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Ann Thorac Surg 2003;76:659-660
© 2003 The Society of Thoracic Surgeons

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Correspondence

Coronary flow reserve in composite arterial Y grafts

^a Department of Cardiac Surgery, Centre Cardiologique du Nord, 32-36 Rue des Moulins Gémeaux, 93200 St Denis, France

e-mail: alattar{at}ifrance.com

To the Editor:

I read with interest the article by Sakaguchi and associates [1] on flow reserve in composite arterial Y grafts. The authors conclude that myocardial coronary flow reserve (CFR) in these grafts is not as effective as independent grafts soon after coronary artery bypass grafting. This study carries an important message, especially with the current trends in myocardial revascularization towards exclusive use of arterial grafts.

The authors compared a Y graft versus an independent group, but used a variety of arterial grafts in each, resulting in heterogeneous, small-sized subgroups. Furthermore, whereas positron emission tomographic scan demonstrated significant differences in CFR between groups, this was not associated with any clinical or biochemical (ie, creatine kinase) manifestations. The evaluation took place 2 weeks after coronary artery bypass grafting (CABG).

The use of the internal mammary artery (IMA) in Y grafting should probably be considered separately. Hanet and associates have shown that the vasomotor tone of IMAs responds to myocardial flow demand (induced by tachycardia) by consequent dilatation (compared with venous grafts) [2]. I agree with the authors that the radial and gastroepiploic arteries are muscular arteries with a high propensity to spasm, even though recent work has shown that skeletonized radial arteries harvested with ultrasonic scalpel have improved angiographic results. But the authors’ advise against composite grafting with the IMAs for fear of flow competition [3]. Nevertheless, the use of the radial artery in composite Y grafts has not adversely affected clinical outcomes in another series of 490 patients [4].

Finally, no less than 12% of IMAs have been shown to increase diameter by 20% to 50% up to 5 years after CABG [2], and the increase in flow is not only due to an increase in velocity [5]. This suggests that the flow rates in Y grafts are probably more dependant on the severity of obstruction in the native coronary arteries grafted than the artery chosen for creating the Y graft, and that flow could be expected to improve with time.

As with bilateral IMA grafting, the evidence of improved patency rates and superior long-term results with arterial conduits will require cohorts in randomized trials with long-term follow-up.

References

1. Sakaguchi G., Tadamura E., Ohnaka M., Tambara K., Nishimura K., Komeda M. Composite arterial Y graft has less coronary flow reserve than independent grafts. Ann Thorac Surg 2002;74:493-496.[Abstract/Free Full Text]
2. Hanet C., Schroeder E., Michel X., et al. Flow-induced vasomotor response to tachycardia of the human internal mammary artery and saphenous vein grafts late following bypass surgery. Circulation 1991;84(Suppl III):268-274.
3. Amano A., Takahashi A., Hirose H. Skeletonized radial artery grafting: improved angiographic results. Ann Thorac Surg 2002;73:1880-1887.[Abstract/Free Full Text]
4. Wendler O., Hennen B., Demertzis S., et al. Complete arterial revascularization in multivessel coronary artery disease with 2 conduits (skeletonized grafts and T grafts). Circulation 2000;102(Suppl 3):79-83.
5. Gurne O., Chenu P., Buche M., et al. Adaptive mechanisms of arterial and venous coronary bypass grafts to an increase in flow demand. Heart 1999;82:336-342.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Nawwar Al Attar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Attar, N. A. Search for Related Content PubMed PubMed Citation Articles by Attar, N. A. Related Collections Coronary disease