Ann Thorac Surg 2003;75:1836-1841
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
The descending branch of lateral femoral circumflex artery in arterial CABG: early and midterm results
Mario Fabbrocini, MDa,
Khalil Fattouch, MDa*,
Glauco Camporini, MDa,
Gloria DeMicheli, MDa,
Carla Bertucci, MDa,
Paolo Cioffi, MDa,
Domenico Mercogliano, MDa
a Department of Cardiovascular Surgery, Nuova Casa di Cura Città di Alessandria, Alessandria, Italy
Accepted for publication December 31, 2002.
* Address reprint requests to Dr Fattouch, Via Saluzzo 42, 00182, Rome, Italy
e-mail: khalilfattouch{at}hotmail.com
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Abstract
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BACKGROUND: Different arterial conduits have been used for coronary artery bypass grafting (CABG), avoiding remote cardiac events associated with graft failure and improving the quality and expectancy of life in patients with coronary artery disease. The goal of this study was to evaluate the early and midterm results of total arterial CABG with the descending branch of the lateral femoral circumflex artery (DLFCA).
METHODS: Between February 1997 and December 2001, 147 patients underwent arterial CABG using the DLFCA at our department. The patients were followed to determine perioperative cardiac events. Angiographic follow-up controls were performed at the end of surgery in 81patients (55.1%), within 1 year in 82 patients (55.7%), and within 3 years in 48 patients (32.6%). The actuarial survival and event-free rates, the occurrence of late cardiac events and death, the cumulative rate of the DLFCA graft patency, and the incidence of spasm were investigated.
RESULTS: The DLFCA was used in all patients (113 men and 34 women, with a mean age of 56 ± 12.6 years). The proximal anastomoses of the DLFCA was performed with the left internal mammary artery (LIMA) in 95% and with the right internal mammary artery (RIMA) in 5% of patients. The distal anastomoses of the DLFCA was performed with the left anterior descending (LAD) coronary artery in 3.5%, with the diagonal artery in 17%, with the intermedius ramus in 7.5%, with the posterior interventricular artery in 2%, and with the branch of circumflex artery in 70% of patients. The in-hospital mortality and morbidity rates were 0% and 7.4%, respectively. Complications related to DLFCA harvesting was transient dysesthesia of the thigh, observed in 6 patients (4%). No postoperative myocardial infarction attributable to DLFCA bypass was observed. During the late follow-up period of 22.09 ± 16.8 months, cardiac events were observed in 14 patients (9.5%), including recurrence of angina in 6, arrhythmia requiring hospitalization in 4, congestive heart failure in 2, percutaneous transluminal angioplasty in 1, and sudden death in 1 patient. Actuarial 1- and 3-year survival rates after surgery were 100% and 99.3%, respectively. Actuarial 1- and 3-year event-free rates were 97.3% and 90.5%, respectively. Actuarial 1- and 3-year patency rates were 97.5% and 93.7%, respectively.
CONCLUSIONS: No adverse effects were exhibited after CABG using the DLFCA graft in this early and midterm follow-up period. The excellent patency rate of DLFCA and the low incidence of spasm stimulate us to continue and extend the use of the DLFCA in CABG.
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Introduction
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The advent of surgical myocardial revascularization has increased life expectancy and improved the quality of life of a significant cohort of patients with coronary artery disease. Firstly, complete coronary artery bypass grafting (CABG) was performed by combining arterial and saphenous vein conduits but in the last decade total arterial myocardial revascularization has become more popular.
The use of the internal mammary artery (IMA) as a bypass graft has been approved for years, because its long-term patency is better than that of the saphenous vein grafts [1]. Moreover, patients receiving the left IMA (LIMA) to their left anterior descending (LAD) coronary artery have significant long-term event-free survival [2, 3]. This has led to the opinion that "arterial graft is better." Actually, IMA is the ideal arterial graft available because it has some unique characteristics, such as the low incidence of arteriosclerosis, the presence of elastic structure in the media, its similarity with the coronary artery system regarding cross-sectional diameter, its acclimatization to the same arterial hemodynamics characteristics, its intrathoracic respiratory pressure changements, and the biochemical environment [4, 5]. Furthermore, the use of both in situ IMA is still the optimal choice in total arterial CABG [6–9], but it is not always feasible because of the progressive increase of patients with multivessels disease and of patients who undergo coronary reoperation. In the surgical practice today several arterial conduits are used for myocardial revascularization, namely the right gastroepiploic artery (GEA) [10], the inferior epigastric artery (IEA) [11], and the radial artery (RA) [12]; the choice of arterial conduits varies according to the surgeon. Following the first report by Tatsumi and colleagues [13], we used the descending branch of the lateral femoral circumflex artery (DLFCA) as a free graft in 147 patients who underwent total arterial CABG. The aim of this study was to evaluate early and midterm clinical and angiographic results of the DLFCA graft in patients who underwent CABG.
