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Ann Thorac Surg 2004;78:481-486
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Competitive flow in arterial composite grafts and effect of graft arrangement in Off-Pump coronary revascularization

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan

Accepted for publication January 9, 2004.

^* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
e-mail: hnakajim{at}hsp.ncvc.go.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: We sought to investigate the incidence of competitive flow in arterial composite grafts and to delineate the effect of the location of moderately stenotic branch, the extent of the revascularized territories and the arrangement of in situ and free arterial grafts in off-pump coronary artery bypass grafting (OPCAB).

METHODS: Three hundred eighteen patients who underwent OPCAB with aorta no-touch technique using the composite graft with totally arterial materials between December 2000 and March 2003 were studied. A total of 362 composite grafts were used. We reviewed their coronary angiography before and early after operation. Competitive flow was defined as the phenomenon that at least one of the distal anastomotic sites of the composite graft was not opacified in in situ graft angiography, but clearly opacified in native coronary angiography. The number of distal anastomoses was 3.47 ± 0.93 per patient and 2.87 ± 0.81 per composite graft.

RESULTS: Early patency rate of the distal anastomotic sites of composite grafts was 98.7%. Competitive flow was found in 53/362 (14.6%) composite grafts, and graft occlusion occurred in 13/362 (3.6%) composite grafts. In the multivariate analysis of 362 composite grafts, 75% stenosis in right coronary artery (RCA) territory (p < 0.0001) and the number of distal anastomoses (p = 0.004) were significant predictors of competitive flow and graft occlusion. Multivariate analysis of 318 patients demonstrated that 75% stenosis in RCA territory (p < 0.0001) and the total number of distal anastomoses (p = 0.003) were statistically significant predictors of competitive flow and graft occlusion. The use of more than two in situ grafts and the shape of composite graft (branched or straight) did not have significant correlation with the outcome.

CONCLUSIONS: Coronary artery revascularization using composite arterial grafts provided satisfactory early patency rates with an acceptable incidence of competitive flow. Because the implication of competitive flow in an arterial composite graft may differ from that in conventional bypass grafts unpredictably, long-term follow-up is mandatory.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Off-pump coronary artery bypass grafting (OPCAB) combined with aorta no-touch technique has been accepted as an effective procedure to avoid the neurologic and aortic complications, and to reduce operative risks. For this procedure, a composite graft using in situ and free grafts is necessary for complete revascularization in patients with multi-vessel disease, and the arterial graft is commonly used because of its beneficial characteristics in terms of expectancy of graft patency and improved late outcome [1].

It has been reported that the arterial material has adaptability of its own diameter to the circumstances of the blood flow in the lumen [2–4]. Competitive flow can occur when the stenosis in the target coronary branch is not severe, and is considered as a cause of narrowing and closure of the arterial graft. When more than two distal anastomoses share an in situ graft as the inflow, there is a concern over the increased risk of competitive flow as compared with the individual bypass graft. It may be a potential disadvantage of the strategy with aorta no-touch technique and composite grafts. However, little is known about the characteristics of competitive flow in the composite graft.

The aim of this study is to delineate the incidence and the risk of competitive flow in the arterial composite graft and to establish the optimal graft arrangement for minimizing the incidence of competitive flow and graft occlusion in the early and late periods after operation.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
From December 2000 to March 2002, 408 patients underwent OPCAB with aorta no-touch technique in our institution. The coronary angiographies of 318 patients who underwent OPCAB using only arterial conduits were reviewed in a blinded manner. The remaining 90 patients were excluded because of no postoperative coronary angiography, bypass grafting in an individual fashion only, or the usage of saphenous vein graft. There were 267 men and 51 women with a mean age of 65.2 ± 8.7 years. Coronary and graft angiography was performed immediately after operation (mean 14 days). The native coronary artery stenosis and graft patency were independently evaluated by cardiologists. They were managed along with the American Heart Association guideline. The most severe stenosis in the luminal diameter of the coronary artery proximal to the anastomotic site was regarded as stenosis of the target coronary branch.

Composite graft was defined as a bypass conduit having two or more distal anastomoses with one in situ graft as inflow. Although it mostly consisted of one in situ graft and one free graft, in present study, it included an in situ graft sequentially anastomosed to two coronary branches, such as internal thoracic artery (ITA) anastomosed to both diagonal branch in a side-to-side fashion and left anterior descending artery (LAD) in an end-to-side fashion. Individual graft was defined as a conduit having one distal anastomosis and one inflow. This included an in situ graft extended by a free graft to one distal anastomotic site. Competitive flow was defined as a phenomenon where the target coronary branch and anastomotic site were clearly opacified in the native coronary angiography, but not in angiography of the in situ graft at all. When a graft did not fill with contrast at all, it was considered as graft occlusion. It was defined as no-flow situation with closure of the lumen of the bypass graft. String sign was defined as diffuse narrowing of the graft, which had less than a half of the diameter of the proximal part in the same graft. In situ graft was the ITA and gastroepiploic artery (GEA), which was used in a pedicled fashion as inflow.

