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Ethicon, Route 22 W, Somerville, NJ 08876
(Email: jhart7{at}its.jnj.com).
Sequential grafting techniques during coronary artery bypass grafting (CABG) have been in use for decades and have been adopted by different surgeons to varying extents. Purported advantages have included efficient use of available conduits, potentially improved graft patency rates attributable to presumed higher flow rates, and the need for fewer proximal anastomoses for sequential aortocoronary grafts. Intraoperative transit time graft flow measurement and calculation of the pulsatility index have likewise been available for many years and have been adopted by some surgeons as a quality control measure.
Nordgaard and coauthors [1] have provided a retrospective analysis of intraoperative transit time flow measurements from a consecutive cohort of CABG patients operated on at a single center by a single surgeon using a standardized technique during a 5-year time period. The stated objective of this report was to compare the mean flow rates and the pulsatility indices in single grafts with those of double and triple sequential grafts. Sequential grafting techniques were preferred and were used for saphenous vein grafts (SVG) whenever feasible. Routine transit time flow measurements using a standardized technique were used for quality control. Results were tabulated for left internal mammary artery-left anterior descending artery and for SVG-diagonal, other single SVG grafts, and double and triple sequential grafts.
There were 581 evaluable patients with a total of 1552 grafts, of which 1390 were evaluated. Some patients and some grafts were excluded from analysis, most often because of inadequate data. Nordgaard and coauthors based their analysis on previous authors' findings, dividing the data according to gender, target vessel, and left or right coronary systems.
Among the pertinent findings were that measured mean graft flows increased with the number of recipient vessels. Single grafts had the lowest mean flows, followed by double sequential grafts, whereas triple sequential grafts had the highest mean flows. These findings persisted after statistically controlling for gender, recipient vessel, and left or right coronary system grafting. Interestingly, the magnitude of increased flow compared with single grafts was less than double for double grafts or triple for triple sequential grafts. The authors offer some theoretical geometric and physiologic explanations for this finding.
The authors have provided a thorough analysis of a considerable amount of mean flow and pulsatility index data from a consecutive cohort of patients in which surgeon and technique biases were minimized. The findings suggest that sequential grafts do result in higher proximal vein flows and that triple sequential grafts carry the highest proximal flows.
The authors also correctly point out several limitations to their study: Some patients and some grafts were not included, and the technique used only measured total graft flow, so nothing could be said about the relative proportions of flow into each recipient vessel. Flow reserve was not evaluated. Follow-up angiographic data and patient outcome data that would indicate the adequacy or durability of revascularization are not provided. The authors do suggest that from their experience, transit time mean flow and pulsatility index measurement might be considered as useful intraoperative graft quality control measures.
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