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Ann Thorac Surg 2002;73:499-504
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass

^a Department of Cardiac Surgery, Grenoble University Hospital, Grenoble, France

Accepted for publication September 22, 2001.

* Address reprint requests to Dr Chavanon, Service de Chirurgie Cardiaque, CHU Grenoble, BP 217 Grenoble Cedex 9, France
e-mail: ochavanon{at}chu-grenoble.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease.

Methods. From January 1995 to July 2000, 171 consecutive patients were reviewed in a prospective database. Ninety-one patients underwent coronary artery bypass grafting without cardiopulmonary bypass (group A), and 80 patients were operated on under cardiopulmonary bypass with aortic cross-clamp and cardioplegia (group B).

Results. Patient data were similar in both groups except for the Euroscore (mean; 3.4 ± 6.1, group A versus 2.5 ± 4.5, group B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection fraction (mean, 54.6% ± 15.8%, group A versus 63.1% ± 12.7%, group B; p < 0.001). Severe aortic calcification was present in 6 group A patients, versus no patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to cardiopulmonary bypass occurred in 1 patient, who was excluded from the study. Bleeding was higher in group A (852.6 ± 288 mL versus 712.4 ± 274 mL, p < 0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. Myocardial infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon pump was used in 2 patients (group B). One patient died (group A) and 1 had an embolic stroke (group B). After discharge, 2 more patients died (group A, day 91; group B day 141), and 1 patient suffered an embolic stroke (group B). One patient in each group presented with dysfunction of the gastroepiploic artery graft requiring successful percutaneous transluminal angioplasty on the right posterolateral artery.

Conclusions. These results suggest that off-pump coronary artery bypass grafting using the left internal thoracic artery and gastroepiploic artery is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta.

	Introduction

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Coronary artery bypass graft (CABG) operation is constantly evolving, the two main trends being total arterial revascularization and off-pump coronary artery bypass graft (OPCAB). The increasing use of total arterial revascularization is mainly because of the superiority of arterial grafts over venous conduits (long-term patency rates and patient survival) for myocardial revascularization. This has progressively led surgeons to commonly use the internal thoracic artery [1] and to increasingly use arterial grafts such as the radial artery or the gastroepiploic artery (GEA) [2, 3]. The latter arterial conduit is also a pedicled graft allowing arterial revascularization of the right coronary artery without side-bite clamping of the aorta. Long-term follow-up shows a good patency of this graft when used adequately [4]. The second and more recent development is OPCAB, mainly because of a lower morbidity and mortality rate in high-risk patients [5]. Indeed, avoiding cardiopulmonary bypass (CPB) and cardioplegic arrest are the most important objectives of beating heart operations, especially concerning the whole-body inflammatory response and myocardial recovery [6]. However, OPCAB still often involves partial clamping of the aorta when a saphenous vein graft is used for multivessel revascularization. A combined strategy using OPCAB with arterial grafts only allows a total no-touch aortic technique. This article describes our OPCAB experience with the exclusive use of both left internal thoracic artery (LITA) and GEA grafts, by means of median sternotomy, in a subgroup of patients presenting with two-vessel disease.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Patients
From January 1995 to July 2000, 175 consecutive patients undergoing CABG, using the LITA and the GEA exclusively, were reviewed in our prospective database. Ninety-one patients underwent CABG without CPB (group A, n = 91). Three patients underwent revascularization with a beating heart technique under CPB at the beginning of our study. Another patient required conversion to CPB during the OPCAB procedure, to perform the second anastomosis (GEA to posterior descending artery after an extensive endarterectomy of the right coronary artery [RCA]). These 4 patients were among the first 9 patients of the complete series and were excluded from the study. During the same period, 80 patients were operated on under CPB with aortic cross-clamping and cardioplegia (group B, n = 80), allowing comparison with OPCAB patients. Choosing OPCAB was most often made preoperatively in high-risk patients (low ejection fraction, morbid state), if aortic calcification was noted on preoperative chest roentgenogram, or if it was anatomically favorable. The LITA was systematically chosen for the left anterior descending artery (LAD), and the GEA for patients with the following characteristics: age less than 70 years, unsatisfactory vein graft, calcified ascending aorta on chest roentgenogram, and thrombosed or highly stenosed RCA. Aspirin intake was interrupted on hospitalization, 1 day before operation.

