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Ann Thorac Surg 1995;60:523-524
© 1995 The Society of Thoracic Surgeons

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Discussion

Discussion

See also page 517.

DR RICHARD F. BRODMAN (Bronx, NY):

Your results are certainly excellent, and other arterial coronary surgeons should aim to achieve results similar to yours. I have abandoned the use of the inferior epigastric artery and prefer the radial artery as the second conduit of choice because it is longer, it is larger, and it is easier to work with than the inferior epigastric artery. There are also two radial arteries. I have chosen not to sew the radial artery to the end of the internal thoracic artery unless there is a porcelain aorta. I have sewn all but three of the 135 radial arteries that have harvested directly to the aorta. The patency rate is exactly the same as yours in the 48 patients who have had recatheterization.

Your hypothesis that the rate of rise of left ventricular pressure may have an impact on late patency is interesting. This factor is something that is measurable. Do you have any information on what the rate of rise of left ventricular pressure in the ascending aorta is compared with that in the forearm?

DR CALAFIORE: The modified rate of rise of left ventricular pressure can be one of the causes of poor patency in the internal mammary and inferior epigastric arteries when used as free grafts. I have no information about the raw numbers of the different rates of rise of left ventricular pressure. However, I think that the variation in the pressure waveform is the most important aspect, as this modifies the wall stress of the graft. I am aware that this is only a hypothesis; moreover, to date, I have no proof that the long-term results of these arterial grafts can be improved. However, as more and more patients have disease of the ascending aorta, avoiding the aortic anastomosis can become a crucial point for the patency of any graft.

DR CHARLES A. DIETL (Danville, PA): I enjoyed this presentation very much, and I congratulate you on your excellent results. I have used a similar technique in 17 patients who had a heavily calcified ascending aorta, which precludes the safe application of any type of clamp. The radial artery was used in 15 patients and the inferior epigastric artery, in 2. These free arterial grafts were anastomosed to the internal mammary artery before the initiation of cardiopulmonary bypass. The distal anastomoses were usually performed on a beating, decompressed heart on cardiopulmonary bypass with mild hypothermia (32°C), except for the obtuse marginal anastomoses, which were usually performed during a brief period of induced ventricular fibrillation without clamping of the aorta. Dr Calafiore, what percentage of your patients had a heavily calcified aorta?

I have a comment on the technique for the proximal anastomosis to the internal mammary artery. I prefer to create a long anastomosis of approximately 2 cm because this facilitates passing the needle through the delicate arterial walls without traumatizing them. Also, the final appearance of a long anastomosis is similar to the exit lane of a freeway; it is less likely to kink than an anastomosis using a small arteriotomy.

DR CALAFIORE: We have just as low a percentage in this experience. Three patients had a severely calcified ascending aorta. As for the proximal anastomosis to the internal mammary artery, I agree with you that it must be a long anastomosis, about 1 cm, because we prefer to have a gentle curve of 45 degrees instead of 90 degrees or other sharper angles.

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