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Ann Thorac Surg 2001;72:464-468
© 2001 The Society of Thoracic Surgeons
a Department of Cardiology and Cardiac Surgery, University "G. D’Annunzio," Chieti, Italy
b Department of Imaging, University "G. D’Annunzio," Chieti, Italy
Accepted for publication April 13, 2001.
Address reprint requests to Dr Calafiore, Division of Cardiac Surgery, "G. D’Annunzio" University, S. Camillo de’ Lellis Hospital, via C. Forlanini, 50, 66100 Chieti, Italy
e-mail: calafiore{at}unich.it
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Abstract |
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Methods. One hundred sixty-four patients had a RA graft from July 1992 to July 1994. In 128 (group A) the RA was connected end to side (115) or end to end (13) to the left internal mammary artery. In 36 (group B) the proximal anastomosis was on the ascending aorta.
Results. Early mortality was 1.8% (group A 1.6% and group B 2.8%). Eight-year survival was 83.2% ± 3.2% (group A 82.1% ± 3.8% and group B 86.7% ± 6.2%, p = not significant [NS]), and event free survival was 80.1% ± 3.5% (group A 79.9% ± 4.4% and group B 80.2% ± 7.3%, p = NS). Sixty-one patients (37.2%) had an early angiography within 90 days from the operation. Patency rate of RA distal anastomoses were 98.9% (88 of 89), 98.7% in group A (77 of 78), 100% in group B (11 of 11; p = NS). After a mean of 48 ± 27 months (6 to 96), 72 patients (51.1% of the survivors) had a new angiography. Patency rate of RA distal anastomoses was 95.6% (87 of 91), 93.8% in group A (61 of 65) and 100% in group B (26 of 26; p = NS). All the intermediate RA-LIMA anastomoses were patent at the early and late control. Patency rate for RA and IMAs was similar both early (88 of 89 versus 82 of 82; p = NS) and after 48 ± 27 months (87 of 91 versus 93 of 93; p = NS).
Conclusions. Long-term clinical results after RA grafting are satisfying. Angiographic patency rate, both early and after 48 months, is higher than 90% and is similar to that obtained with internal mammary arteries. The site of the proximal anastomosis does not influence early and late patency.
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Introduction |
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We report the clinic and angiographic results of our first 164 patients in whom the RA was used as a graft, proximally anastomosed to an internal mammary artery (IMA) or to the ascending aorta.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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70%, with expected high run off (no previous myocardial infarction and target coronary vessel of reasonable size). In 128 patients the RA was proximally anastomosed to an IMA (group A), and in 36 patients it was anastomosed to the ascending aorta (group B). Clinical characteristics are shown in Table 1.
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The distribution of the coronary anastomoses performed with the RA is shown in Table 2. In group A more anastomoses on the lateral wall were performed, whereas group B had more anastomoses on the anterior and inferior wall.
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In 128 cases the RA was anastomosed to an IMA before CPB started, in 104 cases to the LIMA (in 101 as a Y graft and in 3 end to end) and in 24 cases to the RIMA (in 14 as a Y graft and in 10 end to end). Overall, 115 Y grafts and 13 lengthened grafts were made. The surgical technique has been previously described [4]. When the aorta was the RA blood source, the proximal anastomosis was performed during the cross-clamping time. When possible, a papaverine solution (1 mg/mL) was injected inside the RA graft, which was then distally clipped to allow pharmacologic dilation.
All patients were operated on with cardiopulmonary bypass and intermittent antegrade warm blood cardioplegia [5].
Postoperative course
From the operating room (OR) the patient was admitted in the intensive care unit (ICU) and from there to the regular ward. All the patients were discharged home on a regimen of oral diltiazem 60 mg three times a day for 1 month and aspirin 100 mg a day. They were followed up in our outpatient clinic 3, 6, and 12 months after surgery and thereafter at yearly intervals. The more recent information was obtained by calling the patients or the referring cardiologist. If patients agreed, during a brief hospitalization a coronary angiography was performed. The quality of the anastomoses was graded according to FitzGibbon and coworkers [6]. Follow-up was 100% complete.
Statistical analysis
Results are expressed as mean value ± SD unless otherwise indicated. Statistical analysis comparing two groups was performed with unpaired two-tailed t testing for the means or 
2 test for categorical variables. Survival and event-free survival curves were obtained with the Kaplan-Meier method (SPSS software, Chicago, IL). The statistical significance was calculated with the log rank test. A p value less than 0.05 was considered significant.
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Results |
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Follow-up
Mean follow-up of the patients who survived the first month was 82 ± 31 months (4 to 98). Twenty patients (12.2%) died after a mean of 35 ± 25 months (4 to 75), 11 from cardiac and 9 from noncardiac causes (Table 4). After 8 years from surgery, survival was 83.2% ± 3.2% (group A 82.1% ± 3.8%; group B 86.7% ± 6.2%; p = NS: Fig 1).