Anesthesia
All patients were anesthetized with alfentanil, propofol, and atracurium and had a Swan-Ganz catheter (Baxter, Maurepas, France). For OPCAB procedure, maintenance of normothermia was a concern: room temperature was higher than usual, and a warming mattress and warming blanket were spread over the legs. We used an initial heparin dose of 100 IU/kg administered intravenously, completed with small 50 IU/kg boluses to maintain the serum activated clotting time above 300 seconds.

Surgical technique
All procedures were performed through a median sternotomy. The LITA was harvested in a semiskeletonized manner. After spreading the sternum and opening the pericardium, target coronary vessels were explored. The ascending aorta was assessed for atheroma and calcification, allowing switching to a no-touch technique if not initially planned. The GEA was dissected, and then brought up anteriorly. Arterial grafts were prepared as previously described [7].

Coronary artery bypass grafting without cardiopulmonary bypass
Stabilization was obtained by various devices: chronologically, suspension with epicardial sutures placed around the coronary artery at the beginning of our study (17 patients), and then suction system stabilizers, Octopus I in March 1998 (26 patients) and Octopus II in March 1999 (48 patients).

Anastomoses
A test of coronary clamping was performed for 1 minute, and a shunt was applied before performing the anastomosis if ischemia was noted. In one case, the patient needed conversion to CPB (the patient was then excluded). Hemostasis was obtained by using silicone snares with as little tension as possible, avoiding the distal portion of the vessel. Exposition was improved with gas jet insufflation.

Operative strategy, chronology of bypasses
Usually the LAD territory was bypassed before the RCA territory. However, in some cases, when the RCA was occluded with a noncritical stenosis on the LAD, the RCA territory was bypassed first allowing a backflow to the LAD territory through collateralization to limit ischemia during LAD anastomosis. In case of sequential graft on diagonal artery, we bypassed the diagonal artery first. Thus, the LITA could be left open, allowing perfusion of the diagonal artery during the LAD anastomosis, a bulldog clamp being applied beyond the diagonal artery.

Coronary artery bypass grafting with cardiopulmonary bypass
On-pump procedure was performed under moderate hypothermia (33°C). Aprotinin (low dose, 2 million KIU) was systematically included in the priming of the pump. Cardioplegic arrest was obtained with combined antegrade and retrograde cardioplegia using hyperkalemic cold blood solution and warm reperfusion before unclamping the aorta. Anastomoses were made in the same manner using 8-0 suture.

End of operation
The end of the operation was performed in the usual way for both techniques: neutralizing heparin by protamine, with a ratio of 1 mg of protamine for 100 IU of heparin (initial dose), and performing mediastinal drainage with autotransfusion of shed mediastinal blood.

Postoperative course
Patients were admitted to the intensive care unit, where they remained for 1 day after operation. Extubation was performed as soon as possible when normothermia, minimal blood loss, and hemodynamic stability were acquired. Discharge from hospital depended on patient status and home health care availability.

Follow-up
All patients but 9 in group A and 7 in group B were systematically assessed 6 months after the operation. Each patient had undergone at least one exercise test either at the end of home health care (1 month) or later with a cardiologist (3 months). Cardiologists and family practitioners of the 16 remaining patients were systematically contacted allowing a 100% midterm follow-up.

Statistical analysis
All values were expressed as mean ± standard deviation. The difference between both groups was tested with an unpaired two-tailed Student’s t test for continuous variables and with the ² test for qualitative variables. Probability values less than 0.05 were considered as statistically significant.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Patient data were similar in both groups except for the ejection fraction, Parsonnet score, and Euroscore (Table 1). All but 1 patient, for whom OPCAB was attempted, underwent successful revascularization (rate of conversion, 1.1%). This patient was not included in either group, but his outcome was uneventful with discharge on postoperative day 8. Similarly, the 3 patients initially operated on with a beating heart under CPB presented with an uneventful outcome and were discharged on postoperative days 8, 9, and 11 respectively.

