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Ann Thorac Surg 1999;67:641-644
© 1999 The Society of Thoracic Surgeons

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Original Articles

Recycling of arterial grafts during reoperative coronary artery operations

^a Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium

Accepted for publication July 30, 1998.

Address reprint requests to Dr Noirhomme, Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts.

Methods. Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit.

Results. There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II.

Conclusions. Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Recently the number of patients referred for coronary reoperation has increased [1]. Many of these patients are now presenting with patent arterial grafts but occluded vein grafts and evidence of progression of native vessel atherosclerosis. These conditions present unique problems because availability of suitable bypass conduits for reoperation might be limited; if patients present because of early vein graft failure there could be a sound rationale for using arterial conduits during the second operation. The present series of patients had previously placed arterial grafts that were reused during coronary reoperations to circumnavigate the problem of inadequate conduit and to maximize the use of arterial grafts during this second procedure.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patient population
Between February 1994 and July 1997, 16 patients had arterial grafts recycled. The mean age of the patients was 62.8 years (range, 44 to 75 years) and 13 (81%) were male. Preoperatively, according to the Canadian Cardiovascular Society classification of angina, 1 patient was in class II, 8 patients (50%) were in class III, and 7 patients (44%) in class IV. Of these patients in class IV, 5 were hospitalized with unstable angina treated by intravenous heparin and nitrates. One patient presented for a second reoperation (Patient 12, Table 1).

The angiographic indication for reoperation was progressive native coronary artery disease in 4 patients, a combination of progressive native vessel disease and vein graft failure in 7, and vein graft failure alone in 2. Two patients had an anastomotic stenosis of an arterial conduit, and in another patient an arterial conduit was occluded.

Surgical techniques
In 9 patients the RIMA was harvested for use as a free graft, in 8 patients the gastroepiploic artery was harvested, and in 1 patient the inferior epigastric artery. In 2 of these patients, more than one additional arterial conduit was harvested (combination of gastroepiploic and inferior epigastric arteries and gastroepiploic and right internal mammary arteries). In only 5 patients (31%) was additional venous conduit necessary.

In 10 patients (62.5%) mobilization of previously placed conduits was a previously placed LIMA to LAD graft, and in 2 patients a RIMA to right coronary artery graft. In 3 patients the LIMA had been anastomosed to vessels other than the LAD (one diagonal and two obtuse marginal vessels) and was mobilized for reuse. In 1 patient a previously placed gastroepiploic artery to a posterior descending coronary artery graft was mobilized. Care was taken during this period to mobilize diseased vein grafts as gently as possible, and if the dissection became technically difficult it was continued after the institution of cardiopulmonary bypass.

The details of the operative procedures carried out are given in Table 2. The mean aortic cross-clamp time for these procedures was 88 minutes (range, 42 to 168 minutes) and the mean bypass time 132 minutes (range, 61 to 254 minutes). All arterial grafts were performed using 8-0 prolene sutures and a parachute technique described previously [2].

In 2 patients a patent LIMA to LAD graft was damaged after opening the sternum during dissection of the anterior surface of the heart. In both of these cases the LIMA was repaired using an end-to-end anastomotic technique after excision of the damaged portion of the artery, and both grafts were subsequently used to place the proximal Y anastomosis of a free RIMA graft.

	Results

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Hospital mortality and morbidity
There were no operative or early deaths in this group of patients. Three patients required intraaortic balloon counterpulsation to help weaning from cardiopulmonary bypass. Four patients (including the 3 mentioned above) required inotropic support during weaning (adrenaline range, 0.05 to 0.3 µg/kg per minute). Intensive care stay ranged from 24 to 144 hours with a mean of 69 hours. One patient had a perioperative myocardial infarction. No patient required reoperation for bleeding. All patients were discharged home after a mean hospital stay of 14 days (range, 10 to 28 days).

Postdischarge follow-up
All patients have been followed up after discharge from hospital for a mean of 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society class I in terms of freedom from angina, 3 patients (19%) are in class II and 1 patient is in New York Heart Association functional class III. This patient is currently being examined for mitral regurgitation and congestive heart failure. Eleven (69%) patients currently take antiplatelet medication only. There have been no hospital readmissions for cardiac-related problems except for the patient with congestive heart failure. Ten patients have now undergone exercise testing at a mean of 3 months postoperatively (range, 2.5 to 4 months). In 9 patients exercise test results were negative, 1 patient (patient 9) had chest pain but no electrocardiographic change at maximum exertion.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Patients returning for reoperation present many unique challenges to the cardiac surgeon. Candidates for reoperation frequently have diffuse native coronary vessel atherosclerosis, less usable bypass conduit, and recently present with an increasing number of patent arterial grafts in association with accelerated native vessel disease or vein graft failure. There could be considerable advantages if these patients can be revascularized with arterial conduits during the second procedure.

