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Ann Thorac Surg 1995;60:517-523
© 1995 The Society of Thoracic Surgeons
Cattedra di Cardiochirurgia, Università di Chieti, Chieti, Italy
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Both arteries were used in composite arterial conduits with an internal mammary artery as the blood source. The proximal anastomosis was always constructed before the initiation of cardiopulmonary bypass. From October 1991 to January 1995, 240 patients underwent myocardial revascularization using 163 radial arteries and 124 inferior epigastric arteries with one (224 instances) or both (two instances) internal mammary arteries as inflow conduits. Twenty-five saphenous veins were concomitantly used. There were 208 men and 32 women with a mean age of 60.8 ± 8.6 years (range, 28 to 80 years). In 73 patients (30.4%), the operation was performed on an urgent basis, and in 11 (4.6%), it was a repeat operation. The mean left ventricular ejection fraction was 0.55 ± 0.12, and in 21 patients (8.8%), it was less than 0.35. Of 681 distal anastomoses, 188 were constructed using the radial artery (35 double and one triple sequential anastomosis) and 125, using the inferior epigastric artery (one double sequential anastomosis). A mean of 3.0 arterial anastomoses per patient were constructed (3.1 anastomoses/patient including saphenous veins). Six patients (2.5%) underwent associated procedures: aortic valve replacement (2), carotid endarterectomy (2), mitral valve replacement (1), and aortic valve and ascending aorta replacement (1). Most of the inferior epigastric arteries were grafted on diagonal branches and most of the radial arteries, the circumflex territory.
Results. No deaths occurred in the operating room. Three patients (1.3%) died postoperatively, and 2 patients (0.8%) died 6 months after operation. At a mean follow-up of 18.5 ± 10.4 months (range, 1 to 39 months), 227 patients (96.6%) were asymptomatic. The cumulative patency rate of the radial artery grafts was 93.1% and of the inferior epigastric artery grafts, 95.7%.
Conclusions. Our data suggest that use of the RA and the IEA in composite conduits for myocardial revascularization is feasible. These arteries can be safely used when bilateral internal mammary artery or sequential internal mammary artery grafting is not advisable.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The use of the left internal mammary artery (LIMA) as the conduit of choice for revascularization of the left anterior descending coronary artery has been widely accepted since the publication in the 1980s of the data regarding its long-term patency and patient survival compared with the saphenous vein (SV) [1, 2]. The increasing use of this artery along with the results of bilateral IMA grafting [3, 4] led to the introduction into clinical practice of other arterial conduits, the hypothesis being better results than those obtained with use of the vein. For this reason, the right gastroepiploic artery (RGEA), the inferior epigastric artery (IEA), and the radial artery (RA) were investigated and their use reported by several groups [5–11].
Many reports [12, 13] demonstrate that the IMA and the RGEA show better patency if used as in situ grafts. On the other hand, the results obtained with arterial grafts that could be defined as compulsory free grafts (IEA, RA) have not been definitely assessed for two main reasons: long-term studies are not yet available, and these conduits are used in two different combinations according to the proximal site of anastomosis. Because we think that the proximal site of anastomosis of an arterial free graft could be the main reason for graft failure, since the beginning of our experience in arterial myocardial revascularization, we have used the IEA and the RA as branches or extensions of an in situ IMA, thereby avoiding a proximal anastomosis on the ascending aorta [10]. We report here the late clinical and angiographic results of our experience with use of the IEA and the RA in composite arterial conduits.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Patient Selection
We used a composite arterial conduit under the following conditions: when the three in situ grafts were not sufficient to achieve complete arterial myocardial revascularization or when one of them was not available; when sequential grafting was not advisable for technical reasons; and when we prefer to avoid bilateral IMA use (diabetic or elderly patients) because of the related sternal morbidity. The use of the RA was dependent on the result of the Allen test, which contraindicated the harvesting of this artery in about 5% of patients. The IEA was not used if there had been a previous hernioplasty, if a surgical scar crossed the area of harvesting, or if the patient was obese. Age of 70 years or greater and a left ventricular ejection fraction of 0.35 or less were not a contraindication.
