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Ann Thorac Surg 2002;74:493-496
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Composite arterial Y graft has less coronary flow reserve than independent grafts

^a Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
^b Department of Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan

* Address reprint requests to Dr Komeda, Graduate School of Medicine, Department of Cardiovascular Surgery, Kyoto University, 54 Kawahara-cho Shogoin Sakyo-ku, Kyoto, 606-8507, Japan
e-mail: masakom{at}kuhp.kyoto-u.ac.jp

Presented at the Poster Session of the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. It is not known whether a composite Y graft of the left internal thoracic artery can provide sufficient blood flow to the whole left coronary system. The aim of this study was to compare regional myocardial blood flow (MBF) and coronary flow reserve after coronary artery bypass grafting using arterial composite Y graft or independent arterial grafts.

Methods. Positron emission tomography was performed at rest and after dipyridamole infusion using oxygen-15-labeled water 2 weeks after coronary artery bypass grafting. Regional MBF was calculated in seven segments of the left ventricle. Coronary flow reserve was defined as the ratio of MBF after dipyridamole infusion to MBF at rest. In the Y graft group (n = 22), a free arterial graft to obtuse marginal arteries was anastomosed to the proximal side of in situ left internal thoracic artery, which was anastomosed to the left anterior descending artery. In the independent graft group (n = 13), left anterior descending and obtuse marginal arteries were independently revascularized using in situ left internal thoracic artery and a free arterial graft.

Results. There was no difference between the groups in MBF at rest. Coronary flow reserve in the Y graft group was lower than that in the independent group in the anterobasal (1.43 ± 0.07 versus 1.90 ± 0.13, p = 0.038), apical (1.24 ± 0.06 versus 1.64 ± 0.12, p = 0.003), septal (1.34 ± 0.05 versus 1.75 ± 0.13, p = 0.023), and lateral regions (1.19 ± 0.04 versus 1.66 ± 0.09, p = 0.001).

Conclusions. Although arterial composite Y graft improved MBF at rest, it was not as effective as independent grafts for improving coronary flow reserve soon after coronary artery bypass grafting.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Left internal thoracic artery (LITA) graft has been widely used in coronary artery bypass grafting (CABG) with excellent long-term patency and lower morbidity and mortality when compared with vein grafts [1–3]. Because of the poor long-term patency of vein graft, the current trend in CABG is toward aggressive use of arterial grafts for multiple vessel disease. Although in situ right internal thoracic artery (RITA) has been reported to have excellent patency, comparable to in situ LITA [4], the use of in situ RITA to the circumflex coronary system is occasionally limited because of its insufficient length, especially when used in off-pump CABG. This problem can be overcome by using a free graft of the RITA attached to the ascending aorta or by making a Y graft with the LITA. Free arterial grafts anastomosed to the ascending aorta have an increased graft failure rate at both early and late stages postoperatively [5]. The expanded use of the LITA as a Y configuration with another arterial conduit, such as a radial artery (RA), which allows maximal arterial graft economy and sufficient length of the grafts, has been performed with excellent clinical results [6]. In addition, this method can avoid aortic manipulation, and thereby reduce the risk of stroke during the operation. Whereas the LITA of the composite Y graft has been shown to provide good blood flow [7, 8], it is not known whether the LITA of the composite Y graft can provide sufficient blood flow to the whole left coronary system at the tissue level. Furthermore, no comparative study with individual arterial grafts has been reported. The aim of this study was to compare, using positron emission tomography (PET), the effects on regional myocardial blood flow (MBF) and coronary flow reserve (CFR) of composite Y grafts versus independent grafts.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patients
Twenty-two consecutive patients underwent CABG using arterial composite Y graft of the LITA in which a free arterial graft (RITA, gastroepiploic artery, or RA) was attached to the proximal side of the LITA (Y graft group) near the pericardial window. The branch graft of the composite Y graft was anastomosed to a major branch in the circumflex territory. The independent group was composed of 13 consecutive patients who underwent CABG in which a major branch in the circumflex territory was independently revascularized by arterial grafts. The in situ LITA harvested in a skeletonized fashion was anastomosed to the left anterior descending artery (LAD) territory in all cases. Bypass grafting was indicated only when the degree of native coronary stenosis was greater than 75%. Patency of all grafts was confirmed by coronary angiography within 4 weeks. We routinely used a calcium-channel blocker, nitrate, and aspirin postoperatively.

