Ann Thorac Surg 2002;74:273-275
© 2002 The Society of Thoracic Surgeons
How to do it
Ultrasonic evaluation of graft anastomoses during coronary artery bypass grafting without cardiopulmonary bypass
Yoshihiro Suematsu, MDa*,
Toshiya Ohtsuka, MDa,
Takeshi Miyairi, MDa,
Noboru Motomura, MDa,
Shinichi Takamoto, MDa
a Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Suematsu, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan
e-mail: suematsu{at}aurora.dti.ne.jp
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Abstract
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Performance of the graft-to-coronary anastomosis in coronary artery bypass grafting without cardiopulmonary bypass is more difficult than conventional coronary artery bypass grafting. We report a new method that uses high-frequency epicardial echocardiography to detect technical errors and inadequacies in graft anastomoses. This method improves the operative outcome and enables detection of septal perforator branches and deeply embedded coronary arteries during coronary artery bypass grafting without cardiopulmonary bypass.
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Introduction
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Although the number of minimally invasive direct coronary artery bypass graft (MIDCABG) operations and off-pump coronary artery bypass graft (OPCABG) operations has recently been increasing, performance of the graft-to-coronary anastomosis in such procedures is more difficult than conventional coronary artery bypass grafting [1]. We recently demonstrated that high-frequency epicardial echocardiography (HEE) provides meaningful information on the target coronary artery and enables detection of technical errors and inadequacies during experimental coronary artery bypass grafting without cardiopulmonary bypass [2]. In this article, we describe the usefulness of this technique in patients who underwent MIDCABG or OPCABG operations.
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Technique
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The imaging probe is 39-mm long, has a 36 x 10 mm contact surface, and has a scanning frequency of 13 MHz. It also has a depth of field of 2.0 cm and a two-point phantom resolution of 0.1 mm, and it can be sterilized by standard ethylene oxide techniques. The imaging probe is covered with a sterilized pack and sterilized jelly, which allows clear visualization of the anterior wall of the vessels, and it is connected to a commercially available scanner (SSD-5500; Aloka Co. Ltd, Tokyo, Japan).
We assessed 65 bypass grafts in 31 consecutive patients who underwent an elective MIDCABG (7 patients) or OPCABG operation (24 patients). Triple bypass was performed in 10 of the patients and double bypass in 11 of the patients. The average age of the patients was 67.4 ± 10.5 years (range, 48 to 85 years); there were 6 females and 25 males. Three of the procedures were reoperations. The bypass material used was the left internal mammary artery in 26 grafts, the right internal mammary artery in one graft, the saphenous vein in 23 grafts, the right gastroepiploic artery in seven, and the radial artery in eight. The target vessels were the left anterior descending artery in 31, the right coronary artery in 17, the left circumflex branch in 12, and the diagonal branch in 5.
Standard anesthesia management and exposure of the heart through a median sternotomy or a small left thoracotomy were used for all patients. The left internal mammary artery was dissected from its origin to its bifurcation and wrapped with gauze soaked in papaverine solution in the usual fashion. When needed, saphenous veins, right gastroepiploic arteries, or radial arteries were also harvested. During the OPCABG operations three deep pericardial traction stitches were placed near the left upper and lower pulmonary veins and to the left of the inferior vena cava to allow elevation of the apex of the heart with a stabilizer. To further assist in providing good exposure of the target arteries on the lateral and inferior aspect of the heart, patients were placed in a right decubitus Trendelenburg position. HEE was first used to identify native coronary arteries with walls suitable for anastmosis. If calcification or atherosclerotic plaques was present, the site of the anastomosis was changed. All distal anastomoses were constructed with 7-0 or 8-0 Prolene (Ethicon, Somerville, NJ) using a continuous technique. The quality of the anastomoses was assessed by HEE and power Doppler images, which are based on the total integrated power of the Doppler spectrum after anastomoses in all patients.
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Results
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Echocardiographic images of high quality were easily obtained in patient studies by the approach described previously. The septal perforator branches were also easily visualized by power Doppler imaging (Fig 1),
and HEE was very useful in choosing the site to snare native coronary arteries to prevent backflow through them during the anastomosis. Coronary arteries deeply embedded in epicardial fat or myocardium, or obscured by epicardial scarring especially in reoperation cases, could be precisely located without extensive and time-consuming dissection (Fig 2). Most of the anastomoses were clearly demonstrated by power Doppler imaging (Fig 3).
