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Ann Thorac Surg 2008;86:1861-1865. doi:10.1016/j.athoracsur.2008.06.025
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Total Arterial Revascularization in Triple-Vessel Disease With Off-Pump and Aortic No-Touch Technique

Wook Sung Kim, MDa, Jaejin Lee, MDb, Young Tak Lee, MDa,*, Kiik Sung, MDa, Ji-Hyuk Yang, MDa, Tae-Gook Jun, MDa, Pyo Won Park, MDa

a Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
b Department of Thoracic and Cardiovascular Surgery, Seoul Adventist Hospital, Seoul, South Korea

Accepted for publication June 2, 2008.

* Address correspondence to Dr Lee, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, South Korea (Email: ytlee55{at}yahoo.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: We evaluated the outcomes in patients who have undergone total arterial revascularization using the bilateral internal thoracic arteries (BITA) with off-pump and aorta no-touch technique.

Methods: From March 2001 to September 2007, 512 consecutive patients with triple-vessel disease underwent total arterial revascularization with off-pump and aortic no-touch technique, using BITA or the right gastroepiploic artery (RGEA) in addition to BITA. Only BITA grafts were used for bypass to coronary arteries in 353 patients, and additionally in situ RGEA was bypassed to right coronary arteries in 159 patients. The mean number of distal anastomoses was 4.15 ± 0.8 per patient.

Results: One 30-day death occurred. Deep sternal wound infection occurred in 2 patients. The rate of perioperative stroke was 0.8%. The patients were followed for as long as 6 years (mean follow-up, 37.9 ± 17.7 months). The 1-year and 5-year actuarial freedom from cardiac death was 98.3% and 96.7%, respectively. The 1-year and 5-year actuarial freedom from cardiac events was 97.1% and 89.3%, respectively. Using RGEA was a significant predictor of cardiac event–free survival (p = 0.046).

Conclusions: Total arterial revascularization using off-pump coronary bypass and aortic no-touch techniqe with BITA grafts was safe and effective, with low mortality among patients with triple-vessel disease. Patients undergoing in-situ RGEA grafting for right coronary arteries appeared to have fewer cardiac events than did patients undergoing only BITA grafting in triple-vessel disease.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Because better outcomes have been achieved with internal thoracic artery (ITA) grafts than with saphenous vein grafts in coronary artery bypass graft surgery (CABG), total arterial revascularization has been attempted by many cardiac surgeons [1–5]. It was reported that patients undergoing bilateral internal thoracic artery (BITA) grafts had decreased risk of death and fewer cardiac events than patients undergoing single ITA grafting [5, 6].

Off-pump coronary artery bypass grafting (OPCABG) combined with aorta no-touch technique has been accepted as an effective procedure to avoid neurologic and aortic complications, and to reduce operative risks. For this procedure, surgeons can use arterial grafts, in an in-situ pattern, or a composite graft and free grafts. In the cases where the left anterior descending coronary artery is bypassed with an in-situ right ITA (RITA), problems can occur if reoperation is needed.

All of the left coronary artery can be bypassed with BITAs, but it is not always possible to bypass the left and right coronary artery (RCA) in triple-vessel disease, even when using a composite graft technique. Bypassing the RCA with an in-situ right gastroepiploic artery (RGEA) is an alternative option in that case. The aim of this study was to evaluate the outcomes among patients who have undergone total arterial revascularization using BITA with off-pump and aorta no-touch technique in triple-vessel disease.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Demographics and Definitions
From March 2001 to September 2006, 789 patients with triple-vessel disease underwent OPCABG at the Samsung Medical Center in Seoul, Korea. Among these patients, total arterial revascularization was performed in 512 patients (64.9%) using composite BITA grafts or composite BITA grafts plus in-situ RGEA grafts with off-pump and aorta no-touch technique. We used arterial grafts to the patients whose RCA revealed more than 90% stenosis. The left coronary arteries were bypassed with composite BITA grafts in all the patients. The right coronary arteries were bypassed with the distal extension of the right ITA grafts in 353 patients and in-situ RGEA grafts in 159 patients. We retrospectively reviewed the clinical data of the patients. The Institutional Review Board of Samsung Medical Center approved this study on May 1, 2007. The patients' preoperative characteristics are summarized in Table 1. The surgeons evaluated the length of the RITA and the quality and diameter of the RGEA. They determined their graft strategy based on the results.


