Ann Thorac Surg 2002;74:2208-2209
© 2002 The Society of Thoracic Surgeons
How to do it
Free right internal thoracic artery composite graft: an option in left anterior descending artery grafting?
Dmitry Pevni, MDa*,
Rephael Mohr, MDa,
Gideon Uretzky, MDa,
Oren Lev-Ran, MDa,
Josef Paz, MDa,
Amir Kramer, MD, PhDa,
Itzhak Shapira, MDa
a Department of Cardiothoracic Surgery, The Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Accepted for publication June 20, 2002.
* Address reprint requests to Dr Pevni, Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel.
e-mail: pevni{at}tasmc.health.gov.il
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Abstract
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Myocardial revascularization using bilateral internal thoracic arteries (ITA) decreases the risk of reinterventions and provides potential survival benefit. From May 1996 to April 2000, 1,057 patients underwent myocardial revascularization using skeletonized bilateral ITAs. A free right ITA as a composite graft was used for the left anterior descending artery grafting in 38 (3.6%) cases when the left ITA was not long enough to reach the left anterior descending artery. Operative mortality was 2.6% (1 patient). There was no observable reversible myocardial ischemia on the postoperative thallium single-photon emission computed tomography study. Myocardial revascularization with the use of a skeletonized free right ITA as a composite graft to the left anterior descending artery is an alternative option in cases when an in situ ITA cannot be used.
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Introduction
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Recent studies have reported survival benefit and decreased rate of reinterventions when bilateral internal thoracic arteries (BITAs) were used for myocardial revascularization [1]. These findings have led many surgeons to now routinely use BITAs when this procedure is indicated. The patency rate of in situ right internal thoracic artery (RITA) connected to the left anterior descending coronary artery (LAD) has been shown to be the same as it is when it is connected to the left internal thoracic artery (LITA) [2]. Dion and colleagues [3] had earlier demonstrated that the free RITA connected to an in situ LITA has an excellent patency rate, and their study and one by Tector and associates [4] comprised the rationale for performing arterial myocardial revascularization using a composite graft with the free RITA connected end-to-side to an in situ LITA. Most surgeons have performed arterial revascularization with the use of BITAs when an in situ LITA is connected to the LAD. For patients with a long ascending aorta associated with a very distal anastomotic site, cardiomegaly, or damage to the distal part of LITA, an in situ LITA may not be long enough to reach the LAD. We now describe our modification of the T graft technique for myocardial revascularization using skeletonized BITAs with a free RITA connected to the LAD.
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Technique
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From May 1996 to April 2000, 1,057 patients underwent coronary artery bypass grafting at the Tel-Aviv SouraskyMedical Center with the use of BITAs. In 410 (38.8%) patients, the BITAs were used in situ in a crossover technique in which an in situ RITA supplied the LAD and an in situ LITA supplied branches of the circumflex artery. In the 647 (61.2%) patients in whom the LITA was not long enough to be connected to the LAD, we used a composite graft technique in which a free ITA was connected to another in situ ITA. In 609 (94%) of these patients, the in situ LITA was connected to the LAD and the free RITA to branches of the circumflex artery. In the other 38 (3.6%) cases, a free RITA as a composite graft was connected to the LAD and the in situ LITA was connected to branches of the circumflex artery because the LAD anastomotic site was too distal, there was cardiomegaly or damage of the distal part of the ITA, or the ITA had a small diameter associated with insufficient spontaneous free blood flow (Fig 1).
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Fig 1. A free right internal thoracic artery (RITA) as a composite graft connected to the left anterior descending artery (LAD) and an in situ left internal thoracic artery (LITA) connected to branches of the circumflex artery. (D= diagonal artery;PDA= posterior descending artery.)
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Our experience using the modified technique included 34 men and 4 women whose mean age was 63.5 ± 6 years (range, 49 to 90 years). Three (7.9%) had severe chronic obstructive pulmonary disease, and 8 (21%) had diabetes mellitus. The operation was urgent in 6 (15.8%) patients because of postacute myocardial infarction angina pectoris.
The BITAs were harvested as skeletonized vessels. The operations were performed with cardiopulmonary bypass. A composite graft was performed as a T graft before the patient was connected to cardiopulmonary bypass.
Follow-up data were obtained by telephone contact with the study patients. They all underwent a thallium single-photon emission computed tomographic scan study every year after the operation as part of their regular physical checkup.
