Ann Thorac Surg 2005;80:579-585
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Total Arterial Myocardial Revascularization Using Composite and Sequential Grafting With the Off-Pump Technique
Toshihiro Fukui, MD
a
,
*
,
Shuichiro Takanashi, MD
a
,
Yasuyuki Hosoda, MD
a
,
Shigefumi Suehiro, MD
b
a Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan
b Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
Accepted for publication March 3, 2005.
Abbreviations and Acronyms CABG = coronary artery bypass grafting; GEA = gastroepiploic artery; IEA = inferior epigastric artery; LAD = left anterior descending artery; LITA = left internal thoracic artery; OPCAB = off-pump coronary artery bypass grafting; RA = radial artery; RITA = right internal thoracic artery; SVG = saphenous vein graft
* Address reprint requests to Dr Fukui, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba 271-0077, Japan (Email: tm-fukui{at}gem.hi-ho.ne.jp).
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Abstract
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BACKGROUND: Multiple arterial myocardial revascularizations are increasingly undertaken using off-pump techniques; however, various arterial grafting techniques are utilized. This study aimed to review the outcome of combining arterial composite and sequential grafting with off-pump techniques.
METHODS: We retrospectively reviewed the records of 107 consecutive patients who underwent coronary bypass surgery with off-pump and arterial composite grafting techniques between April 2001 and March 2004. The left internal thoracic artery (LITA) was harvested in all patients, and the right internal thoracic artery (RITA), the radial artery (RA), and the gastroepiploic artery (GEA) were harvested in 69 patients, in 83 patients, and in 53 patients, respectively. Early postoperative angiograms were evaluated in 97 patients.
RESULTS: There were 488 distal anastomoses, an average of 4.5 per patient. Forty-four in situ LITAs were used as LITA Y-composite grafts with a free RITA (n = 19), RA (n = 24), or free GEA (n = 1). Forty-three in situ RITAs were used as RITA-RA grafts (n = 42) or a RITA-GEA graft (n = 1). Twenty-one in situ GEAs were used as composite grafts with the RA (n = 17) or a free RITA (n = 4). There were no hospital deaths. The patency of the LITA was 100%, and that of the RA was 97.3%, while patencies of both in situ and free RITA and GEA were 100%. During the follow-up period (mean: 22.1 months), there were 3 late deaths, but none were cardiac related.
CONCLUSIONS: Total arterial revascularization with composite and sequential grafting is a safe and effective technique in patients undergoing off-pump coronary artery bypass surgery.
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Introduction
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Coronary artery bypass grafting (CABG) is a well-established method for treating multivessel coronary artery disease. Saphenous vein grafts (SVGs) show poor patency rates and have failed to improve long-term morbidity [1]. In contrast, the left internal thoracic artery (LITA) has been demonstrated to have a superior graft patency rate and has provided excellent clinical results [2]. This suggests that the use of arterial conduits for CABG might be beneficial for long-term results [3]. Additional arterial conduits have been utilized, such as the right internal thoracic artery (RITA) [4], the radial artery (RA) [5], and the right gastroepiploic artery (GEA) [6]. With the use of these arterial grafts, total arterial revascularization can be achieved [7, 8]. Arterial composite grafts with sequential grafting techniques can increase the number of distal coronary anastomoses with a limited number of grafts, avoiding proximal aortic anastomoses. Several composite grafting techniques have been proposed such as the use of Y, T, U, and I composites [9–14]. When the LITA is used as the first arterial graft, opinions regarding the choice for the second arterial graft are various [15–17]. Furthermore, limited information is available concerning which grafts should be used as the composite and sequential bypass grafts.
Off-pump CABG (OPCAB) has gained popularity because of the many clinical and economic benefits in comparison with conventional CABG [18, 19]. However, there are still few studies determining the optimum combination of OPCAB and composite arterial graft with sequential bypass [14, 20], and concern remains regarding the quality and patency of grafts when these techniques are combined. This study aimed to determine the early and mid-term clinical and angiographic outcomes of such combinations.