Surgical Technique
In this group, we placed 681 arterial conduits and 25 SV grafts (Table 1
). We constructed 256 composite arterial conduits [10] with the following combinations:
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The mean cardiopulmonary bypass time and the mean aortic cross-clamp time were 69.1 ± 21.0 minutes and 47.8 ± 15.3 minutes, respectively. Six patients received a concomitant procedure: aortic valve replacement in 2, mitral valve replacement in 1, aortic valve and ascending aorta replacement in 1, and carotid endarterectomy in 2. Myocardial protection was achieved by means of intermittent antegrade blood cardioplegia, warm (198 patients) or cold (37). Two patients were operated on under hypothermic ventricular fibrillation and 3, without a pump.
The mean number of anastomoses per patient was 3.1, with a mean of 3.0 arterial coronary anastomoses per patient. We performed complete arterial myocardial revascularization in 221 patients (92.1%) with a mean of 3.0 coronary anastomoses per patient (range, 2 to 5). We used 124 IEAs and 163 RAs, five of the latter being divided into two equal segments and placed separately. We performed 313 coronary anastomoses with these arteries. Of 188 distal anastomoses constructed with the RA, 36 were in sequential fashion (one triple anastomosis); only one IEA was used to perform a sequential grafting. The distribution of the coronary anastomoses is shown in Table 2.
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During weaning from cardiopulmonary bypass, we used small doses of metaraminole bitartrate (1 to 2 mg in bolus injection) to keep the mean systemic arterial pressure at 90 mm Hg. We prefer this drug because at a low dosage, it does not affect the coronary, renal, and cerebral resistances. In addition, we administered small doses of heparin calcium (5,000 IU three times a day) starting a few hours after the operation and continuing until discharge from the hospital. Aspirin, 300 mg/d, was given orally from the first postoperative day to 2 years after the operation.
Follow-up
Most of the patients have been followed up on our service. A few have been seen by the referring cardiologists who gave us the necessary information about their clinical status. The follow-up was complete.
Statistical Analysis
Data are expressed as the mean ± the standard deviation or as percentages.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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An underperfusion syndrome was observed in 6 patients (2.5%). In 4 (1.7%), it occurred during weaning from cardiopulmonary bypass. The causes were a dysfunctioning LIMA (damaged during harvest) in 2, an RGEA grafted distal to a mild coronary stenosis in 1, and the IEA branch of a composite conduit in 1. All 4 patients recovered fully after immediate repeat CABG using the SV. In 2 patients (0.8%), this syndrome occurred during the stay in the intensive care unit. In 1 patient, who had received four arterial conduits (both IMAs, IEA, RGEA), it was evident 9 hours after admission to the intensive care unit; he promptly underwent repeat CABG using SV but died of a low cardiac output syndrome. The other patient manifested the underperfusion syndrome 10 hours after having received three arterial conduits (LIMA, RA, RGEA); he had repeat CABG using SV and recovered completely. Both patients needed an intraaortic balloon pump.
A low cardiac output syndrome was observed in 3 patients (1.3%), 2 of whom had the underperfusion syndrome. A perioperative myocardial infarction occurred in 4 patients (1.7%), and a cerebrovascular accident was evident in 2 (0.8%).
The mean blood loss recorded in the first 24 hours after operation was 621 ± 368 mL, and only 33 patients (13.8%) required transfusion with a mean of 0.45 ± 0.97 blood unit per patient. Only 1 patient had reexploration for bleeding. We noted a sternal dehiscence in 5 patients (2.1%), none of whom died.
Follow-up
At a mean follow up of 18.5 ± 10.4 months (range, 1 to 39 months), 227 survivors (96.6%) were asymptomatic. Two patients died (0.8%), 1 of a stroke 6 months after operation and the other, after the same interval, of a ruptured thoracic aortic aneurysm. Eight patients (3.4%) complained of recurrence of symptoms. In 4, angina recurred at a mean interval of 17.2 ± 9.1 months after operation. In 2 of them, progression of disease in the native vessels was documented; in 1, the symptom was attributable to an ungrafted vessel; and in 1, the cause was unknown. Cardiac failure occurred in 3 patients, 2 of whom had a low preoperative ejection fraction. One patient manifested myocardial necrosis without Q waves 23 months after operation.
At a mean interval of 39 months after operation, the overall survival rate was 97.52% ± 1.00%, and the event-free survival rate was 91.89% ± 2.92% (Fig 1).
