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Ann Thorac Surg 2002;74:704-711
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
* Address reprint requests to Dr Mohr, Department of Cardiac and Thoracic Surgery, The Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv 64239, Israel
e-mail: raphmohr{at}tasmc.health.gov.il
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract |
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Methods. From April 1996 to July 1999, bilateral skeletonized internal thoracic arteries were used as T grafts (composite group, n = 649) and in situ grafts (cross group, n = 351) in 1,000 consecutive patients. In the cross group, in situ right internal thoracic artery was routed anterior to the aorta across the midline for grafting to the left anterior descending artery, and the left internal thoracic artery was used for the circumflex branches.
Results. The two groups had comparable preoperative risk profiles. Bypass time and aortic cross-clamping time were longer in the composite group (80 ± 38 and 67 ± 29 minutes versus 66 ± 43 and 55 ± 34 minutes, respectively). Number of anastomoses per patient was similar (3.1 versus 3.2). However, more sequential anastomoses were performed in the composite group (62% versus 53%), and the gastroepiploic artery was used more often in the cross group (30% versus 19%). Thirty-day mortality was 3.9% in the composite and 2.3% in the cross group (not significant). Occurrence of postoperative complications (sternal infection, myocardial infarction, cerebrovascular accident, and bleeding) was similar. Late follow-up (2 to 56 months) showed increased return of angina (6% versus 3.1%; p = 0.046) and decreased 4-year survival (Kaplan-Meier; 86% ± 2.7% versus 92.4% ± 1.5%; p = 0.07) in composite patients.
Conclusions. Early results of bilateral internal thoracic artery grafting with composite T graft are comparable with those of in situ grafts. However, increased angina return and decreased midterm survival led us to recommend in situ grafting whenever technically possible.
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Introduction |
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Several arrangements of bilateral ITA grafting have been proposed to achieve complete left-sided myocardial revascularization. Two of the commonly applied techniques are bilateral in situ ITA grafting (anterior to the aorta right ITA to LAD and left ITA to Cx artery), and the composite T graft configuration, using free right ITA grafts connected proximally to the left ITA [5–7]. The superiority of one method over the other, and appropriate conditions for the selection of either arrangement have not been established.
The objective of this report is to compare the T graft technique and the in situ grafting with crossover right ITA for left-sided arterial revascularization. Midterm results of 1,000 consecutive patients are evaluated.
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Material and methods |
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In situ bilateral internal thoracic artery grafting (cross group)
The cross arrangement (right ITA to the LAD and left ITA to Cx marginals) is based on the assumption that patency rates of the right ITA on the LAD is similar to that of the left ITA on the LAD [10]. The two ITAs in combination with the right gastroepiploic artery provide three sources of blood supply.
The right ITA was directed anterior to the aorta to graft the LAD. Preventive measures are taken with respect to resternotomy. The ITA is tunneled through a right pericardial incision at the level of the aorta and pulmonary trunk, and directed leftward, crossing the midline at the most cranial point before angulating toward the LAD. The lateral rather than the oblique direction of the right ITA, facilitated by the deep pericardial incision, allows the crossover graft to lie adjacent to the aorta. Thus, at retrosternal position, a space is maintained between the crossover right ITA and the posterior table of the sternum. This maneuver allows free space on the aorta for future instrumentation, and provides a safety distance between the crossover ITA and sternum [6].
A giant metal clip was used to mark the right ITA midline location in relation to the sternum for possible subsequent midsternotomy. Mediastinal fat was used to cover the artery and fixate it in the selected route, to prevent tenting after removal of the retractor and closure of the sternum.
In situ left ITA was used to graft the Cx branches. We allowed up to three sequential anastomoses on a single conduit. Grafting of the right coronary artery branches was performed, preferentially, with in situ right gastroepiploic artery. However, in cases of less than critical coronary stenosis (<70%), a saphenous vein graft was preferred [6].
The T configuration (composite group)
The T graft arrangement was implemented when the cross technique was not feasible. This was based on intraoperative anatomic considerations. The main prerequisite for the application of the cross technique is sufficient length of the crossover right ITA to comfortably reach the desired anastomotic site on the LAD (without compromise). Despite the fact that the maximal length is obtained by skeletonized right ITA harvesting, this is still the definitive limiting factor for application of this configuration in most cases. Thus, exclusion criteria for the use of the cross technique were a short right ITA, a very long ascending aorta, enlarged right ventricle, too distal or unpredictable LAD anastomotic site, or high probability of subsequent reoperation (for example, combined aortic valve operation). Similarly, a T graft configuration was favored when the distal right ITA bifurcation could not loosely reach the LAD, and in most patients required a graft to the diagonal artery.