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Results
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The 38 patients included in the present study received 2 to 4 grafts (mean, 2.7 grafts) per patient. One patient (2.6%) died in the early postoperative period (within 30 days after operation) of a perioperative myocardial infarction and multiorgan failure. There were no cases of low-flow syndrome (defined as temporary ST elevation associated with hemodynamic instability), cerebrovascular accident, or sternal or wound infection. There was no postoperative bleeding that required reopening of the chest.
A postoperative follow-up of 12 to 60 months (mean, 28 ± 7 months) was available in all 37 surviving patients. There was one late death, which was unrelated to the initial operation (ie, breast cancer). There were no myocardial infarctions, return of angina pectoris, or new cases of congestive heart failure. Postoperative coronary angiography was performed 2 to 12 months postoperatively in 4 patients who were symptomatic despite their negative nuclear scan. All anastomoses were patent.
A thallium single-photon emission computed tomographic test was performed 1 year after operation in 37 patients, after 2 years in 34, after 3 years in 27, after 4 years in 13, and after 5 years in 3. There was no evidence of reversible ischemia in any of these tests. The Kaplan-Meier analysis of the entire cohort showed 3-year and 5-year survival rates of 100% and 97.3%, respectively.
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Comment
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This report summarizes our experience of arterial revascularization using a skeletonized free RITA as a composite graft to the LAD in cases when the in situ LITA was not long enough for LAD grafting. An ITA is the current graft of choice for myocardial revascularization because it results in an excellent patency rate when used in situ [1] or in a free form as a composite graft [3–5].
The main objective of a coronary artery bypass grafting procedure is to connect an in situ LITA to the LAD because of the demonstrated survival benefit [6]. In some cases, however, an in situ ITA is not long enough to perform the anastomosis in the chosen site: this was the situation in 38 (3.6%) of our patients who consequently received a free RITA composite graft to the LAD. Our decision to use this approach was based on a report by Dion and colleagues [3], in which they demonstrated that a free ITA used as a composite graft has almost the same patency rate as an in situ ITA. Only 1 of our 38 patients died of perioperative myocardial infarction, there were no complications such as low-flow syndrome, deep sternal infection, or cerebrovascular accident, and midterm survival was excellent. Moreover, there were no late symptoms of return of angina pectoris or evidence of reversible ischemia in the LAD-supplied area.
In summary, we now routinely perform arterial revascularization with the use of skeletonized BITAs in situ or as a composite graft in which an in situ LITA is connected to the LAD. In cases when an in situ ITA cannot be connected to the LAD—usually because of insufficient length or poor free blood flow—we use the free RITA composite graft technique. The good early and midterm results that were observed in our patients who received a free RITA composite graft to the LAD, taken together with all the reported benefits derived from the use of free skeletonized ITAs as composite grafts, support the use of this technique in cases in which an in situ ITA cannot be anastomosed to the LAD.
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Acknowledgments
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We thank Esther Eshkol for editorial assistance.
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References
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- Buxton B.F., Komed M., Fuller J.A., Gordon I. Bilateral internal thoracic artery grafting may improve outcome of coronary surgery. Circulation 1998;98:11-16.
- Buxton B.F., Ruengsakulrach P., Fuller J., Rosalion A., Reid C.M., Tatoulis J. The right internal thoracic artery graft—benefits of grafting the left coronary system and native vessels with a high-grade stenosis. Eur J Cardiothorac Surg 2000;18:255-261.[Abstract/Free Full Text]
- Dion R., Etienne P.Y., Vershlest R., et al. Bilateral mammary grafting. Eur J Cardiothorac Surg 1993;7:287-294.[Abstract]
- Tector A.J., Kress D.C., Downey F.X., Schmahl T.M. Complete revascularization with internal thoracic artery grafts. Semin Thorac Cardiovasc Surg 1996;8:29-41.[Medline]
- Calafiore A.M., Contini M., Vitolla G., et al. Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts. J Thorac Cardiovasc Surg 2000;120:990-998.[Abstract/Free Full Text]
- Cameron A., Kemp H.G., Green G.E. Bypass surgery with internal mammary artery graft: 15-year follow-up. Circulation 1986;74(Suppl. 3):30-36.
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Abstract
Introduction
