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Ann Thorac Surg 2007;83:1168-1169
© 2007 The Society of Thoracic Surgeons
a Department of Department of Cardiovascular Surgery, Charité Hospital, Medical University Berlin, Berlin, Germany
b Department of Radiology, Charité Hospital, Medical University Berlin, Berlin, Germany
Accepted for publication August 1, 2006.
* Address correspondence to Dr Dohmen, Department of Cardiovascular Surgery, Charité Hospital, Medical University Berlin, Luisenstrasse 13, D-10117 Berlin (Email: pascal.dohmen{at}charite.de).
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Introduction |
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A 79-year-old woman presented at our hospital with angina pectoris. Her medical history included arterial hypertension, peripheral arterial vascular disease, esophageal reflux, and severe bilateral varicosis. Transthoracic echocardiography showed a normal left ventricular ejection fraction and no valvular disease. Angiography revealed general arteriosclerosis with significant stenoses at the proximal left anterior descending, first diagonal, proximal circumflex, and medial right coronary arteries. Because we lacked suitable autologous graft material owing to a positive Allen test and prior bilateral saphenectomy (due to varicosis), we decided to use a seeded NR-SIMA, for complete revascularization.
After institutional review board approval and informed consent were obtained, an 8-cm skin vein from the right forearm was taken in March 2004. Endothelial cells were harvested and cultured as previously described [3]. The NR-SIMA was selected because previous studies had shown that this graft provided a higher density of endothelial cells after seeding compared with expanded polytetrafluoroethylene (ePTFE) grafts [2].
In April 2004, the patient underwent grafting using the left internal mammary artery to the left descending artery (including endarterectomy), the right vena saphena parva as a sequential bypass for the first diagonal and circumflex artery, and the seeded NR-SIMA to bypass the right coronary artery. The internal diameters were left descending artery, 1.0 mm; first diagonal artery, 1.5 mm; circumflex artery, 1.5 mm; and right coronary artery, 2.5 mm. A no-touch technique was used during implantation to avoid endothelial cell loss resulting from manipulation.
During the postoperative period, the patient experienced arterial bleeding of a duodenal ulceration, which needed to be treated interventionally. The patient was sent home on postoperative day 19 in good health. During follow-up, the patient did not have any adverse events or restrictions. Patency of the grafts was evaluated by a noninvasive multislice computed tomography scan at discharge and at 20 months’ postoperatively. All grafts were patent at both intervals (Fig 1).
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These data were supported by Osswald and colleagues [5], who showed similar results. In their study, 180-day mortality was significantly higher (24%; p = 0.005) in patients with incomplete revascularization compared with those who underwent complete revascularization (15%). Alternative grafts are therefore needed for those situations in which autologous material is not available or the quality of such graft material does not permit its use.
An ideal artificial graft for coronary bypass surgery should have a small diameter, be easy to implant, and have "off-the-shelf" availability. Craig and colleagues [1] presented a study of 7 patients who underwent implantation of a bovine internal mammary artery treated by dialdehyde and sterilized with ethanol and propylene oxide (Bioflow, Biovascular Inc, St Paul, MN). All 11 examined grafts were occluded at a mean follow-up of 19 months after implantation, despite the target vessels being at least 1.5 mm in diameter. Among the remaining patients, each of whom refused to be reevaluated, 42.8% experienced recurrent angina pectoris.
Mitchell and colleagues [6] reported an angiographic study of the Bioflow, with a patency rate of 15.8% at a mean follow-up of 9.5 months (range, 3 to 23 months). The dialdehyde tanning procedure removes the dendritic cells and renders immunogenicity, but inevitably, the lack of endothelial cells means that collagen is exposed to blood circulation, creating a thrombogenic surface [6].
The No-React treatment is a heparin-based detoxification process that further stabilizes tissue cross-linking and prevents the release of aldehydes [7]. No-React treated tissue has been shown to inhibit calcification and inflammatory reactions and resist infection while preserving cellular and connective tissue structures, which denotes its biocompatibility [8]. A previous in vitro study performed at our institute confirms this statement, that No-React treated bovine internal mammary arteries can be seeded with endothelial cells. We were, furthermore, able to show that the endothelial cell density of the seeded NR-SIMA graft was significantly higher than ePTFE grafts. Encouraged by these results and an in vivo study, we implanted the seeded NR-SIMA in a patient with insufficient autologous graft availability to perform complete revascularization. After 20 months of follow-up, the mammary artery and the vena saphena parva were both patent. Furthermore, the NR-SIMA was also patent, and the patient was in New York Heart Association functional class I, without any restrictions.
This excellent clinical result notwithstanding, this new technique has some restrictions. For the moment, this treatment is only available for patients with stable angina pectoris, because the waiting time for a seeded NR-SIMA graft is 4 to 6 weeks. A cell-culturing modification we have performed has lead to a reduction of this waiting time by 2 weeks. Nevertheless, new cell sources need to be evaluated, such as progenitor cells, which have more growth potential. This is under investigation and should, in the future, allow time to treat patients with unstable angina pectoris.
In conclusion, this alternative can be safely used in patients with stable angina pectoris in which elective bypass surgery can be performed.
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  L. Englberger, J. Noti, F. F. Immer, M. Stalder, F. S. Eckstein, and T. P. Carrel The Shelhigh No-React(R) bovine internal mammary artery: a questionable alternative conduit in coronary bypass surgery? Eur. J. Cardiothorac. Surg., February 1, 2008; 33(2): 222 - 224. [Abstract] [Full Text] [PDF]
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