The composite arterial graft can be performed either as a T-shaped or Y-shaped anastomosis at the level of the main pulmonary artery. This can be performed before connection to cardiopulmonary bypass; however, the safest way to precisely determine the location of the composite anastomosis without compromising the left ITA flow to the LAD is to construct it on bypass after completion of all distal anastomoses.
Sequential grafting is essential for complete arterial revascularization with composite grafts. Diamond-shaped side-to-side anastomosis and terminal T shaped anastomosis for branches of the Cx and right coronary artery are our preferred approach. This approach carries the advantage of sparing ITA length by using adequate intercoronary segments. Assessment of ITA segments between anastomosis is confirmed after filling the ventricle. This maneuver is essential to prevent ITA tension. The length of the ITA segment between anastomoses should be 5 to 10 mm longer than the actual distance between coronary arteriotomies. The parallel side-to-side anastomosis is preferred for the intramyocardial coronary artery or for vessels buried inside a deep layer of epicardial fat. Constructing a diamond-shaped anastomosis in these cases exposes the ITA to the risk of seagull-wing kinking [11]. The parallel sequential technique in these situations may also be used for LAD-diagonal sequential grafting with the left ITA.
Injury to the ITA requiring a revision of the original operative plan occurred in less than 5% of our patients, and in most, the operation could still be performed using both ITAs.
If injury is caused to the proximal right ITA, the operation can still be performed by constructing a composite graft, in which the free graft of the right ITA is anastomosed end-to-side to the in situ left ITA. The operative plan is changed here only when we originally planned to use the cross technique. If the proximal left ITA is injured, and can no longer be used as an in situ graft, a reverse composite graft can be constructed, in which the free left ITA is connected end-to-side to the in situ crossover right ITA. This arrangement of free left ITA on in situ right ITA can also be used when the spontaneous free flow of the left ITA is inadequate (Fig 2).
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Postoperative protocol included high-dose intravenous infusion of isosorbide dinitrate (Isoket, 4 to 20 mg/h) during the first 24 to 48 hours [12]. Systolic blood pressure was maintained greater than 100 to 120 mm Hg. When the right gastroepiploic artery was used, patients were treated with calcium-channel blockers (Diltiazem, 90 to 180 mg/d orally) for at least 3 months, starting from the second postoperative day.
Cardiac enzyme analysis and electrocardiography were performed in all patients 8 hours after the operation and at daily intervals for 3 days. All patients underwent a routine radionuclear scan within 3 months after the operation, and have been examined by an independent cardiologist twice annually. Postoperative coronary angiography was offered to every patient for assessment of graft patency and detection of technical graft dysfunction. Eventually, coronary angiography was performed mainly in patients with recurrent angina, undetermined chest pain, or positive radionuclear scan.
Patients’ data were collected and analyzed according to the Society for Thoracic Surgeons National Cardiac Surgery database guidelines and definitions. Follow-up obtained by a telephone questionnaire ranged between 4 and 52 months (median, 32 months) and was available in 98% of the patients.
Statistical analysis
Data are expressed as mean ± standard deviation or proportions. The 
2 test and Fisher’s exact test were used to compare discrete variables. Two-sample Student’s t test was used to compare continuous variables. Cox proportional hazard model was used to evaluate the influence of preoperative variables on late and overall mortality. Multivariate logistic regression analysis was used to evaluate the influence of patients’ group and the explanatory variables on recurrence of angina. Postoperative survival was expressed by the Kaplan-Meier method. All analyses were performed using SPSS 9 software (SPSS Inc, Chicago, IL).
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Results |
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The right gastroepiploic artery was used more often in the cross group (30% versus 19%). In a greater proportion of patients in the composite group it was possible to revascularize the right coronary artery system with the right ITA (31% versus 12%).
Thirty-day mortality was 3.5% in the composite group and 2.3% in the cross group (p = 0.12). No significant difference was found between the groups in occurrence of postoperative myocardial infarction (0.9% versus 1.1%), sternal wound infection (2.2% versus 2.3%), cerebrovascular accidents (1.5% versus 1.7%), and reexploration for bleeding (1.7% versus 1.1%; Table 2).
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Early return of angina occurred in 11 patients in the cross group (3.1%) and in 39 (6%) in the composite group (p = 0.046). Multivariable logistic regression analysis failed to identify any of the preoperative variables as a significant predictor for recurrence of angina. Postoperative coronary angiography was performed in 59 patients who consented to follow-up angiography, who were clinically symptomatic, or who demonstrated a positive radionuclear scan. This included 22 (5.7%) patients in the cross group and 37 (5.7%) patients in the composite group. Coronary angiography was performed an average of 19 months (range, 2 to 41 months) and 10 months (range, 1 to 30 months) after the operation in the cross and composite groups, respectively.