Strategy of graft selection and arrangement
Our standard strategy for OPCAB has been based on total arterial revascularization with aorta no-touch technique, especially using one or two ITAs and radial artery. The bilateral ITAs were preferably used for patients who had active life and were less than 75 years old with neither severe chronic obstructive pulmonary disease nor diabetes mellitus treated by insulin therapy. Even for the elderly patients, we used at least one ITA as composite Y graft with an in situ ITA and a radial artery. The average number of the distal anastomotic sites was 3.47 ± 0.93 per patient (Table 1).

We utilized various composite grafts as summarized in Table 2. The decision of arrangement of the in situ and free arterial grafts mostly depended on the positional relationships of the target coronary artery branches. A total of 362 composite grafts (282 branched and 80 straight) were constructed in 318 patients of the present series. The average number of distal anastomotic sites was 2.87 ± 0.81 per composite graft.

OPCAB technique and pharmacologic management
The details of the operative technique of OPCAB were reported previously [5]. In brief, through a standard median sternotomy, the pericardial cavity was widely opened and the deep pericardial sutures were placed for traction. Heparin was administered and the activated coagulation time was maintained at more than 300 seconds until completion of anastomosis. All arterial grafts were harvested and treated with a papaverine hydrochloride solution.

The distal anastomoses were carried out while stabilizing the coronary vessels using the Octopus II+ or III stabilizer (Medtronic, Minneapolis, MN). Retract-O-tape (Quest Medical, Inc, Allen, TX) was placed for temporary proximal occlusion. The surgical field was maintained by CO₂ blower and intracorornary shunt, which was Anastaflo (Edwards Lifesciences, LLC, Irvine, CA) for coronary arteries of 1.5 and 2.0 mm in diameter, or Clearview (Medtronic) for coronary arteries of 1.25 and 1.0 mm in diameter.

Continuous infusion of diltiazem was started during operation and continued until oral medication was started, usually on the first postoperative day. It was terminated and replaced by nicardipine hydrochloride if sufficient heart rate could not be obtained. In the intensive care unit, heparin was prescribed continuously for 24 hours and replaced by oral administration of aspirin.

Statistical analysis
The continuous variables are expressed as the mean values ± SD. Univariate and multivariate analyses were performed by the logistic regression method. The data of two groups were compared by Fischer's exact test. The differences were considered statistically significant at p less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There was no stroke immediately (< 7 days) after operation. Two patients (0.6%) had a stroke before discharge. One was during postoperative coronary angiography, and the other had intractable atrial fibrillation. The overall patency rate of the distal anastomoses was 1088/1104 (98.6%). Patency rate of the distal anastomoses of the composite grafts was 1025/1038 (98.7%). Of 362 composite grafts, competitive flow was found in 53/362 (14.6%), and graft occlusion occurred in 13/362 (3.6%) (Table 3). The incidence of competitive flow was 46/282 (16.3%) in the branched composite grafts and 7/80 (8.8%) in the straight composite grafts, respectively (p = 0.09). Graft occlusion was found in 10/282 (3.5%) of the branched composite grafts, and in 3/80 (3.8%) of the straight composite grafts, respectively (p = 0.93). One of the patients who had two composite grafts presented both competitive flow and graft occlusion.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Avoidance of cardiopulmonary bypass and manipulation of the ascending aorta can decrease the incidence of perioperative complications. In this aorta no-touch technique, the usage of the in situ ITA is almost essential. The ITA graft provides a favorable long-term survival with an excellent graft patency [1, 8], because it has a lower incidence of atherosclerotic graft disease than the saphenous vein graft. In the previous reports, the early and midterm graft patency rates of the radial artery were equivalent to those of the ITA [9, 10], even when the target coronary branch was small in diameter or had severe arteriosclerosis [8]. The radial artery is advantageous in terms of the possibility to avoid the use of bilateral ITAs in patients with considerable risks and the low incidence of wound complications. Recently, there has been a tendency to use the arterial grafts frequently and to restrict the employment of a vein graft.

By making the proximal anastomosis of the radial artery to the side of ITA as a composite Y graft, a total arterial revascularization was attained with only two grafts in most patients having multivessel disease with a simple and safe operative maneuver [11, 12]. This procedure preserves one ITA to be used in the future. Because exposure of the radial artery graft to an excessive pressure of the aorta and wall stress and the mismatch of the wall thickness can be avoided, the radial artery in the composite graft may provide a better durability than the radial artery proximally anastomosed to the ascending aorta [11, 13]. For patients who are in active life and have no obvious operative risk, the use of the bilateral ITAs is considered favorable, because it was reported that the bilateral ITAs provided more abundant coronary flow than the single ITA in intraoperative transit Doppler measurement [14].

