Ann Thorac Surg 2002;73:818
© 2002 The Society of Thoracic Surgeons
Invited commentary
Anthony P.C. Yim, MDa,
Song Wan, MD, PhDa
a Division of Cardiothoracic Surgery The Chinese University of Hong Kong Prince of Wales Hospital Hong Kong, P.R. China
e-mail: yimap{at}cuhk.edu.hk
The quality of the vascular anastomosis remains a critical issue for off-pump coronary artery bypass grafting (OPCAB). This is particularly pertinent because several variations of the OPCAB technique exist and there is a learning curve associated with each. As the technical goal of CABG is to achieve a satisfactory anastomosis, this is something that has to be proven, not assumed, at least at the beginning of one’s learning curve. Although ultrasound-based flowmeters and thermal imaging could be helpful, on-table coronary angiography is still held by many to be the gold standard in evaluating the quality of the anastomosis and provides an option for the operator to revise it if needed. Along this line of thinking, Hol and colleagues should be complimented for this timely and stimulating study.
The findings presented in this article, however, are confusing with respect to the role of routine intraoperative angiography. A quarter of the LIMA grafts studied had significant angiographic lesions on-table, and among these, the authors only chose to revise two grafts. Despite this, about half of the grafts with kinks and two-thirds with "significant lesions" became normalized on follow-up even without revision. The reasons why remain unclear. One limitation of this study is that the angiographic lesions and the revision criteria were not carefully defined. Did the authors decide before surgery that they were not going to act on the intraoperative angiographic findings? If so, could they justify the additional risk, operative time and costs? A significant number of patients with abnormal angiography remained the same or got worse radiologically on follow-up. As the authors admit, it would be difficult to argue that at least some of these patients would not have benefited from an attempted graft revision.
Another important aspect brought out in this article is the potential advantage of a hybrid procedure in enhancing clinical outcome. Although this may appear to be clumsy and unnecessary at first sight, surgeons, radiologists and cardiologists could work together in a combined operative angiography suite to achieve something that each specialist alone may not be able to do. It would be very interesting to see the long-term results of the group of patients who underwent a hybrid procedure.
This provocative article stimulates us to dissect deeper into the rationale behind intraoperative angiography, and how to interpret the results. However, the paper raises more questions than for which we currently have answers.
Related Article
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The importance of intraoperative angiographic findings for predicting long-term patency in coronary artery bypass operations
- Per K. Hol, Erik Fosse, Runar Lundblad, Sigurd Nitter-Hauge, Paulina Due-Tønnessen, Karleif Vatne, and Hans-Jørgen Smith
Ann. Thorac. Surg. 2002 73: 813-818.
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