Overall, 183 ITA anastomoses were demonstrated, of which 37 were constructed as proximal T graft anastomoses. Results were evaluated by an independent cardiologist. In the cross group, patency rate of both ITA grafts was 95% and all sequential anastomoses were patent. Postoperative angioplasty was performed in 6 (1.6%) patients. The procedure was required because of ITA graft failure in 2 patients (one left ITA and one right ITA), and in 3 cases, ungrafted coronary arteries were involved. Repeat coronary artery bypass grafting was performed in 1 patient 23 months after the initial operation. In contrast, among the composite group, angiographies of only 17 (46%) patients were considered normal, with intact ITA grafts. Technical problems associated with the free right ITA were observed in 18 patients. This included problems related to competitive flow of the native coronary arteries and kinking of intercoronary segments. An alarming observation was that technical faults were observed particularly in catheterized patients, in whom the right ITA was pulled to graft the posterior descending artery. Kink of a proximal composite T anastomosis occurred in 1 patient. Left ITA graft failure was documented in 2 cases (patency rate of 94.5%); in 1 case the left ITA was occluded at the anastomotic site to the LAD, and in 1, left ITA string-sign had occurred. Reintervention was performed in 14 (2.1%) patients of the composite group, including two repeat operations and 12 postoperative coronary angioplasties.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentDiscussionReferences |
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Dissimilarities occurred between the two groups with regard to several descriptors. The final decision regarding which bilateral ITA configuration is to be used is made intraoperatively, ie, only after the skeletonized right ITA has been mobilized. The main prerequisite for implementation of the cross technique is sufficient length of the crossover right ITA to reach the desired anastomotic site on the LAD (without compromise). Despite the extra length obtained by skeletonized harvesting, the length of the right ITA is still the main limiting factor for application the cross technique (the skeletonized left ITA is usually sufficient to reach even the very distal Cx marginals). Thus, patient allocation is inherent to the feasibility of the surgical technique, and is not related to preoperative patient selection.
The use of sequential grafting is essential in any configuration of extensive arterial revascularization, regardless of the technique used [10]. However, to achieve complete arterial revascularization, more sequential anastomoses were constructed in the composite group.
The two groups had similar early mortality; however, analysis of midterm survival (Kaplan-Meier) documented a trend in favor of the crossover arrangement. Although this difference in survival may be related to preoperative descriptors (diabetes mellitus, female, and acute myocardial infarction patients were more prevalent in the T graft technique), rather than to the surgical technique used, Cox regression analysis failed to identify them as significant predictors of overall (early and late) mortality.
A higher return of angina was observed in the composite group. It should be emphasized that a multivariable logistic regression model failed to identify dissimilarities in preoperative (more female sex and diabetic patients in the composite group) and operative characteristics (sequential grafting and cross-clamp time) to have significant effect on this result. The increased occurrence of angina may be related to technical details, such as the complexity of composite grafting. The fact that return of angina tended to occur early in the postoperative period suggests it is mainly related to technical operative errors (more frequent in the composite group). It may reflect a steeper learning curve required for the composite technique, which is technically more demanding. Whether the T graft configuration is more prone to atherosclerotic lesions than the in situ ITA in diabetic patients cannot be concluded from this limited angiographic data, and should be subjected to further angiographic evaluation.
It appears that choosing a conduit for the right coronary system should not depend on the technique used for revascularization of the left coronary system. However, although an ITA may reach a distal anastomotic site on the posterolateral branch or the posterior descending artery (in situ left ITA in the crossover arrangement or the free right ITA arm of the T graft), our experience has shown that in many patients the right ITA is not long enough to reach the right coronary system, and that an independent conduit (saphenous vein graft, radial artery, or in situ right gastroepiploic artery) is required. This policy is based on angiograms performed in the early days of our experience with bilateral ITA grafting. Unsatisfactory angiographic results were more prevalent among distal right ITA anastomoses used for these right coronary sites. Reduced patency rate of ITA anastomoses to distal sites in the right coronary artery system has also been reported by Dion and colleagues [10].
Our results stand in contradiction to a comprehensive report by Calafiore and coworkers [5], who demonstrated no difference between the two techniques with respect to early and late results. Furthermore, recent reports confirm the benefits obtained by using the T graft configuration with regard to midterm clinical results [5, 7], angiographic patency [7, 15], and the left ITA stem flow reserve [15]. It should be emphasized, however, that bilateral skeletonized ITA grafting has been adopted in our department as the routine pattern of myocardial grafting performed by all surgeons and for the majority of patients. Hence, these results reflect a relatively large number of patients operated on with these techniques during a short period of time. The better long-term results and the lower rate of technical problems obtained with in situ grafting indicate that this surgical method is less demanding. It is our opinion that this should be the method of choice whenever feasible.
Nevertheless, the overall results in both groups are encouraging, and with accumulating experience, results are expected to further improve in the composite group.
In conclusion, despite the fact that this study confirms the good midterm results obtained by the T graft configuration, even better results should be expected with in situ bilateral ITA grafting.