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  		Table 1 Preoperative Patient Characteristics
 
Postoperative atrial fibrillation was defined as a new atrial fibrillation, lasting more than 2 hours by electrocardiogram. Postoperative myocardial infarction was defined as new Q waves by electrocardiogram or a peak creatine kinase–MB level greater than 10% of the creatine kinase. A postoperative stroke was defined as a central neurologic deficit persisting for more than 72 hours, and was confirmed by computed tomography or magnetic resonance imaging. Cardiac event was defined as a cardiac death, myocardial infarction, heart failure, reintervention, return of angina, and sudden death. Follow-up was obtained by direct patient contact or by a telephone questionnaire. The patients whose RGEA was used were not treated with any additional drugs such as calcium-channel blockers during the in-hospital period or after discharge.

Surgical Technique
The ITAs were prepared by the skeletonization technique with sharp dissection and clipping of the branches. The RGEA was prepared in a pedicled manner. We did not use a Harmonic Scalpel. After dividing the distal end of the RGEA, diluting papaverine (1 mg/mL) solution was injected intraluminally, then the distal end of the RGEA was clipped to prevent spasm. Heparin was given at a dose of 150 IU/kg to achieve a target activated clotting time of 300 s or more. After the pericardium was opened, the RITA was anastomosed to the left side of the left ITA (LITA) with a continuous running suture to form a Y anastomosis with 8-0 Prolene suture (Ethicon, Piscataway, NJ). Then the distal end of the ITA grafts was clipped for pressure dilatation. Our strategy was to revascularize the collateral arteries first, but in most cases, the LITA was anastomosed to the left anterior descending coronary artery and its branches first, and then the RITA was sequentially anastomosed to the left circumflex artery. Next, the RCA system was subsequently revascularized with either the RITA or the RGEA. All anastomoses were performed with either the Medtronic Octopus (Medtronic, Minneapolis, MN) or the Axius (Guidant, Santa Clara, CA) off-pump system. A deep pericardial stay suture was not used.

To obtain a bloodless field, the target coronary artery was occluded proximally using a 5-0 Prolene suture with a needle,16 mm in diameter, passed deeply to the surrounding vessels. The needle, after the first bite, was passed through the wall of a small piece of silicone tubing. In addition to a proximal snare suture, we routinely used a carbon dioxide blower. An intraluminal shunt was sometimes used for grafting the distal RCA or intramyocardial coronary artery. Each anastomosis was performed with an 8-0 Prolene running suture. The quality of the anastomosis sites was evaluated by recording postoperative transit-time flow rate with a Transonic Flowmeter (Transonic Systems, Ithaca, NY). Heparin was partially reversed with protamine sulfate (0.5 mg/kg).

Statistical Analysis
Continuous variables are reported as the mean ± SD. Continuous variables were compared by Student t test and paired t test. Discrete variables were compared by the Pearson {chi}2 test or Fisher's exact test. Cardiac death included in-hospital mortality, cardiogenic death, and sudden death. Cardiac event–free survival, freedom from late death, freedom from cardiac death, freedom from reintervention, freedom from recurrent angina, and freedom from myocardial infarction were calculated by means of the Kaplan-Meier method, and the log-rank test was used to compare the curves. The Cox proportional hazards model was used to analyze the cardiac event–free survival. The univariate Cox proportional hazards model was used to analyze patient preoperative and operative factors. Preoperative factors included age (≥ 70 years old), female sex, renal failure, chronic obstructive pulmonary disease, peripheral vascular disease, previous myocardial infarction, cerebrovascular disease, hypertension, diabetes mellitus, previous percutaneous coronary intervention, and ejection fraction (< 0.40). In addition, the operative factors included RGEA use, new arrhythmia, reoperation for bleeding, neurologic complications, and wound complications. Factors with a probability of 0.25 were entered into the multivariate Cox proportional hazard model. The hazard ratio (HR), with a 95% confidence interval (CI) and the levels of statistical significance (p value) were calculated. All statistical analyses were performed using SPSS version 12.0 (SPSS, Chicago, Illinois).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Operative Results
The number of mean distal anastomoses per patient was 4.15 ± 0.8. The grafts used and bypassed vessels are shown in Table 2. Double Y grafts with ITA were used in 14 patients, and I-graft extension was performed in 26 patients. Coronary endarterectomy was performed in 6 patients.


