graft flow is predictive of early occlusion [16–18]; and the low-flow downstream areas of plaques contain significantly more smooth muscle cells, which could provide the background for slowly progressive growth at distal ends of plaques [19]. These facts indicate that optimal flow velocity might be necessary to prevent intimal hyperplasia and maintain graft patency for a long time.

A previous study of the human coronary artery during bypass grafting to LAD showed that a transient bypass graft occlusion caused a marked reduction in diastolic flow velocity in the LAD [20]. This fact indicates that the diastolic peak velocity of the coronary artery depends on the graft flow. That is, diastolic-predominant flow velocity of the ITA graft has great significance for coronary perfusion, and the result that the diastolic velocity is unchanged for the long term is especially important.

The limitation of this study is that this was an interpatient study not an intrapatient one. Nonetheless, we anticipate that these phenomena translate similarly among patients with ITA preoperatively and 6 months, 5 years, and 10 years after CABG.

Conclusion
In the ITA grafts the MV was maintained, the SPV was lower especially at the proximal end, and the DPV was higher especially at the distal end when compared with the native ITA. The ITA grafts receive blood flow predominantly during systole and supply blood to the coronary artery predominantly during diastole. These flow velocities of the ITA grafts, including MV, SPV, and DPV showed no significant difference among graft groups. We conclude that flow velocity dynamics of ITA grafts change their native systolic predominance to the hemodynamics of coronary arteries and become diastolic predominant, especially at the distal end for distal perfusion. Moreover, flow velocity dynamics of ITA grafts were unchanged even 10 years after CABG. Internal thoracic artery graft flow dynamics are suitable for coronary perfusion.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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