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After a mean of 48 ± 27 months (6 to 96), 72 patients (51.1% of the survivors) had a new angiography (Fig 3). Patency rate (grade A+B) of RA distal anastomoses was 95.6% (87 of 91; 93.8% in group A [61 of 65] and 100% in group B [26 of 26]; p = NS). Globally, 4 anastomoses were occluded (all in group A, p = NS) and 1 was stenotic (group B). Grade A anastomoses were 95.6% in group A and 90.9% in group B (p = NS). All 54 intermediate RA-LIMA anastomoses were patent (52 end to side and 2 end to end). Table 5 summarizes the angiographic results. RA patency rate according the different territories was similar, both early and after 48 ± 27 months, respectively: LAD territory 12 of 12 (100%) and 16 of 17 (94.1%); circumflex territory 43 of 44 (97.7%) and 45 of 46 (97.8%); right coronary artery territory 18 of 18 (100%) and 26 of 28 (92.8%; p = NS for each territory).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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The RA shows an important vasoreactivity in comparison with IMA [20] and its propensity to spasm has some important surgical implications. RA harvesting with the surrounding tissue avoids any touch, and intraluminal injection of a papaverine solution allows obtaining the highest dilation possible. Whether this tendency to spasm is at the base of the string sign observed in some angiographic controls [3, 10, 12, 14, 21, 22] is not clear. However, many authors reported an attenuation or a disappearance of the string sign in serially observed controls [14, 21], as if this aspect were peculiar to the first months after grafting. Possati and associates [14] found at midterm angiographic follow-up, the early RA propensity to spasm after serotonine challenge was markedly decreased. The same group [23] showed that 5 years after surgery the RA graft had a tendency to increase significantly its size, to the same extent as the IMA, and that dilation of these two types of graft in response to acetylcholine administration was similar. It seems that after the first months following surgery, the RA loses its peculiar characteristics of increased vasomotricity. Interestingly, chronic postoperative administration of calcium channel blockers did not influence either the patency rate or the incidence of string sign [14, 21].
Royce and colleagues [22] showed that in the great majority of cases the angiographic evidence of a string sign was not related to reversible ischemia in the same territory at mibi protocol (exercise myocardial scintigraphy). They found also that the mean coronary stenosis of the territories where RAs with the string sign were grafted was 56% ± 5%. This finding supports the hypothesis that the string sign represents flow adaptation of a muscular graft, as with the RA, to a low flow situation, and often this aspect is related not to the graft itself but to a not-correct surgical indication. The authors found also that the "cut off" for coronary stenosis able to assure a higher patency rate was 80% for composite RA grafts and 60% for aortocoronary RA grafts.
Another unsolved problem is the proximal anastomotic site of the RA, whether it has to be a LIMA or the ascending aorta directly. Our group [9] postulated that placement of a third- or fourth-order artery on the aorta could impose abnormal and potentially harmful shear stress on the conduit, being the radius of the aorta is bigger than the radius of the vessel from which the RA originates. Reports from the literature, in which the patency rate of the free IMA grafted proximally to the aorta is uniformly shown lower than the patency rate of in situ IMA, support this hypothesis [24–26]. This policy is followed by many groups [12, 16, 19, 27], whereas others [3, 8, 10, 14, 16–18, 21] prefer to anastomose the RA directly on the aorta. Patency rate seemed to be satisfactory with both techniques.
Our experience started in 1992 and was reported in different studies [4, 7, 9]. We herein evaluate the first cohort of patients who underwent myocardial revascularization using the RA graft in order to assess its long-term clinical results together with its patency rate.
The early and late survival as well as freedom from cardiac events were satisfying. Early patency rate (grade A+B) and nonrestrictive patency rate (grade A) were similar to the IMAs patency rate. After a mean of 48 months, the angiographic results were again similar to that of the IMAs, leading us to question whether in selected cases the RA can be the second arterial conduit of choice.
We tried to evaluate any difference in clinical or angiographic results according the site of proximal anastomosis. Survival and event-free survival were similar as were patency rate and nonrestrictive patency rate. The proximal anastomotic site seems to have no influence on clinical and angiographic results.
In our experience we had no string sign. It is difficult to understand why. The only possibility is that we tried to follow carefully, since the beginning, strict indications for RA grafting. What was demonstrated by Royce and associates [22] was postulated by us since the first papers we published on this topic. Furthermore, it is possible that patients who refused control angiographies could have this abnormality, as we know that often the string sign has no clinical equivalent.
After the results of our study, we think that the RA has to be considered as a second choice arterial conduit, as its angiographic results are similar to those of the IMA. The Y graft can be used when an extensive grafting is necessary, providing the target coronary vessel has a degree of stenosis 80% or higher. If sequential grafting is needed, the intermediate anastomoses can have a lower degree stenosis if the last territory is severely stenosed. In case of less severe stenosis, the Y graft is not indicated but if the RA has to be used, the proximal anastomosis has to be performed on the ascending aorta. On the right coronary territory, the best solution seems to be the aortocoronary graft.
In conclusion, RA grafting gives good long-term clinical and angiographic results and it is now a conduit that has to be in the armamentarium of every surgeon as a tool to increase the number of arterial anastomoses and to improve the overall quality of our surgical results.
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