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Ann Thorac Surg 2009;88:57-58. doi:10.1016/j.athoracsur.2009.04.118
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Invited Commentary

Andre Plass, MD

Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemistr 100, 8091, Zurich Switzerland

(Email: andre.plass{at}usz.ch).

Shimokawa and colleagues [1] present a follow-up study of a technique for left anterior descending coronary artery (LAD) reconstruction using the internal thoracic artery (ITA). In this article, the diameter changes in different parts of the LAD and grafted (ITA) for the short-term and the long-term (ie, at 1 year) follow-up after use of this technique were assessed.

The authors demonstrate changes in the lumina of coronary arteries after 12 months and also diameter changes in proximal compared with distal reconstructed parts.

The authors termed narrowing of reconstructed parts beyond the ITA anastomosis distal LAD vascular remodeling. However, the proximal reconstructed LAD diameter also decreased from 3.16 ± 0.71 to 2.09 ± 0.47 mm. This is less than the 2.14 ± 0.35 mm ITA. This suggests there is not only a tendency to approximate the uniform vessel diameter of the proximal reconstructed LAD, but this may proceed further in time.

The authors describe vascular remodeling as a positive event based on the study of Barner [2]. However, vascular remodeling is not only observed during physiological adaptation (physiological remodeling), but it is also the main factor responsible for re-stenosis after balloon angioplasty (pathophysiological remodeling) [3].

This study demonstrates the decrease of coronary diameter, which could be caused by vascular remodeling as adaptation to wall and shear stress, and can be considered a positive effect. However, the crucial question is: Does the shrinking of diameter (or remodeling) stop after adapting to the lumen diameter of the anastomosed bypass graft (ITA) and the coronary run-off (dist-LAD)? If physiological remodeling can be proven, it would be a clear advantage for bypass grafting compared with percutaneous transluminal coronary angioplasty, which leads to a pathophysiologic remodeling.

This study by Shimokawa and colleagues [1], despite having a number of limitations, could demonstrate very nicely the changes of diameters in the different parts of the performed reconstruction. Cardiac surgeons should be aware of the changes in the vessels, which can be seen as an advantage. However, these advantages of the described technique with the remodeling aspect should also be assessed 1 year later to be sure that the remodeled situation after arterial bypass grafting with the described technique stays stable.


   References
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 References
 

  1. Shimokawa T, Manabe S, Fukui T, Takanashi S. Remodeling of reconstructed left anterior descending coronary arteries with internal thoracic artery grafts Ann Thorac Surg 2009;88:54-58.[Abstract/Free Full Text]
  2. Barner HB. Remodeling of arterial conduits in coronary grafting Ann Thorac Surg 2002;73:1341-1345.[Abstract/Free Full Text]
  3. Post MJ, Borst C, Kuntz RE. The relative importance of arterial remodeling compared with intimal hyperplasia in lumen renarrowing after balloon angioplasty. A study in the normal rabbit and the hypercholesterolemic Yucatan micropig. Circulation 1994;89:2816-2821.[Abstract/Free Full Text]

Related Article

Remodeling of Reconstructed Left Anterior Descending Coronary Arteries With Internal Thoracic Artery Grafts
Tomoki Shimokawa, Susumu Manabe, Toshihiro Fukui, and Shuichiro Takanashi
Ann. Thorac. Surg. 2009 88: 54-57. [Abstract] [Full Text] [PDF]




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