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Patients and Methods
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Patient Population
Between April 2001 and March 2004, 605 patients had isolated CABG with 541 patients (89.4%) having OPCAB at the Shin-Tokyo Hospital. Our strategy of isolated CABG is directed toward obtaining complete myocardial revascularization using arterial grafts with OPCAB techniques whenever feasible. Thus, there were 420 patients (79.4%) who received total arterial OPCAB revascularization, and 313 of these underwent CABG with proximal aortic anastomosis, or without composite or sequential grafting. A combination of arterial composite and sequential grafting techniques and OPCAB procedures without aortic anastomosis was performed on the remaining 107 patients, who were enrolled in this study, had their records reviewed retrospectively. This study was approved by our institutional review committee, and informed consent was obtained from each patient in respect to the surgical method and postoperative angiography. Follow-up involved direct communication with the patient, their family, attending physician, or a combination of these. Survival and any cardiac events (recurrent angina, myocardial infarction, congestive heart failure, re-intervention, or re-operation) were assessed. The preoperative characteristics of the patients are summarized in Table 1.
Graft Harvesting
All arterial grafts were harvested in a skeletonized fashion using an ultrasonic scalpel (Harmonic Scalpel, Ethicon Endosurgery, Cincinnati, OH). The LITA, the RITA or the GEA was taken down after milrinone solution (50 mg/L) was injected in the distal end [21]. The RITA used as a free graft or the RA was preserved in a warm milrinone solution. The LITA was harvested in all patients, and the RITA, the RA and theGEA were harvested in 69 patients, in 83 patients and in 53 patients, respectively.
Grafting Strategy
The strategy of CABG was to bypass all significant stenosis (at least 50% diameter reduction) in all coronary vessels larger than 1 mm in diameter. Arterial composite and sequential grafting techniques without aortic anastomosis were selected when ascending aortic atherosclerosis was demonstrated by epiaortic echogram or when length of a conduit was too short to reach the aorta. The choice and combination of grafts were based on coronary artery anatomy, severity of coronary stenosis, and size of the grafted vessel. Representative patterns of composite and sequential bypass grafting are illustrated in Figure 1. In any situation, only one branched graft was connected to a single feeder artery.
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Fig 1. Patterns of composite grafting with sequential bypass (from left to right). (Top row) Left internal thoracic artery (LITA) with a Y-composite graft; right internal thoracic artery (RITA) with a Y-composite graft; and RITA with an I-composite graft. (Bottom row) RITA with a U-composite graft; gastroepiploic artery (GEA) with an I-composite graft; and GEA with a U-composite graft.
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Surgical Technique
Median sternotomy was performed in all patients. Grafts were prepared after heparinization (300 IU/kg). A deep pericardial stay suture was not used, and commercially available heart positioner and stabilizer were applied to the heart (Starfish and Octopus; Medtronic Inc., Minneapolis, MN). A bloodless field was obtained using a proximal silastic snare suture and a CO2 blower. An intraluminal shunt was sometimes used for grafting to the right coronary artery. Anastomosis was performed with an 8-0 polypropylene running suture using the parachute technique.
When sequential grafting is constructed, diamond-shaped side-to-side anastomosis and terminal T-shaped anastomosis are our preferred approaches. If necessary, the anastomosis was rotated to accord with the angle between the graft and vessels. Terminal anastomosis was done first, followed by sequential anastomoses toward the proximal portion of the graft. After all distal anastomoses were completed, anastomosis between donor and branched arteries was performed at the end of the procedure. We did not assess graft patency during the operation.
Angiographic Study
Postoperative angiography was performed to assess graft patency only in patients who gave informed consent and was performed before discharge at 5 to 22 days (mean: 7.5 ± 2.5 days) after surgery. The quality of the anastomoses was graded according to the Fitzgibbon classification system [1]: grade A, unimpaired graft run-off; grade B, reduced graft caliber less than 50% of the grafted coronary artery; and grade O, occluded graft.