Positron emission tomography
Each subject was positioned in the gantry of the PET camera (Advance; General Electrical Medical Systems, Milwaukee, WI) with the aid of ultrasound. The characteristics of this camera have been previously described [9]. The spatial resolution of the reconstructed clinical PET images is approximately 8 mm in full-width half-maximum at the center of the field of view, and the axial resolution is approximately 4 mm. A 10-minute transmission scan was made using two rotating germanium-68 pin sources for attenuation correction. After the transmission scan, subjects were requested to inhale [¹⁵O]CO for 2 minutes. After inhalation, carbon monoxide was allowed to combine with hemoglobin in red blood cells for 3 minutes before a 4-minute static scan was started. During the scan period, three blood samples were drawn at 2-minute intervals and radioactivity was measured. A 10-minute period was allowed for [¹⁵O]CO radioactivity decay before the flow measurements. At baseline, approximately 740 MBq of [¹⁵O]H₂O was injected intravenously for more than 2 minutes, and a 20-frame dynamic PET scan was performed for 6 minutes consisting of six 5-second, six 15-second, and eight 30-second frames. In addition, [¹⁵O]H₂O was injected 3 minutes after intravenous administration of dipyridamole (0.56 mg/kg. body weight for more than 4 minutes), and serial images were recorded in the same sequence. All data were corrected for dead time, decay, and photon attenuation. Heart rate, arterial blood pressure, and electrocardiogram were monitored continuously during the PET studies.

Positron emission tomography data analysis
The analysis of PET images was conducted as previously described [9]. The PET images, including transmission images, [¹⁵O]CO images, and [¹⁵O]H₂O dynamic images, were reoriented into short-axis planes. Myocardial regions of interest (ROIs) were drawn in the anterobasal, anterolateral, apical, inferior, posterobasal, septal, and lateral regions. Values of regional MBF (in milliliters per minute per gram of tissue) were calculated using a single-compartment model that includes corrections for spillover and the partial volume effect.

Statistical analysis
Myocardial blood flow and CFR data are expressed as the mean ± standard error of the mean. Comparisons of MBF and CFR between the groups in each ROI were performed by two-way analysis of variance. If significance was found for group effect or group-by-ROI interaction, post hoc comparisons were performed between the groups in each ROI, when appropriate, using unpaired Student’s t test. Statistical analyses were performed with StatView for Windows version 5.0 (SAS Institute Inc., Cary, NC). A probability value less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Demographic data of the patients are shown in Table 1. These data were comparable between the groups. The degree of stenosis of the LAD was 93% ± 7% in the Y graft group and 90% ± 11% in the independent group. The degree of stenosis of the obtuse marginal artery was 91% ± 9% in the Y graft group and 91% ± 10% in the independent group. The LAD was occluded in five cases in the Y graft group and in four cases in the independent group. The obtuse marginal artery was occluded in four cases in the Y graft group and in three cases in the independent group. There was 1 patient in the independent group who had occlusion of both LAD and obtuse marginal arteries. The use of arterial conduits for the circumflex artery is listed in Table 2. Free RITA, gastroepiploic artery, and RA grafts were used almost equally in the Y graft group. Six free arterial grafts (three RITAs and three RAs) attached to the ascending aorta were used in the independent group. Sixteen patients in the Y graft group and 3 in the independent group underwent operation without cardiopulmonary bypass. There was neither death nor perioperative myocardial infarction in either group. There was no significant difference in maximal cardiac creatine kinase between the groups. Postoperative angiography performed within 4 weeks after the operations showed that all grafts to LAD and obtuse marginal arteries were patent without any significant stenosis. Myocardial blood flow at rest and CFR are shown in Figure 1. Two-way repeated measures analysis of variance for CFR showed high group and ROI effects (Table 3). Although MBF at rest did not differ between the groups in all ROIs, CFR in the Y graft group was significantly lower than that in the independent group in the anterobasal (1.43 ± 0.07 versus 1.90 ± 0.13, p = 0.038), apical (1.24 ± 0.06 versus 1.64 ± 0.12, p = 0.003), septal (1.34 ± 0.05 versus 1.75 ± 0.13, p = 0.023), and lateral regions (1.19 ± 0.04 versus 1.66 ± 0.09, p = 0.001).

View larger version (21K): [in this window] [in a new window]   Fig 1. Myocardial blood flow (MBF) at rest and coronary flow reserve (CFR). Values are represented as mean ± SEM. (AB = anterobasal; AL = anterolateral; APX = apical; INF = inferior; PB = posterobasal; SEP = septal; LAT = lateral; NS = not significant.)