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  		Table 2 Operative Data and Postoperative Course
 
Early Outcome
One patient died within 30 days. The patient died of low cardiac output and multiorgan failure 3 days after surgery. The postoperative morbidity is shown in Table 3. The incidence of stroke was 0.8% (4 of 512). All strokes occurred in patients with a history of a previous stroke or postoperative atrial fibrillation. Mean postoperative creatine kinase-MB level was 15.5 ± 19 ng/mL, and perioperative myocardial infarction occurred in 4 patients. Five patients underwent reoperation for bleeding. Deep and superficial wound infections occurred in 2 patients and in 18 patients, respectively. The mean intensive care unit and postoperative hospital stays were 1.5 ± 2.2 days and 7.4 ± 5.2 days, respectively.


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  		Table 3 Distal Anastomosis
 
Late Outcome
Late follow-up was available for 95% of the surviving patients (Table 4). The mean follow-up was 37.9 ± 17.7 months. There were 14 late deaths. Late cardiac mortality included 6 deaths (5 to 22 months) after the operation. Return of angina occurred in 34 patients and acute myocardial infarction occurred in 2 patients. The 1-year and 5-year freedom from cardiac events was 97.1% and 89.3%, respectively (Fig 1). The 1-year and 5-year survival rate was 98.3% and 96.7%, respectively (Fig 2).


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  		Table 4 Late Results
 

Figure 1
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  		Fig 1. Actuarial cardiac-related event-free survival rates estimated by Kaplan-Meier analysis. Cardiac-related events included angina, acute myocardial infarction, percutaneous coronary intervention, cardiac death, and sudden death.

 

Figure 2
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  		Fig 2. Actuarial survival rates estimated by Kaplan-Meier analysis.

 
In a univariate analysis, four variables (female sex, new-onset arrhythmia, ejection fraction < 40%, and using RGEA) were significant, with a probability of 0.25. The multivariate Cox proportional model was used to analyze these factors. Using RGEA was significant predictors of cardiac event–free survival (p = 0.046, CI: 1.02 to 6.60).


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Since bilateral internal thoracic artery (BITA) grafting to the left anterior descending coronary artery and circumflex coronary arteries was reported to provide the best long-term survival and the lowest rates of reintervention in patients undergoing CABG, many surgeons have adopted this approach [1–3, 5, 6]. However, the best graft for the right coronary artery in patients with triple-vessel disease has not been well established. The right coronary artery can be bypassed with a saphenous vein graft, RGEA, the radial artery, or a composite ITA graft. When OPCABG is planned with the aorta no-touch technique and using BITA grafts, the right coronary artery can be bypassed with an in-situ RGEA or an extension of the composite ITA graft.

When all target vessels in triple-vessel disease were bypassed with a composite ITA graft, a major concern was that the single attached LITA would not be able to supply enough blood to the revascularized myocardium. However, reports show that hypoperfusion was rare, and total arterial revascularization using a composite graft provided a 2.3-fold increase of reserve blood flow to the coronary vascular bed through the grafts [6, 7]. Long-term clinical and angiographic results as well as early postoperative stress myocardial perfusion were reported to be similar for BITA used either in situ or as a composite graft [8, 9]. Pevni and colleagues [10] reported that early and midterm results in patients undergoing left-sided BITA grafting were not affected by the conduit used for RCA grafting with comparing RITA and RGEA. But long-term outcome of total arterial revascularization using BITA and RGEA was reported to be excellent [2, 11]. It was reported that the reoperation rate for graft failure was significantly higher when the in situ RITA graft was used for the right coronary artery than when the in situ GEA was used [12].

In our study, the 34 patients reported a return of angina, but graft failure including significant stenosis of the anastomosis site was demonstrated in only 6 patients on the coronary angiogram. In the others, except 1 patient whose native coronary stenosis had progressed, competitive flow patterns were observed. Using RGEA graft was a significant predictor of cardiac event–free survival. We assumed that the blood stream by only LITA might cause the recurrent angina because it did not sufficiently supply the myocardium. We previously reported early angiographic findings for patients with patients with triple-vessel disease who underwent revascularization with only BITA grafts [13]. We observed competitive flow patterns in 10.5% of the distal anastomosis sites. The number of distal anastomoses and the degree of proximal coronary stenosis were identified as predisposing factors for competitive flow [3, 14]. In our study, considering fewer distal anastomoses with BITA grafts were performed when RGEA grafts were used (3.39 ± 0.9 versus 4.04 ± 0.7, p < 0.001), and a competitive flow pattern was more likely to occur in patients, only BITA were used.

Deep sternal infection occurred in 2 patients (0.4%), although BITA were used even in diabetic patients, accounting for more than 40% of this study. Recently, OPCABG with a skeletonizing ITA harvesting technique was reported as a factor to reduce deep sternal wound infection [15]. We routinely irrigated the mediastium with saline before sternal closure and used more than 10 wires to close the sternum.