Technical errors were detected in only 2 patients. In 1 patient, dissection of the left internal mammary artery extended to the anastomoses, and in the other patient, acute thrombus formation caused by inadequate anastomosis was detected (Fig 4).
In the former patient, a scheduled catheter intervention was successfully performed immediately after the operation. In the latter patient, the anastomosis was opened, the presence of a thrombus was confirmed, and reanastomosis was successfully performed.
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Fig 1. Power Doppler echocardiographic image showing a longitudinal section of the left anterior descending artery (LAD). The arrow is pointing to stenosis. (PF = perforator branch.)
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Fig 2. Echocardiographic image showing a longitudinal section of a deeply embedded left anterior descending artery (LAD).
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Fig 3. Representative power Doppler echocardiographic image showing the left internal mammary artery (LIMA) anastomosis to the left anterior descending artery (LAD).
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Fig 4. Echocardiographic image showing the saphenous vein graft (SVG) anastomosis to the right coronary artery (RCA). The arrow is pointing to a thrombus.
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No complications related to epicardial imaging occurred, such as coronary vessel injury or compromise, infection, or electrical or mechanical injuries.
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Comment
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MIDCABG and OPCABG operations have recently become popular for the treatment of coronary artery disease. However, the incidence of technical errors has been reported to be greater than with conventional coronary artery bypass grafting, and there is evidence that inadvertent placement of grafts proximal to stenotic plaques may play a role in graft occlusion [1]. It is therefore important to devise a reliable method of assessing anastomoses so that MIDCABG or OPCABG operations will become more universally accepted. Coronary angiography is generally considered the "gold standard" for detecting technical errors in graft anastomoses, but it is invasive, costly, time consuming, and not always readily available in the operating room. Thermal coronary artery imaging with an infrared camera was introduced by Suma and colleagues [3] as a noninvasive and effective method for evaluating graft anastomoses during OPCABG operations, but the quality of the available technology only allows detection of grossly stenosed anastmoses. Not only does it not allow visualization of the posterior circumflex or right coronary artery branches, but it also does not allow visualization of the intramyocardial arteries and arteries surrounded by fat. Although flow measurement techniques have frequently been used for intraoperative assessment of the quality of anastomoses, it has been documented that graft flow is not reliably well correlated with anastomotic quality and that lesser degrees of stenosis at risk for failure may go undetected [4].
Previously, intraoperative HEE was suggested to be capable of locating coronary arteries that are deeply embedded in epicardial fat or myocardium or that are obscured by epicardial scarring [5]. HEE also allows accurate measurement of coronary arterial bypass graft anastomoses and was found to have the potential to detect technical errors intraoperatively [6]. Our previous work also demonstrated that graft anastomosis measured by ultrasonic imaging correlated well with the angiographic measurements [2]. In our study this method was found to enable detection of technical errors and inadequacies, and it also allows detection of septal perforator branches and obscured native coronary arteries during coronary artery bypass grafting without cardiopulmonary bypass. Because this method is also simple to use and highly accurate, we think that it can be widely applied.
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References
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- Gundry S.R., Romano M.A., Shattuck O.H., Razzouk A.J., Bailey L.L. Seven-year follow-up of coronary artery bypasses performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;115:1273-1277.[Abstract/Free Full Text]
- Suematsu Y., Takamoto S., Ohtsuka T. Intraoperative echocardiographic imaging of coronary arteries and graft anastmoses during coronary artery bypass grafting without cardiopulmonary bypass. J Thorac Cardiovasc Surg 2001;122:1147-1154.[Abstract/Free Full Text]
- Suma H., Isomura T., Horii T., Sato T. Intraoperative coronary artery imaging with infrared camera in off-pump CABG. Ann Thorac Surg 2000;70:1741-1742.[Abstract/Free Full Text]
- Jaber S.F., Koenig S.C., BhaskerRao B., et al. Role of graft flow measurement technique in anastomotic quality assessment in minimally invasive CABG. Ann Thorac Surg 1998;66:1087-1092.[Abstract/Free Full Text]
- Hiratzka L.F., McPherson D.D., Brandt B., 3rd, Lamberth W.C., Jr, Marcus M.L., Kerber R.E. Intraoperative high-frequency epicardial echocardiography in coronary revascularization: locating deeply embedded coronary arteries. Ann Thorac Surg 1986;42:S9-S11.
- Hiratzka L.F., McPherson D.D., Brandt B., et al. The role of intraoperative high-frequency epicardial echocardiography during coronary artery revascularization. Circulation 1987;76:V33-V38.
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Abstract
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