Free RITA Versus RA
We compared clinical and angiographic outcomes between free RITA and RA grafts that were mainly used to revascularize the circumflex coronary artery system. The grafted territories were not different between the two grafts. There were 22 patients who received a free RITA graft, but did not receive an RA graft. The RA group included 37 patients who received an RA graft without a RITA graft.
Statistical Analysis
Continuous variables are reported as the mean ± standard deviation. Continuous variables were compared by the Student’s t test. Discrete variables were compared by the 
2 test or Fischer’s exact test. Actuarial survival and event-free survival curves were estimated by the Kaplan-Meier method. Differences were considered statistically significant at a p value less than 0.05. Statistical analyses were performed using the StatView 5.0 software package (SAS Institute Inc, Cary, NC).
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Results
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Distribution of Grafting
A total of 107 patients with 108 composite grafts were enrolled in this study. There were 488 distal anastomoses with an average of 4.5 ± 1.0 anastomoses per patient. The graft arrangements in these patients are listed in Table 2. In all patients, the LITA was grafted to the left anterior descending coronary artery (LAD), and sequential LITA grafting to the LAD and diagonal branch was performed in 13 patients. Forty-four LITAs were used as LITA Y-composite grafts with the free RITA (n = 19), the RA (n = 24), or the free GEA (n = 1). Forty-two RITAs were used as RITA-RA composite grafts (9 as Y, 19 as I, and 14 as U configurations), and 1 RITA as a RITA-free GEA composite graft. Twenty-three free RITAs were connected to the LITA (n = 19) and the GEA (n = 4). Twenty-one GEA were used as GEA-RA composite grafts (12 as I and 5 as U configurations) and GEA-free RITA composite grafts (n = 4). The RA was used for composite grafts with the LITA (n = 24), the RITA (n = 42), and the GEA (n = 17). The maximum number of distal anastomoses with one branched graft was 5 in 2 patients using RA. The mean operation time was 318.9 ± 79.3 minutes. Blood transfusions were undertaken in 36.4% of cases.
Early Outcome
There were no in-hospital deaths. Postoperative morbidity is presented in Table 3. Low output syndrome was defined as the need for a dose of more than 5 µg/kg per minute of inotropic agent (dopamine or dobutamine). Four patients developed strokes, but only 1 patient had an intraoperative stroke while the other 3 patients had postoperative strokes; because of 80% stenosis of the left internal carotid artery in one, and atrial fibrillation in 2. In all patients except one, neurologic deficits were transient. The intubation time ranged from 3 to 157 hours (mean: 12.5 hours). Mean ICU and postoperative hospital stays were 1.7 ± 1.7 days and 15.1 ± 9.6 days, respectively.
Postoperative angiography was performed in 94 patients (87.9%). The total number of distal anastomoses was 432 and there were 4.6 ± 1.0 average anastomoses per patient. The angiographic results are summarized in Table 4. The patency rate of the 94 LITAs (37 composite and 57 noncomposite grafts) was 100% (grade A, 88; grade B, 6). The patency rates of in-situ RITA (39 grafts) and free RITA (21 grafts) were both 100% (grade A, 59; grade B, 1). The patency rate of RA was 97.3% (grade A, 69; grade B, 2; grade O, 2). One RA sequentially grafted from the GEA I-composite graft to a posterolateral branch and a posterior descending branch was occluded. The other occluded RA was a sequential graft branched from the RITA U-composite to 4 coronary vessels. The patency rates of the in-situ GEA graft (19 composite and 27 noncomposite grafts) and the free GEA were 100%. Overall, all of 94 inflow grafts were patent.