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). The early study was done at 12 months postoperatively or less and the late one, 13 months or more. We calculated the cumulative patency rate by multiplying the early patency rate by the late one. The details are reported in Table 3.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Besides the bilateral IMAs, the utilization of which is still questioned because of the adverse effects on the sternal blood supply and some concerns about the target coronary artery of the RIMA, other arteries have been investigated. Among these, the RGEA gained popularity after the demonstration of its 5-year patency rate of 95% [13].
Use of the RA and the IEA is still under investigation because of the lack of homogeneous results. Two groups [7, 8] described a similar early and midterm patency rate (
90%) for the IEA. The IEA angiographic patency rates recently reported by Schroeder and colleagues [16] were 90% at 10.8 days after operation, 90% at 12 months, and 87% after 24 months, which fell to 84% if only completely patent grafts were considered. In that experience, the longest length possible of the artery was harvested, and the ascending aorta was the usual site of the proximal anastomosis.
Since the beginning of our experience, our approach to using this artery has been completely different. Harvesting was limited to the proximal 6 to 8 cm up to the first muscular branch; the graft is shorter than that in the experience of Schroeder and co-workers [16], but the caliber is similar to that of the IMA and quite similar at the ends of the conduit. Further, the IEA was always proximally anastomosed to an in situ IMA for several reasons. First, the proximal anastomosis on the ascending aorta could represent a pitfall because of the mismatch between the relative wall thicknesses. In addition, the aortic wall is frequently diseased, especially in elderly patients. These conditions could lead to early graft failure caused by technical factors.
The second reason could be more important in our opinion, even if it could seem more philosophic. The arterial grafts in current use are second (IMA), third (RA, IEA), or fourth order (RGEA) aortic branches. Therefore, the rate of rise of left ventricular pressure in their natural position is different from that in the aorta–coronary artery position. If they are placed as free grafts (in the case of the RA and the IEA, this is obviously the only procedure that must be followed) with the proximal anastomosis on the ascending aorta, they are exposed to a rate of rise of left ventricular pressure different from usual. The modified wall stress could be the basis of early or late graft failure. In addition, as these conduits are nourished chiefly from the lumen, ischemia can occur during the interval between removal of the artery and its declamping at the end of the grafting procedure. The duration of ischemia could be responsible for the increased sensitivity to damage such as the stretching produced by a modified rate of rise of left ventricular pressure and the effects of some endogenous pharmacologic substances. The potential danger is enhanced by the particular structure of those arterial grafts that show more fenestrations in the internal elastic lamina than the IMA [15]; in this situation, it is easier for the smooth muscle cells of the media to migrate to the subintimal layers to initiate the first step of plaque development. For all these reasons, we began to use the IEA in composite grafts with an in situ IMA at the start of our experience with this artery.
The RA was used in the early 1970s by Carpentier and colleagues [17] with unsatisfactory results. At the beginning of the 1990s, this graft was again suggested for clinical use by Acar and associates [11], who reported a 92% patency rate at 9 months. The improved results were considered to be attributable to more appropriate handling of the graft during harvesting, the extensive use of calcium-channel blockers, and gentle hydrostatic dilation to counteract the high tendency of this artery to spasm. In the experience of Acar and his group, the site of proximal anastomosis was the ascending aorta in all cases.
When we started our experience with the RA, we followed the same philosophy just described for the IEA. Also, we were aware that the size of the proximal end of the RA, bigger than the ends of the other arteries commonly used in CABG, makes a proximal anastomosis on the ascending aorta easier than with all other arterial grafts.
The choice of the target coronary branch for the RA and the IEA is another important issue in the strategy of composite arterial graft usage. These two arteries (particularly the RA) have a thick media layer [15] that makes them particularly prone to spasm. We prevent this phenomenon by the extensive use of intraluminal papaverine hydrochloride [10], thus passively obtaining the largest caliber for the conduit without compromising its adaptation to the flow conditions of the coronary vessel to which it is anastomosed.
Regarding the adaptability of the RA and the IEA, we noted that in the presence of high runoff (occluded or tightly stenosed coronary artery with a large territory), the graft will stay widely patent with a size proportional to the amount of flow. In the opposite situation (mildly stenosed coronary artery or poor runoff), it is able to adapt itself immediately to a low-flow condition by reducing its internal caliber; this behavior is angiographically evident from the so-called string sign up to complete occlusion in the no-flow condition. The latter finding is, in our opinion, always due to an incorrect surgical strategy. We therefore decided to reserve the RA and the IEA for those territories with the higher expected runoff to enhance the composite graft patency rate.