Postoperative course
Postoperative data are shown in Table 4. There was no significant difference between the two groups except for bleeding and ventilation. The incidence of MI was less frequent with OPCAB (1 versus 4, not significant). Myocardial infarction was defined as a maximal creatine kinase-MB level of more than 100 IU/L with or without new Q wave on postoperative electrocardiogram. There was only one, but fatal, Q wave MI in group A, versus four MI (5%) without mortality in group B, including two Q wave MI and two non-Q wave MI. Postoperative intraaortic balloon pump was used in 2 patients in group B, but not in group A. Preoperative intraaortic balloon pump was inserted in 1 group B patient. One patient had a stroke with a left hemiplegia in group B, but none did in group A. One patient in group A had a heart block on postoperative day 3 with prompt resuscitation but nevertheless suffered from neurologic sequelae; she was discharged on postoperative day 90. She had extensive endarterectomy on the RCA. One patient in group A suffered from mediastinitis, with favorable evolution after surgical debridement and open management; he was discharged on postoperative day 81.

Midterm mortality (>3 months)
Two patients died after discharge from hospital in the OPCAB group: the patient with neurologic sequelae died on postoperative day 91, the day after discharge from hospital, and the second patient died of a sudden death on postoperative day 134. He was in cardiac failure but could not undergo heart transplantation because of severe psychotic contraindication.

Other events
One patient in the CPB group had a stroke (left hemiplegia) on postoperative day 17, 10 days after discharge from hospital. The transesophageal echocardiography showed a 25-mm-long ulcerated plaque in the horizontal portion of the aortic cross. Unfortunately he only partially recovered and had neurologic sequelae. One patient in the CPB group was in heart failure and is still waiting for heart transplantation, 59 months after operation.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This study had as its goal to assess OPCAB, using two arterial grafts, on a subset of two-vessel disease patients operated on through a median sternotomy. The rate of complete revascularization was high because, in all patients but one, we had selected patients presenting with two-vessel disease (LAD and RCA). This technique may appear to have a limited impact, because it represents less than 10% of isolated CABG operations performed in our institution. However, it combines the advantage of (1) using arterial grafts for long-term patency, (2) OPCAB operation in subsets of selected patients, and finally (3) an absolute no-touch technique of the aorta, very favorable in atheroma of the ascending aorta. It may usefully complete the surgeon’s alternatives in the field of CABG.

The superiority of arterial grafts for myocardial revascularization led us to extensively use arterial grafts in our institution, as almost 34% of our patients have a total arterial revascularization. The specific choice of GEA for the RCA territory is because of the fact that it is a pedicled graft, not requiring reimplantation or lateral aortic cross-clamping. It is harvested in about 15 minutes, and avoids leg or arm incision. Because the main GEA drawback concerns flow, owing to its histologic muscular and highly vasoactive status, prone to spasm, the degree of RCA stenosis is a very important factor, and we use the GEA only in cases of thrombosed or very tight stenosis of the RCA [4, 8]. In our practice 16.4% of GEA were discarded [9] if, despite a careful preparation, the graft was not satisfactory and too small for the recipient coronary artery, as recommended by Yasuura and associates [8]. In this case we used the right internal thoracic artery or a saphenous vein graft, and in some cases we had to implant the saphenous vein graft into the internal thoracic artery because of an unclampable aorta, as previously described by Mills and Everson [10].

The second feature of our strategy is OPCAB technique. In our study, as in our general practice, OPCAB operation was applied to high-risk patients, or to patients with favorable anatomy. Indeed, the advantage of off-pump procedures seems to be especially true for high-risk patients [5], although some surgeons may use this approach for all patients [11]. Patients with a low ejection fraction [5] present a superior preservation of left ventricular function, and various studies have reported less postoperative complication in the geriatric population [12], better neurologic outcome [13], shortened postoperative hospital stay, and reduced need for blood transfusion in high-risk patients [11].