Harvest of the RGEA requires a laparotomy, which can be performed 2 to 3 cm lower with extension of the median sternotomy incision. The RGEA was prepared to reach the coronary target through the anterogastric course. Although the anterogastric course is a longer route than the retrogastric course, it is easier to control bleeding and prevent torsion of the graft. Preparation for the RGEA graft and closure of the peritoneum after control of bleeding usually take about 40 minutes at our hospital. The RGEA size is associated with a wide interindividual variation, and spasm of the graft frequently occurs during harvesting. We did not discard the RGEA graft unless the diameter of the graft at the anastomotic site was less than 2.0 mm and atheroma was found on the graft. The RGEA graft could be applied in about 90% of attempted cases.

In conclusion, total arterial revascularization using OPCABG and aortic no-touch techniqe with BITA grafts was safe and effective, with low mortality among patients with triple-vessel disease. Patients undergoing in-situ RGEA grafting appeared to have fewer cardiac events than did patients undergoing only BITA grafting in triple-vessel disease.

Limitations
This study had a retrospective and nonrandom design. We did not routinely perform preoperative and postoperative myocardial perfusion testing; therefore, we could not determine competitive flow patterns to contribute to myocardial ischemia. Furthermore, the follow-up was too short to draw a definite conclusion.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Chowdhry TM, Loubani M, Galinanes M. Mid-term results of radial and mammary arteries as the conduits of choice for complete arterial revascularization in elective and nonelective coronary bypass surgery J Card Surg 2005;20:530-536.[Medline]
  2. Formica F, Ferro O, Greco P, Martino A, Gastaldi D, Paolini G. Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery Eur J Cardiothorac Surg 2004;26:1141-1148.[Abstract/Free Full Text]
  3. Fukui T, Takanashi S, Hosoda Y, Suehiro S. Total arterial myocardial revascularization using composite and sequential grafting with the off-pump technique Ann Thorac Surg 2005;80:579-585.[Abstract/Free Full Text]
  4. Kobayashi J, Sasako Y, Bando K, et al. Multiple off-pump coronary revascularization with "aorta no-touch" technique using composite and sequential methods Heart Surg Forum 2002;5:114-118.[Medline]
  5. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
  6. Tector AJ, McDonald ML, Kress DC, Downey FX, Schmahl TM. Purely internal thoracic artery grafts: outcomes Ann Thorac Surg 2001;72:450-455.[Abstract/Free Full Text]
  7. Royse AG, Royse CF, Groves KL, Bus B, Yu G. Blood flow in composite arterial grafts and effect of native coronary flow Ann Thorac Surg 1999;68:1619-1622.[Abstract/Free Full Text]
  8. Calafiore AM, 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;120:990-996.[Abstract/Free Full Text]
  9. Kang CH, Kim KB, Park CS, Paeng JC, Lee DS. Improvement of myocardial stress perfusion after off-pump revascularization using bilateral internal thoracic in situ grafts versus Y-composite grafts Ann Thorac Surg 2005;79:93-98.[Abstract/Free Full Text]
  10. Pevni D, Uretzky G, Yosef P, et al. Revascularization of the right coronary artery in bilateral internal thoracic artery grafting Ann Thorac Surg 2005;79:564-569.[Abstract/Free Full Text]
  11. Bergsma TM, Grandjean JG, Voors AA, Boonstra PW, den Heyer P, Ebels T. Low recurrence of angina pectoris after coronary artery bypass graft surgery with bilateral internal thoracic and right gastroepiploic arteries Circulation 1998;97:2402-2405.[Abstract/Free Full Text]
  12. Dietl CA, Benoit CH, Gilbert CL, et al. Which is the graft of choice for the right coronary and posterior descending arteries?. Comparison of the right internal mammary artery and the right gastroepiploic artery. Circulation 1995;92:II92-II97.[Medline]
  13. Sung K, Lee YT, Park KH, Jun TG, Park PW, Yang JH. Beating heart revascularization using only bilateral internal thoracic arteries for triple-vessel disease: early angiographic findings Heart Surg Forum 2003;6:336-340.[Medline]
  14. Pevni D, Hertz I, Medalion B, et al. Angiographic evidence for reduced graft patency due to competitive flow in composite arterial T-grafts J Thorac Cardiovasc Surg 2007;133:1220-1225.[Abstract/Free Full Text]
  15. Kai M, Hanyu M, Soga Y, et al. Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics Ann Thorac Surg 2007;84:32-36.[Abstract/Free Full Text]

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