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Ann Thorac Surg 1997;63:1764
© 1997 The Society of Thoracic Surgeons
836 W Wellington Ave, Chicago, IL 60657
After coronary angioplasty, the degree of patency of the target artery is routinely evaluated by the angiographer. After coronary bypass grafting, no such evaluation is undertaken, and many surgeons never measure graft flows. The anastomoses are presumed to be patent purely because outcomes after traditional bypass operations, especially with LIMA grafts, have been excellent. With the advent of less invasive surgical techniques, such presumptions of patency are invalid because performance of the anastomosis is much more technically challenging, and because other aspects of the operation are changing as well.
Luise and colleagues have not conclusively demonstrated that hypoperfusion of the myocardium can never occur when side branches of the LIMA are left intact, because the study is small and none of the patients had symptomatic or objective evidence of ischemia. Therefore, even though they suggest that a physiologic "steal" cannot occur, their finding that the diastolic-to-systolic velocity ratio in the distal portion of incompletely harvested LIMA grafts was significantly less than that in completely harvested grafts needs to be further elucidated. Ideally, this will be done using measurements of flow volumes rather than of flow velocities.
Despite this limitation of the study, Calafiore's group is to be commended for scientifically addressing the issue of anastomotic patency after less invasive bypass grafting. Their illustrations of normal and abnormal flow patterns in LIMA-to-LAD grafts are beautiful and should be familiar to every surgeon performing less invasive bypass grafting. With newer instrumentation such determinations can be made in the operating room at the time of the operation so that, ideally, no patient will leave the operating room with evidence of low flow or an abnormal flow pattern in the graft.
Impediments to complete harvesting of the LIMA have been largely solved through recent technical innovations. The full length of the conduit now can be harvested rapidly with little or no endoscopic guidance. Because complete harvesting allows the luxury of changing the planned site of the anastomosis, of trimming the LIMA back to a better or larger area, or even of amputating the distal portion of the LIMA and using it as a second bypass graft, many surgeons may prefer to harvest the LIMA completely, especially during the learning curve of this difficult operation.
A patent IMA graft to the LAD is a potent determinant of survival. It is difficult to justify any alteration in performance of this graft until there is incontrovertible evidence that such alteration does not affect the patient's long-term outcome. This article is the first to address this important issue.
Related Article
Ann. Thorac. Surg. 1997 63: 1759-1764.
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