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Centre Chirurgical Marie Lannelongue, 133 Avenue de la Resistance, Le Plessis Robinson, 92350 France
(Email: azmoun{at}yahoo.com).
We read with interest the remarks of Dr Qi [1] in regard to our article [2]. On one hand, we fully agree that flow competition is a minor and very occasional phenomenon with this technique. The grand majority of patients fare quite well and at least do not manifest clinical signs of any possible competition of flow.
Concerning the kinking aspect demonstrated by the postoperative coronary angiography, we wish to insist on the fact that this was a transient phenomenon and had disappeared on subsequent follow-up. We tend to believe that this is due to positioning of the graft. Because all of the internal thoracic arteries (ITA) were harvested in a skeletonized fashion, the repositioning of the grafts was not hindered by the endothoracic fascia or concomitant veins.
As for subclavian artery stenosis, prior to coronary artery bypass grafting and as part of the systematic work-up, all patients had a Doppler study of the subclavian (and carotid) arteries. None of the patients included in this study had significant stenosis or occlusion of the left subclavian artery. However, should such a lesion exist, prior treatment (endovascular or surgical) would have been undertaken. In exceptional cases (not published) we have kept the right internal thoracic artery (ITA) in-situ with anastomosis of the left ITA in a mirror configuration of the described technique. This carries the obvious risk of having the right ITA cross the midline with all the potential problems of subsequent sternotomies. On the rare occasion when this was performed, special care was taken to protect the right ITA in case of future sternotomy.
Finally, we wish to debate the use of intraoperative post-grafting Doppler flow measurement or intraoperative post-grafting coronary angiography. For the latter, interpretation of immediate postoperative catheterization is difficult because of significant native vessel and graft spasm. Although it reliably determines patency but its value is suspect for determination of long-term graft adequacy [3]. Moreover, it necessitates a structure adapted to perform both the surgical procedure and the coronary angiography (eg, hybrid operating room), a situation scarcely available at the moment. As for intraoperative post-grafting Doppler flow measurement, our personal experience with the procedure has been rather disappointing with heterogenous results and poor reproducibility. Furthermore, studies with this technique are more likely to predict graft failure in saphenous vein grafts than in ITA conduits [4]. Regardless, it is very important to keep in mind that Doppler flow measurement has low positive predictive values that should be taken into consideration to avoid unnecessary graft revision [5].
We do recognize that graft flow assessment, whether by Doppler, angiography, or other techniques, can help predict coronary artery bypass graft failure and should be carried out whenever the surgeon is not satisfied with the quality of his/her anastomoses. We also believe that one of the reasons that exclusive ITA grafting is not widespread is the relative difficulty of performing the anastomoses. The surgeon should pass the learning curve and acquire experience in coronary artery bypass grafting to assure high post-coronary artery bypass grafting anastomotic patency.
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