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Ann Thorac Surg 2002;73:1990-1992
© 2002 The Society of Thoracic Surgeons

How to do it

A new pattern for using both thoracic arteries to revascularize the entire heart: the {pi}-graft

Sotirios N. Prapas, MD*a, Constantine E. Anagnostopoulos, MDa,b, Vassilios N. Kotsis, MDa,b, George P. Stavropoulos, MDa,b, Alexis V. Sidiropoulos, MDa,b, Olga G. Ananiadou, MDa,b, George M. Palatianos, MDc,b

a Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
b Department of Cardiac Surgery, Columbia University College of Physicians and Surgeons at St. Luke’s/Roosevelt Hospital Center, New York, New York, USA
c Onassis Cardiac Surgery Center, Athens, Greece

Accepted for publication February 5, 2002.

* Address reprint requests to Dr Prapas, Department of Cardiac Surgery, Henry Dunant Hospital, 107 Mesoghion Ave, Athens 11526, Greece
e-mail: sprapas{at}dunanthospi.gr


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
We present a complex graft for total arterial revascularization based on bilateral skeletonized internal thoracic arteries (ITA). The lower two-thirds of the free right ITA is anastomosed to the proximal segment of the left in situ ITA using the T-graft technique (Tector-Barner-Calafiore). The free, transected distal part of the left ITA is then anastomosed end-to-side on free right ITA (T-on-T anastomosis). In addition, the technique may use another graft extending the proximal third of the in situ right ITA with the free radial artery for right-sided revascularization. The entire operation can be performed off-pump to avoid any procedure on the ascending aorta.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
The diseased ascending aorta can lead to complications in coronary artery bypass grafting (CABG). Off-pump CABG offers solutions to patients at high risk of stroke from aortic arteriosclerosis or carotid disease. The combination of off-pump CABG with bilateral use of attached internal thoracic arteries (ITA) seems to be the most favorable method to avoid any procedure on the ascending aorta. However, it has the potential disadvantages of (1) ITA length not reaching the distal branches of the circumflex and right coronary arteries and (2) conditions leading to the inability for multiple anastomoses.

We present a pattern of "deviation"(rerouting) of ITA to overcome these limitations [1]. The graft in the shape of Greek pi ({pi}-graft) is included in addition to other reported techniques for preconstructed composite conduits [2] or strategies for nonaortic origin of arterial revascularization [3]. We report the technical aspects for the construction of the {pi}-graft and describe its use for total arterial left-sided revascularization on extracorporeal circulation or off-pump CABG.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Patients
Fifteen patients with severe coronary artery disease were operated on between April 2000 and October 2001. Three of them at Onassis Cardiac Surgery Center and the remainder 12 at Henry Dunant Hospital in Athens, Greece. Euroscore was noted on every patient.

Surgical technique
After a median sternotomy incision, the pericardial cavity is entered and the ITA are dissected in a skeletonized fashion preserving both pleuras. Using cautery, the left pleura is separated from the upper mediastinal tissues and the left side of the opened pericardial sac is divided vertically just opposite the pulmonary trunk and 2 to 3 cm above the phrenic nerve. The closed pleura may be plicated to eliminate tension [4]. The left ITA is marked just above the distal bifurcation. Then, occluding its distal end with a ligaclip, the pulsatile left ITA is tunneled toward the left anterior descending artery and appropriately divided. The remaining distal part of the left ITA is preserved in a cup filled with papaverine solution. Keeping the lungs inflated, we also mark the spot where the T-graft anastomosis is going to be performed, just after the entry of the in situ left ITA into the pericardial cavity. The right ITA is then transected at the level of its bifurcation and becomes a free graft cutting the proximal part 4 to 6 cm from its origin from the subclavian artery. It is then anastomosed in a T-fashion as described by Tector and colleagues [2] to the previously marked spot of the attached left ITA (posteriorly).

The next stage of the construction of the {pi}-graft is the performance of a T-on-T anastomosis. The free, preserved distal piece of the left ITA is connected end-to-side to an appropriate point of the free right ITA depending on the branch that should be anastomosed, by keeping the heart slightly lifted and the free right ITA toward the atrioventricular groove. As a consequence, it is performed (1) at the proximal part of the free right ITA for diagonal grafting, (2) approximately at the middle of the free right ITA’s course when the intermediate branch is anastomosed, and (3) at the distal part when any of the two obtuse marginal branches must be grafted (Fig 1). In our opinion, it is important that the heel of the proximal anastomosis of the distal graft (left ITA distal) must be sutured to the middle of the upper edge of the free right ITA opening.