Although trying to use arterial conduits at reoperation might make an already complex operation more arduous, other authors have documented the recycling of internal mammary artery grafts during coronary reoperation with excellent clinical results, although in very few patients [3–6]. In our series of patients, we reused previously placed arterial conduits with no perioperative deaths and minimal in-hospital morbidity. The midterm angiographic patency of recycled internal mammary artery grafts has previously been reported [5] and although we have not performed such follow-up, the clinical results in our patients have been excellent. Furthermore, it is difficult to justify follow-up angiography in a patient who is now asymptomatic and taking only antiplatelet medication. The single patient in our series who did not improve clinically developed mitral insufficiency and congestive cardiac failure and remains in New York Heart Association class III without residual ischemia. Indeed, as part of the assessment of his heart failure this patient was recatheterized, and all grafts were patent.

In just over half of our patients, we used a previously placed and patent LIMA to LAD conduit as a source of inflow for a Y anastomosis of an additional arterial conduit. Some concerns are justified regarding the adequacy of the inflow in such a circumstance, because the LIMA is now expected to supply a vastly increased area of myocardium. Other investigators, however, use similar techniques routinely during initial coronary operations with excellent results [7], and we believe there are advantages in not placing the proximal anastomosis of an arterial conduit on the aorta (which might be more difficult during a reoperation), not only in terms of increasing the scope of target vessels that can be reached, but also regarding the long-term patency of the conduit [2, 8].

In other patients we reused the arterial grafts more distally on the same coronary vessel, and in 2 patients we reused a LIMA graft to bypass the LAD after it had been used on a different coronary vessel during the primary procedure. Because it is recognized that a LIMA to LAD bypass is the gold standard graft, we were able to reconvert the operations of these patients to one in which we know the clinical outcome to be superior.

There have also been concerns regarding reoperations in patients who have had previous arterial revascularization using more than one arterial conduit and who then present with significant native vessel disease, as described elsewhere [9]. In our series, only 4 patients previously had more than one arterial conduit used. In 2 of these patients we reimplanted the conduit more distally onto the same coronary artery without cardiopulmonary bypass. In more complex cases we used a combination of techniques, including conversion of a pedicled RIMA to right coronary artery graft into a free RIMA graft that was used to graft both the right coronary artery and a diseased obtuse marginal vessel that had been normal at the time of the primary operation. We believe these are useful strategies to increase the incidence of possible arterial anastomosis at reoperation and might be especially useful in patients who previously had more than one arterial conduit used but now require multiple distal anastomoses. In the present series we required additional venous conduit in only 5 patients, such that nearly 70% of our cases were revascularized exclusively with arterial conduits.

We have shown that by reusing previously placed arterial conduits the problem of inadequate conduit material can be solved, the number of arterial anastomoses performed for each patient can be maximized, and these goals can be achieved with acceptable morbidity and with excellent early results in terms of freedom from angina and antianginal medication. Although these techniques might not be appropriate in all patients, we believe they are useful solutions for patients requiring coronary reoperations.

	References

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1. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Re-operation for coronary atherosclerosis: changing practice in 2509 patients. Ann Surg 1990;212:378-386.[Medline]
2. Dion R. Complete arterial revascularisation with the internal thoracic arteries. Oper Techn Cardiac Thorac Surg 1996;2:84-107.
3. Noyez L., Lacquet L.K. Recycling of the internal mammary artery in coronary reoperation. Ann Thorac Surg 1993;55:597-599.[Abstract]
4. Velebit V., Maurice J.P. Recycling of mammary arteries [Letter]. Ann Thorac Surg 1996;62:947-948.[Free Full Text]
5. Antonia C., Parolari A., Zanobini M., Arena V., Biglioli P. Mid-term angiographic study of five recycled mammary arteries during four coronary redos. Ann Thorac Surg 1996;61:702-705.[Abstract/Free Full Text]
6. Tector A.J., Kress D.C., Amundsen S.M., et al. Reoperation in patients with closed SVG and patent LITA-LAD graft: T-grafts approach. Ann Thorac Surg 1995;59:1509-1512.[Abstract/Free Full Text]
7. Tector A.J., Amundsen S., Schmal T.M., et al. Total revascularization with T-grafts. Ann Thorac Surg 1994;57:33-39.[Abstract]
8. Verhelst R., Etienne P.Y., El Khoury G., et al. Free internal mammary artery grafts in myocardial revascularisation. Cardiovasc Surg 1996;4:212-216.[Medline]
9. Joyce F.S., McCarthy P.M., Taylor P.C., Cosgrove D.M., III, Lytle B.W. Cardiac reoperation in patients with bilateral thoracic artery grafts. Ann Thorac Surg 1994;58:80-85.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Philippe H. Noirhomme Malcolm J. Underwood Gebrine A. El Khoury Robert A. Dion Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Noirhomme, P. H. Articles by Dion, R. A. Search for Related Content PubMed PubMed Citation Articles by Noirhomme, P. H. Articles by Dion, R. A. Related Collections Related Article