The role of the compulsory free grafts (RA, IEA) is important mainly when they are used to lengthen an IMA, because in this case, the fate of the whole conduit depends entirely on the free graft and not on the IMA. If we examine this concept, we see how important the state of the coronary flow is to the future of the grafts. We learned that treatment with calcium-channel blockers for up to 1 year postoperatively when the RA has been used could not be justified, and we have just planned to reduce the treatment period by 4 weeks for all arterial conduits.
When we considered all these points, the choice between the RA and the IEA become only a matter of length. Use of the IEA is indicated to graft a coronary branch near the left anterior descending coronary artery (eg, a diagonal branch or an obtuse marginal branch) if a sequential IMA graft is not advisable. The RA can be used if the target coronary vessel is distant, if the planned site of the anastomosis is distal, or when multiple sequential anastomoses are needed and the sites of the occlusions are not at the same level. In the latter condition, the course of the graft winds and is too difficult for the LIMA to follow, even if skeletonized. We emphasize that when a compulsory free graft is to be used, the distal anastomosis must be performed on the vessel with the expected highest runoff.
We had to discard the IMA as the inflow conduit in 4 patients because the graft was injured during harvesting; in 2 other patients, the IMA size was not considered suitable to support a composite conduit. In all these patients, we chose the RA as the inflow conduit, anastomosing it to the ascending aorta, and the LIMA or the IEA as its end-to-side branch. The coronary territory allotted the RA was in all instances that with the expected higher runoff. In 1 of these patients, the RA had to be lengthened with an IEA, the target vessel being an occluded marginal branch. The excellent early and late patency rates in these patients validate our strategy in similar situations.
A potential pitfall in myocardial revascularization with arterial conduits (simple or composite) is the underperfusion syndrome, which occurred in 2.5% of our patients. This syndrome (acute heart failure progressing to cardiac arrest) is due to an abrupt fall in blood flow through an arterial graft. It occurs more often in the operating room and hence is easily managed by adding aSV graft. The cause is unclear; we think that it depends on technical factors, mainly a focal injury during graft harvesting, that can cause an early or late spasm, subintimal hemorrhage, or dissection. On the basis of our experience, we think that among the arterial conduits present in a composite conduit, the IMA, whose risk of damage during harvesting is higher than that of more superficial arteries (RA, IEA), is the graft more frequently responsible for an underperfusion syndrome.
However, if this syndrome is due to a composite graft, the amount of cardiac muscle involved is higher than in the use of single grafts, as is the risk to the patient. This is confirmed by the high mortality when acute graft failure occurred in the intensive care unit: 1 of 2 patients died of intractable heart failure. In our series, this complication was seen less as the experience of the surgical team increased, and it has occurred in the operating room in only 1 patient in the last 36 months.
Another factor that contributes to optimal function of an arterial graft (simple or composite) is the use of normothermic perfusion and warm myocardial protection. Under these circumstances, eventual vasoconstriction of the graft induced by low temperature does not occur, and the coronary circulation offers low resistance just after the graft opening, thus allowing a high flow through the conduit from the beginning. In this respect, intermittent antegrade warm blood cardioplegia, according to the protocol proposed by our group [18], could be very effective. In fact, along with other benefits [19], this technique seems to stimulate the synthesis of nitric oxide, as demonstrated by Engelman and associates [20]. This substance exerts a strong vasodilating effect on the coronary circulation.
In conclusion, we think that successful use of the compulsory arterial free grafts (RA, IEA) can be achieved by adhering to the following principles:
In our experience with these guidelines, the RA and IEA patency rates are fully satisfactory, and we hope that the results will further improve in the future. In fact, the incidences of grafts failure (occlusion or string sign) were all at the beginning of our experience with arterial conduits when we were not yet aware of the aspects summarized in the guidelines just reported. We are convinced that composite arterial grafts, if carefully placed, represent a useful tool to achieve complete arterial myocardial revascularization, even if longer follow-up is mandatory to draw definitive conclusions.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Di Giammarco, Clinica Cardiochirurgica, Ospedale ``S. Camillo de Lellis,'' via Forlanini, 50, 66100 Chieti, Italy.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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