Mid-Term Outcome
During the follow-up period (mean 22.1 ± 9.2 months), there were 3 late deaths. Two patients died of visceral cancer at 10 and 22 months after the surgery, respectively, and 1 died of pneumonia at 10 months after surgery. The actuarial survival rate was 96.1% at 41 months. There were 7 patients who had recurrent angina at 14.4 ± 6.8 months after surgery; coronary angiography and percutaneous angioplasty were performed in all 7, and a stenosis of an ungrafted coronary vessel progressed in 4 of these. Graft occlusion was observed in the other 3 patients. In the first patient who underwent endarterectomy of the LAD, the LITA grafting to the LAD was occluded. In the second, the composite RITA-RA I-composite graft to 4 distal vessels was occluded. In the third, the RA of the RITA-RA composite graft was occluded as shown in Figure 2. There was 1 patient who developed cardiac failure, although the implanted grafts were patent 3 months after surgery. The rate of freedom from death and cardiac event was 86.0% at 41 months (Fig 3).
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Fig 2. Postoperative coronary artery angiography. In situ right internal thoracic artery (RITA) was anastomosed to the diagonal branch (Diag.). The radial artery (RA) connected to the RITA as a Y-composite graft was sequentially anastomosed to the obtuse marginal artery (OM [with 50% stenosis]) and posterolateral artery (PL [with 75% stenosis]). (A) Early postoperative angiogram showing all conduits patent. (B) Late postoperative angiogram showing occlusion of the RA.
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Free RITA Versus RA
Preoperative and postoperative data are listed in Table 5. The number of total distal anastomoses or the number of sequential anastomoses per one graft in the RA group was significantly greater than that in the free RITA group. Perioperative morbidity was not different. Early postoperative angiography was performed in 20 patients with free RITAs and 31 with RAs. The graft patency rate in this RA group was 100%.
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Comment
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This retrospective study shows that arterial composite grafting with sequential bypass is a feasible and effective method for multiple vessel myocardial revascularizations, and that the combination of arterial composite graft and OPCAB technique is safe and provides good early clinical and angiographic outcomes.
Recently, the use of arterial grafts has been widely accepted for myocardial revascularization based on the clinical advantage of the use of the LITA as a bypass conduit [2, 3]. Many retrospective studies have supported the safety and the effectiveness of arterial grafting, and it has become clear that the free arterial graft can be used as a branched or a lengthened conduit to the in situ arterial graft [7–14]. However, the patency of free arterial grafts proximally anastomosed to the aorta is similar to that of SVG. Calafiore and colleagues [8] hypothesized that the reason for this poor graft patency rate was due to a mismatch between the aorta and the conduit wall, and a difference in the flow pattern. Based on their hypothesis, we have used the composite grafting technique whenever possible. Moreover, we believe that composite grafting can save a side anastomosis to the aorta and secure the length of the graft to a distal target vessel.
Several retrospective OPCAB studies have revealed that the average number of grafts per patient undergoing OPCAB is significantly lower than that in on-pump CABG patients [22, 23]. In this study, we could perform multiple revascularizations using a sequential grafting technique (an average of 4.5 anastomoses per patient). Sequential grafting on the beating heart is somewhat technically demanding. We agree that exposure and stabilization of target vessels are the crucial steps for sequential grafting with the OPCAB technique [20, 24]. We also believe that determining the correct direction and course of the conduit are important to prevent kinking of the graft. In performing sequential grafting, the distance between the two anastomoses can be determined easily while the heart is beating with the OPCAB technique [24].
There are some reports concerning the combined use of arterial composite grafting and OPCAB [14, 20]. The combination of composite arterial grafting, sequential bypass grafting, and OPCAB technique have not been accepted widely; however, this combination can achieve multiple vessel revascularizations less invasively and with a limited number of arterial grafts without aortic manipulation. The possible weak point of this composite and sequential graft is that the flow is dependent on one in situ arterial graft. In our patients, occlusion of the inflow artery was not observed in the period early after surgery, and in only 1 patient in the mid-term period. These results suggest that the patency of a donor artery graft can be well maintained. Several authors have demonstrated decreased RA graft patency rates if the target vessel has a nonsevere stenosis [25, 26]. This may have been the result in the mid-term occlusion of the RA graft that was patent early after surgery in this study. Several studies support the safety of composite grafting with respect to hemodynamic parameters [27, 28]. The configurations of the composite grafts are various. Our experience is that the patency of composite grafts does not depend on the configurations of the grafts. The quality of the graft and the degree of stenosis of the target vessel seem to be important for the construction of composite and sequential grafts.