	Comment

Top Abstract Introduction Material and methods Results Comment References

Markwirth and colleagues [8] measured quantitative flow and CFR of the LITA in a T graft using a Doppler guidewire, and they concluded that the functional and morphologic adaptability of the LITA was sufficient to meet the higher flow-volume requirements. In their study, the Doppler guidewire was placed in the proximal part of the LITA and measured the blood flow in the proximal LITA, not at the myocardial level. In addition, they injected adenosine directly into the LITA to induce hyperemia, which might have advantages over our method. Perhaps those factors have made CFR of the proximal LITA in their study higher than CFR at the tissue level in our study. Intraoperative measurement of blood flow of the Y graft with transit-time Doppler has been reported to show excellent CFR [7]. Those studies, unlike ours, were not comparative studies, and the regional distribution of the blood flow was not examined. In our study, we used PET, which can provide noninvasive measures of the absolute MBF in selected regions of the heart. This provides an integrated ability of both the native coronary artery and the bypass graft. The Y graft group showed lower CFR in both LAD and circumflex territories. This might be caused mainly by insufficient adaptation of the proximal LITA to the whole left coronary system in comparison with independent grafts.

Vasospasm of arterial grafts has been reported to result in internal thoracic artery hypoperfusion syndrome with high mortality [11]. Spasm of the proximal LITA in Y graft patients may result in hypoperfusion of the whole left coronary system and may lead to catastrophic consequences. We used a free RITA, RA, or gastroepiploic artery as a branch of the composite Y graft in this study. These arterial grafts are usually used for revascularization of the circumflex or right coronary system because LITA-LAD is a gold standard with established reliability. The RA and gastroepiploic artery are muscular arteries with a high propensity to spasm. It is not known whether the nature of such muscular arterial grafts in composite Y grafts can affect clinical outcomes, especially in the LAD territory.

The growth potential of the LITA as a living conduit has previously been reported [12, 13]. This is influenced by competitive native flow and exhibits adaptation potential even in the early postoperative phase, followed by sustained growth potential in the late phase. The growth potential of LITA in a composite Y graft can also be anticipated. Furthermore, a persistent microvascular dysfunction, probably caused by ischemia or surgical trauma in the early postoperative period, was reported to recover slowly after operation [10]. Markwirth and associates [8] reported that CFR of the LITA with T graft significantly increased 6 months after CABG as compared with 1 week after CABG. Our study examined the patients soon after the operation and the results might differ in a long-term study. Further follow-up is required to confirm the long-term effects of the composite Y grafting.

There are some limitations to this study. First, this study was not a randomized study conducted retrospectively. In the Y graft group, unlike the independent group, most of the patients underwent operation without cardiopulmonary bypass. Off-pump CABG is a major indication for Y grafting because this technique can avoid manipulation of the aorta, thereby reducing the risk of stroke during the operation. It is not known whether the use of cardiopulmonary bypass can influence MBF soon after the operation. Microvascular dysfunction can be caused by the use of cardiopulmonary bypass. If so, off-pump CABG might improve the outcome of the Y graft group, contrary to our results. In addition, there was some variability of the grafts in both groups. There might be some differences of the flow results among the grafts. Second, this study was performed in Asian (ie, Japanese) patients. In Asians, the LITA generally appears to be smaller than in European people in part because of the difference in body size. Suma and coworkers [14] reported that the smaller body size was associated with lower LITA free flow. A larger LITA would facilitate better CFR. In our series, we harvested LITA in a skeletonized fashion. Free flow in skeletonized internal thoracic artery grafts is significantly higher compared with that in the conventional pedicled internal thoracic artery grafts [15]. This technique might contribute to maintaining basal MBF in the whole left coronary system in the Y graft group.

In this study, PET detected a significant difference in CFR between the groups; however, the clinical importance of this difference is unclear. The CFR in the Y graft group, which was significantly lower than in the independent group, might still be sufficient for revascularization of the left coronary system.

In summary, this study shows that while the composite Y graft demonstrated improved MBF at rest, composite Y graft was not as effective as independent grafts for improving CFR in the early period after CABG in Asian patients. The indications for Y graft should be carefully reviewed, especially in the case of a small LITA.

	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): Genichi Sakaguchi Kazunobu Nishimura Masashi Komeda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakaguchi, G. Articles by Komeda, M. Search for Related Content PubMed PubMed Citation Articles by Sakaguchi, G. Articles by Komeda, M. Related Collections Coronary disease