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Correspondence

Flow Competition in Coronary Artery Bypass Grafting With Exclusive Arterial Conduits and Clinical Trial

Division of Cardiothoracic Surgery, Mt. Prospect Medical Center, 1940 S. Carboy Rd, Mt Prospect, IL 60056

(Email: xiaoshiqi.md{at}gmail.com).

To the Editor:

Azmoun and his colleagues deserve to be congratulated for their recent publication regarding exclusive internal thoracic arteries (ITA) as grafts in coronary artery bypass grafting (CABG) under normothermic cardiopulmonary bypass [1]. The description of this intriguing and elegant surgical technique is one more report on this topic from Jegaden and colleagues [2], who were first reporters from France in 1994. This technique was reported from the US as early as the 1980s [3, 4].

However, some parts of this presentation are questionable. The flow competition, by their statement, is the main culprit. It is true some flow competition exists with this technique, but competitive flow phenomenon should not be overstated. At the very least, the suboptimal anastomoses need to be ruled out. In the authors' data, the anastomoses with the right internal thoracic artery (RITA) in the lateral and inferior parts of the heart: part of the ramus intermedius, the obtuse marginal, the right posterolateral, and the posterior descent arteries (N = 208) are far more than those with the left internal thoracic artery (LITA) in the anterior part: the LAD, the diagonal, and part of ramus intermedius arteries (N = 166). In their postoperative data, there were three cases of graft kinking plus nine cases of "competitive flow," which amounts to 12 patients among a total of 92 patients in the study. According to the data, all of the adverse cases previously mentioned were grafted with the right internal thoracic artery (RITA) in the lateral and inferior parts of the heart. These cases had not yet presented clinical significance as of the follow-up date.

In our experience, to anastomose with RITA on the coronary artery of the lateral and inferior parts of the heart are more challenging than to do it with the LITA on the coronary artery in the anterior area of the heart. Therefore, it is important to detect, in a timely manner, any technical errors by surgeons rather than true competitive flow. Intraoperatively post-grafting Doppler flow measurement or intraoperatively post-grafting coronary angiography, or both, are uniquely designed for this purpose. So-called "flow competition" on any postoperative follow-up coronary angiography falls short of convincing evidence. Instead, intraoperative detection is one of the fundamental and correct steps to rule out artificial errors. Furthermore, dynamic flow monitor or angiography, or both, are the best methods of doing this. Unfortunately the authors did not detect them intraoperatively.

The application of this technique necessitates the display of the preoperative Duplex ultrasound data in detail. In the authors' data with this exclusive artery grafting, 19.6% of the cases have peripheral vascular disease. But the authors mentioned that the cases with subclavian artery stenosis were excluded from this study. On the other hand, because the LITA is responsible for the entire circulation of the heart with this technique, what are the data regarding preoperative test(s) on the LITA? Additionally, there is no description of a randomized control trial in this "prospective" report.

Pure internal thoracic artery (ITA) conduits, with their long superior patency are the optimal option for CABG. The aorta no-touch technique is ideal for CABG, because aortic manipulation, with its associated risks, may be minimized, especially for off-pump CABG. Exclusive artery grafting enables all of the previously mentioned aims. The report by Azmoun and his colleagues, as well as other articles on the same topic, are sure to invite more comprehensive studies.

	References

Top References

 

1. Azmoun A, Ramadan R, Al-Attar N, et al. Exclusive internal thoracic artery grafting in triple-vessel–disease patients: angiographic control Ann Thorac Surg 2007;83:2098-2102.[Abstract/Free Full Text]
2. Jegaden O, Eker A, Montagna P, et al. Risk and results of bypass grafting using bilateral mammary and right gastroepiploic arteries Ann Thorac Surg 1995;59:955-960.[Abstract/Free Full Text]
3. Tector AJ, Schmahl TM. Techniques for multiple internal mammary artery bypass grafts Ann Thorac Surg 1984;38:281-286.[Abstract/Free Full Text]
4. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of internal-mammary-artery on 10-year survival and other cardiac events N Engl J Med 1986;314:1-6.[Medline]

This article has been cited by other articles:

				A. Azmoun, R. Ramadan, N. Al-Attar, and R. Nottin Reply Ann. Thorac. Surg., April 1, 2009; 87(4): 1325 - 1326. [Full Text] [PDF]

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Qi, X.-s. Search for Related Content PubMed PubMed Citation Articles by Qi, X.-s. Related Collections Coronary disease Related Article