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  		Fig 1. The {pi}-graft. The free right internal thoracic artery is anastomosed to the left in situ internal thoracic artery using the T-graft technique. The free distal part of the left internal thoracic artery is anastomosed end-to-side on the free right internal thoracic artery. The T-on-T anastomosis is performed at the appropriate spot according to the branch that must be grafted. (X DIAG = diagonal; X INT = intermediate; X OM = obtuse marginal branch.)

 
Stabilization of the heart is then instituted. First, we bypass the left anterior descending artery with the in situ left ITA, then the diagonal or intermediate or first obtuse marginal branch with the {pi}-graft and finally the obtuse marginal branch artery with the T-graft (Fig 2).



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  		Fig 2. Off-pump revascularization of the left anterior descending artery, intermediate branch, and obtuse marginal branch using the {pi}-graft.

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
The isolated {pi}-graft was performed on 7 patients. Also, 8 patients were operated with a right-sided anastomosis in addition to a left-sided graft with a {pi}-graft. Twelve patients underwent off-pump CABG and 3 patients had extracorporeal circulation. Average number of grafts per patient was 3.5 for off-pump CABG and 3.7 for extracorporeal circulation [5]. All patients had an uneventful early postoperative recovery and are doing well with a follow-up of 1 week to 18 months. Length of hospital stay averaged 4.2 days. Euroscore averaged 3.3 (Euroscore 0 to 3 is considered low risk with 1% to 3% mortality, whereas Euroscore 3 to 5 is considered medium risk with an expected mortality of 3% to 5%).


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
This report focuses on the technical aspects of a new pattern of revascularization of the entire heart using the advantages of bilateral ITA [6, 7]. The use of multiple free grafts as well as Y-grafts for such revascularization by Calafiore and colleagues [8] during extracorporeal circulation is noted. Our current modifications, which have several additional advantages, should prove beneficial to selected patients. First, it avoids any procedure on the ascending aorta and should be safe when applied to patients with high risk of stroke or porcelain aorta. Also, it offers the ability to easily reach the distal-most branches of the lateral and inferior wall and to increase the potential number of grafted vessels to four (all as arterial revascularization) without cross-clamp on extracorporeal circulation or off-pump CABG. It has the potential to increase long-tern event-free survival and to reduce the need for reoperation [2, 6]. The {pi}-graft is constructed by the use of skeletonized free pieces of ITA connected to the in situ left ITA. This may have (1) less bleeding from the chest wall in patients with bloodless surgery or Jehova’s witnesses because of the narrow bed of skeletonized take-down and (2) a better long-term patency rate when compared with grafts attached to the aorta [9]. In addition, leg incisins and their complications are eliminated.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Gilbert Ballentine for his photography.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Prapas S., Kotsis V., Zarbis N., Protogeros D., Stavropoulos G., Palatianos G. Off pump coronary artery bypass with "deviation" of ITA’s: the most natural revascularization. Heart Surg Forum 2001;4(suppl 2):S62.
  2. Tector A.J., Dress D.C., Doweny F.X., Schmahl T.M. Complete revascularization with internal thoracic artery grafts. Sem Thorac Cardiovas Surg 1996;8:29-41.
  3. Pitsis A., Cullen H., Musumeci F., Zaman A., Butchart E. A new strategy of total arterial revascularization. Ann Thorac Surg 1999;67:1186-1187.[Abstract/Free Full Text]
  4. Palatianos G, Prapas S, Mastorakou I, Astras G, Michalopoulos A, Kelekis N. Preservation of a closed pleural space while harvesting the IMA reduces pulmonary morbidity. Poster Session, 81st Annual Congress of ACS, N. Orleans, 22–27 Oct. 1995.
  5. Calafiore A.M., Di Mauro M., Contini M., et al. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg 2001;72:456-463.[Abstract/Free Full Text]
  6. Schmidt S.E., Jones J.W., Thornby J.I., Miller C.C., Beall A.C. Improved survival with multiple left-sided bilateral internal thoracic artery grafts. Ann Thorac Surg 1997;64:9-15.[Abstract/Free Full Text]
  7. Ioannidis J.P.A., Galanos O., Katritsis D., et al. Early mortality and morbidity of bilateral vs single internal thoracic artery revascularization: propensity and risk modeling. J Am Coll Cardiol 2001;37:521-528.[Abstract/Free Full Text]
  8. Calafiore A.M., Giammarco G.D., Luciani N., Maddestra N., Nardo E.D., Angelini R. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg 1994;58:185-190.[Abstract]
  9. Dion R., Etienne P.Y., Verhelst R., et al. Bilateral mammary grafting. Eur J Cardio-thorac Surg 1993;7:287-294.[Abstract]



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This Article
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George M. Palatianos
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