There are several reports describing that the early and mid-term results using the RA are superior as a second arterial graft to the free RITA [15, 17, 29]. Lemma and coworkers [15] have reported that the RA is more accessible than the RITA because it has a thicker wall and larger diameter. In this study, morbidity was not different between the RA and the free RITA groups; although there were more anastomoses per patient and per graft in the RA group, simply because the conduit length of the RA is greater than that of the free RITA. We think that handling the free RITA is almost as easy as the RA, and that anastomosis between the free RITA and LITA or RITA and GEA is more suitable than that between the RA and LITA/GEA, because the internal diameter and the wall thickness of the RITA are similar to those of the LITA or the GEA. Furthermore, the RITA rarely develops atherosclerosis. Our results suggest that graft patency and clinical results are similar; indicating that the choice of graft should be decided according to the anatomic features of target coronary vessels and considering the advantage of each graft.
In this study, the incidence of stroke was high, considering that our patients had minimal aortic manipulation; however, the 3 patients had strokes postoperatively due to the carotid stenosis or atrial fibrillation, suggesting that these strokes were not related to the surgical procedures investigated.
Study Limitations
The limitations of this clinical study are that the number of patients included in the study is small and the length of clinical follow-up is only 22.1 months. Furthermore, this is a retrospective observational study and was not randomized. Because there was no control group, we cannot conclude that composite arterial grafting with sequential bypass in OPCAB is superior to conventional CABG.
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TSFRE Research Funding is Growing
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The Thoracic Surgery Foundation for Research and Education (TSFRE) began a major effort 3 years ago to enhance its support of the cardiothoracic surgical investigators. The Research Committee, led by Robin Pierson, developed more stringent advance review methods and standards similar to those of the NIH. In 2005, TSFRE funded 16 investigators for a total of $295,000.
TSFRE continued to fund Research Grants and Fellowships, including the Nina Starr Braunwald Award for a woman cardiac surgeon. Career development partnerships with the National Heart, Lung and Blood Institute (NHLBI) and the National Cancer Institute (NCI) were created. These K08 (basic science) and K23 (patient-oriented science) TSFRE/NIH partnerships match the NIH salary awards of $75,000 per year for 5 years, thus giving the surgeon $150,000 per year of salary support for a total of $750,000 that allow him or her to devote 75% of time to research. The young investigators are mentored by senior, established, NIH funded scientists. TSFRE/NHLBI received 8 applications for K awards and TSFRE/NCI received 4 applications between 2004 and 2005. Four years ago, there was a single K award for a cardiothoracic surgeon and now there are 5 K awards funded by TSFRE/NHLBI. The first TSFRE/NCI award will be funded. The current TSFRE commitment for K awards is $450,000 per year, projected to be at least $750,000 per year in 2008.
To be funded in this extremely competitive environment, investigators must have exceptionally good scores. Our young investigators are prospering. The entire CT surgery community should be proud of what they are accomplishing.
As compared to 2003, the percentage of cardiothoracic surgeons who have donated to TSFRE has doubled. More help is needed because TSFRE resources are limited. The TSFRE Board of Directors has given an average of $17,000 per Director, thus making each Director at least a Life member of TSFRE. If you are already a Life member, TSFRE thanks you. If you are not yet a Life member, please consider giving what you can. A pledge of $1000 per year for 10 years makes one a Life member.
John R. Benfield, MD
President
TSFRE
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Top
Abstract
Introduction