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsCommentDiscussionReferences |
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Coronary angiography at an average of 19 months in the 22 crossover patients and 10 months in the 37 composite patients revealed 95% patency in the former but only 46% in the latter, with technical problems observed in 18 free right ITA grafts, including kinking and competitive flow. Despite these patency differences, 7 crossover patients had reintervention versus 14 composite patients, 2.0% and 2.1%, respectively. Thus, the need for reintervention is a valuable yardstick and suggests that the problems noted with free right ITA grafts were not that profound, particularly those relating to competitive flow.
Not all surgeons are equal. Your angiographic follow-up is small and the surgeons numerous. Did you find that problems with the free ITA graft were surgeon-related?
Angiography is vitally important for assessing new revascularization strategies, not only to document success but to visualize technical problems that the surgeon can learn from and avoid in future operations. We all recognize that complexity of the T graft is greater. Do you believe that this configuration is so problematic that any potential advantages are thereby lost?
Your group has been reluctant to use the transverse sinus route for the in situ right ITA, but I continue to have concerns about difficulties associated with the anterior crossing right ITA during reoperation. There are ample data from Buxton, Puig, and Ura and their associates indicating that the transverse sinus route achieves patency equal to that of the left ITA to the left anterior descending (LAD) or to the marginal arteries. Do you continue to believe that the anterior position is preferable to the transverse sinus route?
Having concluded that bilateral in situ ITA grafting is preferable to the composite technique, what is your practice today and what will it be in the next year with regard to composite ITA grafting? Will you continue to use it as you have in this experience when the right ITA is short, the ascending aorta long, the right ventricle enlarged, and the LAD anastomotic site distally located or the probability of reoperation is greater?
DR MICHAEL C. MAXWELL (Charlotte, NC): I have a question concerning the angina on late follow-up. In the abstract in the bulletin, it says that your rate of angina was 6% in the one group versus 3.1% in the composite group. On your slide it said 6% versus 6.3%, and I was just wondering which one it is.
DR THORALF M. SUNDT (Rochester, MN): You are to be congratulated for an outstanding series and for collecting data on 1000 consecutive patients. I can add little to what Dr. Barner—my personal hero in the field of arterial grafting—has said. My principle concern relates to the comparability of the two groups. Despite multivariable analysis, there are subtleties in patient selection that may well account for the differences in outcomes. That contention would, in fact, be substantiated by the difference in survival. My question then is, quite pointedly, do you really think that these two groups were comparable? Thank you.
DR DUANE S. BIETZ (Portland, OR): Did you use any particular management technique for diabetics and was there a difference in sternal wound infection rate for diabetics versus nondiabetics?
DR LEV-RAN: Thank you very much for your comments. I would like to emphasize that we do appreciate the T graft technique. It is still our main form of grafting. We do not think that competitive flow is a major concern with the exception of an isolated left main lesion. This is actually our only absolute contraindication for performing the T graft, whether it is bilateral ITAs or radial artery constructed on left ITA. We also believe that the left ITA stem is sufficient to provide the large territory of the myocardium required. Thus, we do think that the T graft is a good technique that can and should be performed. However, we prefer three sources of blood supply to the myocardium and the use of independent grafts. Unfortunately, the crossover technique cannot be applied regularly. This is related to technical aspects of insufficient length of the right ITA to reach the anastomotic site on the LAD, if very distal. In addition, the maneuvers described with regard to future repeat sternotomy add to the required length of the right ITA.
Unfortunately we do not have a large experience with the technique of retroaortic ITA through the transverse sinus. Our main concern is to control postoperative bleeding, particularly when skeletonized ITAs are used. Additionally, there were reports of graft tenting (kinking) caused by the aorta, which cannot be identified or managed before sternal closure. The third problem is related to redo operation, which if done conventionally with placement of a cross-clamp, could damage the retroaortic graft.
Preventive measures during the initial operation reduce the risk of repeat sternotomy, and new methods for revascularization, such as off-pump operation and targeted incisions, simplify redo coronary artery bypass grafting. Although limited, we had a good experience. So far no crossover right ITA was damaged during early reexplorations and formal repeat sternotomy.
We apologize for the misunderstanding with regard to the rate of recurrent angina. The rates are 3.1% in the cross group and 6% in the composite group.
We had a good experience with the use of bilateral skeletonized ITA in diabetic patients. We published a large series of 250 patients with a low rate of sternal infection comparable to nondiabetics. Currently, a larger group has accumulated—almost 500 diabetic patients who underwent bilateral skeletonized ITA grafting—with acceptable rate of sternal infection. We hope to publish these data soon.
We think that the groups are practically comparable within the limits of a retrospective study. Patient selection was related to technical aspects, and particularly to the length of the right ITA to reach the desired LAD anastomotic site. This selection stems from the inherent limitation of the cross technique.
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