We have compared feasibility and results with a cohort of patients operated on under CBP according to the classic technique with cardioplegia. The results show that even though OPCAB patients were at higher risk than patients operated on under CPB, they had a lower morbidity rate with less MI, no intraaortic balloon pump, and no cerebrovascular accident related to an embolic event. Furthermore, the technique is simpler, less expensive, and very elegant. Other series of OPCAB operations using various arterial grafts, including the radial artery, were reported by Calafiore and colleagues [14] and Pym [15] with comparable results. Subramanian and Patel [16] reported a similar experience using limited access with two separate minimal access incisions: minithoracotomy for LITA to LAD, and lower partial sternotomy for GEA to posterior descending artery. Our results correlate with previous reports except for bleeding and a reduced length of stay (not significant). Concerning bleeding, two main reasons can explain the discrepancy. First, all patients were given aspirin until the day before operation, but those in the OPCAB group had no aprotinin contrary to those operated on under CPB. Second, many patients in the OPCAB group went back to the intensive care unit with a central core temperature of 34°C, a very critical state for hemostasis.

The main justification for this combined approach is to avoid any aortic clamping. Potential complications of aortic clamping are represented mainly by the neurologic risk owing to embolization of aortic atherosclerosis and the risk of aortic dissection. These risks are present at several stages during the surgical procedure: (1) cannulation of the aorta, (2) aortic cross-clamping, and (3) aortic side-clamping for the anastomosis of the saphenous vein graft. Moreover, lateral clamping of the aorta during OPCAB may increase the risk of parietal lesions that can lead to aortic dissection because the systemic systolic arterial pressure is pulsatile and higher than under CPB [17]. In our series we had two strokes in group B that were probably related to an embolic event compared with no embolic stroke in the arterial and OPCAB group. However, we had one stroke in group A, the mechanism of which was not embolic but postanoxic after heart block. This stroke rate of 2.5% in our CPB group correlates to that of reported neurologic complications [18]. These complications are less frequent during beating heart operation [13] and it was recently demonstrated that patients undergoing multiple-vessel OPCAB had significantly fewer cerebral emboli detected intraoperatively by transcranial Doppler ultrasound examination than patients undergoing CABG under CPB [19]. Moreover, as the few embolic signals in the OPCAB group occurred only during aortic side-clamping [20] to reimplant the saphenous vein graft, emboli would probably be fewer with the no-touch technique, but this remains to be demonstrated.

Finally, because significant atheromatous disease of the ascending aorta in patients undergoing cardiac operation range between 14% and 29% [21] and are strongly associated with perioperative stroke [22], the evaluation of ascending aortic atherosclerosis is clinically relevant. Preoperatively, chest roentgenogram may show evidence of calcification, and echocardiography may demonstrate calcification or even a noncalcified disease with atherosclerotic debris of the aorta. Intraoperatively, if calcified lesions such as hard thick plaque or "eggshell" calcification of the aorta may be revealed by palpation of the aorta, noncalcified lesions or friable aorta is often underdiagnosed. Epiaortic echography is certainly the best tool to assess the aortic wall [23]. Alternative techniques suggested for coronary revascularization in case of a diseased ascending aorta usually involve a single-clamp technique [24], arterial cannulation of femoral or axillary artery, and hypothermic fibrillatory arrest avoiding clamping of the aorta [25]. Off-pump CABG operation is an interesting alternative, and avoiding lateral side-clamping of the aorta remains possible by performing proximal anastomosis in the innominate artery or in the internal mammary artery [10], or by using pedicled arterial grafts. When it can be used, this last technique is elegant, allowing an absolute no-touch of the aorta.

The follow-up, although limited to 6 months, is extensive. Each patient was assessed either by us (90.6%) or by his or her own cardiologist with at least one exercise testing. Recurrence of angina was similar in both groups and led to coronary angiography with no difference in term of graft dysfunction.

The limit of our study is the lack of angiographic control, because of logistic and economic reasons and the reluctance of the cardiologist to control the GEA graft systematically, because of its difficult angiographic access. However, we can now consider that the use of a new mechanical stabilizer allows performing anastomoses in safe conditions, providing the surgeon is accustomed with OPCAB technique [26] and arterial revascularization. Furthermore, patients showed good functional results at midterm follow-up even if only a completely randomized study with systematic angiographic control and long-term follow-up could confirm the efficiency of this procedure.

To conclude, these results suggest that OPCAB using the LITA and GEA is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta and may usefully complete the surgeon’s alternatives in the vast field of CABG.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Dr E. Colle for editing the manuscript.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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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): Dominique Blin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chavanon, O. Articles by Blin, D. Search for Related Content PubMed PubMed Citation Articles by Chavanon, O. Articles by Blin, D. Related Collections Coronary disease