There may be some potential disadvantages related to coronary bypass surgery using a composite graft. At first, it is still controversial whether a single ITA can be always a sufficient blood source, especially in the composite Y graft to three territories. Royse and colleagues [15] reported that construction of a composite Y graft led to 75% increase of the free flow through a single ITA pedicle and that the composite Y graft had a considerable potential of flow reserve. Wendler and associates [16] reported that there was a sufficient flow reserve of the composite Y grafts consisting of in situ ITA and radial artery or free ITA. On the contrary, in a previous report, the incidence of hypoperfusion syndrome was 2.4%, mostly due to failure of ITA harvesting [11]. To avoid this complication, we carefully assess the quality of the ITA graft and the subclavian artery by the preoperative angiography, insertion of 1.5-mm flexible probe into the ITA and the radial artery after harvesting, and flow measurement using transit time Doppler flow meter after completion of anastomosis. In addition, we have attempted several anastomotic fashions of making composite grafts to avoid stenosis and kinking of the ITA graft, because it is usually anastomosed to the LAD or another important branch [5]. Thus, none of the patients experienced hypoperfusion syndrome even those with three-vessel or left main trunk disease. The high percentage of OPCAB, which was more than 98% during this period, may be one of the reasons for the absence of hypoperfusion syndrome.

Another possible disadvantage is a concern over the increased risk of competitive flow in the composite graft as compared with the individual bypass graft. Competitive flow decreases the antegrade flow particularly in the diastole, and the phasic delay in pressure wave in the ITA results in a retrograde flow in the early systole [17, 18]. This oscillating flow pattern in the competitive situation affects the endothelium releasing nitric oxide and prostacyclins and may predispose to string sign, which is regarded as a physiologic vasoconstriction of the arterial graft and may occur when the target coronary stenosis is moderate [10], and functional closure of the arterial conduit [17]. Aris and coworkers [20] reported the reversibility of functionally closed bypass conduit by progression of the native coronary lesions. In contrast, there were also clinical and experimental studies which concluded that the functional closure of the ITA graft was not only due to competitive flow from the native coronary artery [19, 21].

In the composite graft, the mechanism of competitive flow is more complex than that in the individual graft. It is not caused only by the relation between the graft and its target coronary branch where competitive flow occurs, but also by the interactions of all anastomosed branches within the composite graft, the phasic delay between the in situ grafts, and the whole graft arrangement in the patient. Therefore, prevention of competitive flow and graft occlusion depends on both adequate surgical strategy and maneuver [11]. In the present study, we investigated the risk of competitive flow and no-flow situation by the analysis of every composite graft and every patient, not by the analysis of every anastomotic site.

The most significant predictor of competitive flow and graft occlusion was the presence of moderately stenotic branch in the RCA territory. There has been a controversy regarding the management of moderately stenotic RCA branches. Calafiore and colleagues [11] recommended that the radial artery should be used only for the coronary branch with high expected runoff, and consequently string sign did not occur [9]. The use of saphenous vein graft as aorto-coronary bypass grafting was recommended when the stenosis was not severe [8, 22]. However, the satisfactory graft patency rate may not be achieved only by choosing a graft material in an individual bypass [8, 10, 23]. Even in the moderately stenotic RCA branches, the arterial composite graft provided the satisfactory early graft patency rate, while competitive flow occurred. It is necessary to examine the fate of the composite graft presenting competitive flow, and to detect the determinants of the durable patency in the competitive situation by the late follow-up study.

The shape of the composite graft, ie, straight or branched, was also examined. The disadvantage of the branched composite graft, as compared with the straight composite graft, was not detected. In addition, although the actually large diameter of the target coronary branch is a considerable risk, small branches could be a cause of competitive flow in our results. We consider that the overestimation of the target coronary stenosis in small branches may be a potential reason for this observation.

The use of two in situ grafts was not necessarily effective for prevention of competitive flow. The high average number of distal anastomoses per patient, which was also the significant predictor of competitive flow and graft occlusion, is considered as an explanation for this finding. Although the routine use of three in situ grafts may be a strategy of choice, we did not have enough cases of GEA grafts, and it is necessary to take the procedural risk into consideration for comparison with the other strategies for coronary bypass surgery.

The purpose of this study is not to prove the superiority of our strategy, but to minimize the potential disadvantage, and to select optimal patients for OPCAB with aorta no-touch technique using only arterial grafts. We focused mainly on the effect of the shape and the arrangement of the in situ and free grafts and the target coronary artery with moderate stenosis on the occurrence of competitive flow and no-flow situation. Besides them, the distal run-off of the coronary artery has been recognized as the flow limiting factors. The high expected run-off may be a potential explanation for the observation of the lower incidence of competitive flow in the LAD territory. The size and capacity of the in situ graft may also play an important role in the occurrence of competitive flow. However, we could not evaluate the effect of these factors in the present study. We consider that this is a limitation of the study.

In conclusion, coronary revascularization using composite grafts with arterial materials provided a satisfactory early graft patency rate, while competitive flow was found in the bypass graft to the coronary branches with moderate stenosis especially in the RCA territory. Since the implication of competitive flow may differ from the conventional coronary artery bypass grafting in an individual fashion, long-term follow-up of these patients is mandatory.

	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): Hiroyuki Nakajima Junjiro Kobayashi Osamu Tagusari Ko Bando Kazuo Niwaya Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nakajima, H. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Nakajima, H. Articles by Kitamura, S. Related Collections Coronary disease