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Ann Thorac Surg 1997;64:1268-1269
© 1997 The Society of Thoracic Surgeons
DR HENDRICK B. BARNER (St. Louis, MO): This report from Down Under is on top both quantitatively and qualitatively with a very low mortality and complication rate and excellent 5-year survival. Doctor Tatoulis and his associates have established themselves as leaders in the use of arterial conduits with this presentation. Although from the show-me state, I did not need to be shown that the right ITA is as good as the left or that it should be used as a free conduit. My colleagues and I use it as a free conduit 75% to 80% of the time when it will not easily reach the chosen distal site on the right, or always when directed to the left. For skeptics, Tatoulis and associates have established the value and versatility of this conduit, which is clearly not inferior to the left ITA. It is our application of the right ITA that has made it appear less qualified.
The title of this report is deceptive, and we should not lose sight of the fact that this is a report of bilateral ITA use, and as such is the numerically largest report accrued over the shortest time interval with the lowest mortality and lowest incidence of sternal complications. The prevalence of diabetes is relatively low, with 8% of patients having non–insulin-dependent diabetes, and less than 1% having insulin-dependent diabetes, which compares with 20% to 30% incidence of diabetes in some reports with multiple arterial conduits.
Hypoperfusion is reported in 1% to 2% of patients with arterial conduits. I gather that with papaverine treatment of all conduits you did not see this problem. If you did, how was it managed?
Use of the T graft by Tector or the Y graft by Calafiore have been established as complex but effective techniques for employing free arterial conduits with a 1% incidence of hypoperfusion.
Doctor Tatoulis, how do you currently view proximal anastomosis of the right ITA to the aorta versus to the in situ left ITA? In your opinion, is there benefit to be gained by avoiding proximal anastomosis to the aorta in favor of a conduit-to-conduit anastomosis?
Despite this excellent experience that we have just heard, I am certain that your practice with arterial conduits is continuing to evolve. Considering the many options available today, what is your current choice of conduits for an average patient age 65 with three-vessel disease and an ejection fraction more than 0.40?
DR TATOULIS: I thank Dr Barner for his kind comments. We had the privilege of having him visit in Australia a few years ago and he stimulated our interest in arterial grafting.
With regard to diabetes, we deliberately took heed of the literature and avoided doing these operations on patients who were obese and had insulin-dependent diabetes; this explains the low rate of sternal infection. Also, we routinely closed the pleura by picking up the pleural edges with the sternal wires and thereby completely sealing off the pleural cavities, and the mediastinum was isolated as well by closing the pericardium.
With regard to spasm, we have routinely used intraluminal papaverine with a blunt-ended 1-mm arterial needle, and the graft is left to pulsate in that way while the preparations for cardiopulmonary bypass are undertaken. We have not seen, or have not recognized, spasm with the free grafts. We have certainly seen it with the pedicled left internal mammary artery grafts. What we normally do is to spray the external surface of the internal mammary with papaverine, run intravenous nitroglycerin infusions, and keep the patient on cardiopulmonary bypass for a period of time, usually for an additional 10 to 30 minutes, with high mean pressures to overcome the spasm. If we are still concerned, or if there are electrocardiographic changes on coming off bypass, we would use an additional vein graft.
With regard to the proximal anastomosis, I am not sure what the correct answer is. The advantage of the T graft off the left ITA is that it allows further length for the free right ITA to reach around to the back of the heart and right down to the posterior descending from the left side. And it certainly has benefits. We just wonder occasionally, if we make a mistake with this anastomosis or get the lay of the sequential graft going around the back of the heart wrong, that it might cause problems. But there is no doubt that it has much promise and this is a very much evolving situation.
With your last question about the 65-year-old patient with triple-vessel disease and an ejection fraction of 0.40, our current practice would be to use the left ITA to the left anterior descending. We would use the radial artery, of which we have an experience now of almost a thousand cases, to the circumflex system (sequential grafts). If it readily reached the aorta, we would run it from the aorta; otherwise we would run it as a Y or T graft from the left internal thoracic artery. We would use the free right ITA to the right or the posterior descending coronary artery.
Related Article
Ann. Thorac. Surg. 1997 64: 1263-1268.
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