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Patients and methods
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Between February 1997 and December 2001, a total of 1150 consecutive patients underwent isolated total arterial CABG. Among these, a series of 147 patients were prospectively enrolled to receive the DLFCA as free graft and each signed an informed consent form. Eight patients were operated in urgent status. The mean age was 56 ± 12.6 years, ranging from 36 to 69 years. There were 113 men and 34 women. Eighteen patients (12%) had undergone a previous CABG. Clinical data and preoperative characteristics are illustrated in Table 1.
The DLFCA was used to bypass the LAD in 5 patients (3.5%), the diagonal artery in 25 patients (17%), the branches of the circumflex artery in 103 patients (70%), the intermediate artery in 11 patients (7.5%), and the posterior interventricular artery (IVP) in 3 patients (2%). The proximal anastomoses of the DLFCA was performed end-to-side to the LIMA in 140 patients and in 5 patients to the right IMA (RIMA), as Y graft. In 2 patients the DLFCA was used for graft elongation purposes. Blood samples were taken for subsequent serum creatine kinase (CK) and CK-MB measurements at 0-, 8-, 16-, and 24-hours after surgery. Serial electrocardiograms (ECG) were obtained postoperatively. Myocardial infarction was defined for patients with new Q-waves in contiguous leads or a CK-MB greater than 50 IU/L. Operative characteristics and outcomes are illustrated in Table 2.
Surgical technique
All patient candidates to myocardial revascularization with the use of the DLFCA were studied preoperatively by continous-wave Doppler (Doppler 2000; Cardioline, Inc., Santa Rosa, CA) to investigate the presence of arteriosclerosis in the iliac and femoral arteries. When, continous-wave Doppler revealed significant hemodynamic atherosclerotic lesions, we performed femoral arteriography to assess the DLFCA. In our series, 2 patients were excluded from using DLFCA.
An incision was performed on the anterolateral face of the thigh, about 6-cm from the groin. The fascia lata was incised; the rectus and the vastus lateralis muscles were separated, and the DLFCA was exposed. The DLFCA arises from the lateral surface of the profunda femoral artery; it then runs laterally and deeply into the vastus lateralis muscle reaching the posterior face of the thigh to anastomoses with the medial circumflex and ischiatic arteries and gives rise to an ascending and descending branch (DLFCA). The dissection was started from the end of artery and carried out in a skeletonized fashion. The length of the DLFCA depends on the length of the thigh; the mean length was 14.3 ± 2.3 cm ranging from 12.6 to 17.4 cm. Total harvesting of the artery could be performed easily in a short time (mean 18 ± 4 minutes). The diameter of the first 12 to 15 cm is between 2.5 mm (proximal) and 1.5 mm (distal). When harvesting was completed and after systemic heparinization, the distal end of the DLFCA was occluded with a homeostatic clip and the DLFCA was pharmacologically treated with diltiazem and warm papaverine hydrochloride solution. Moreover, the harvested artery was cannulated and infused with the same solution in order to facilitate the release of spasm and to achieve further hemostasis. Prophylaxis of spasm was performed with intravenous administration of calcium-channel blockers such as diltiazem or verapamil at the end of surgery. In 122 patients (83%), CABG was performed using cardiopulmonary bypass (CPB) carried out under moderate systemic hypothermia (32°C), keeping a continuous flow at 2 to 2.5 L per min/m2 and mean perfusion pressure between 50 and 70 mm Hg. Myocardial protection was achieved with anterograde cold blood cardioplegia. Off-pump CABG was performed in 25 patients (17%). The total number of distal anastomoses performed with the DLFCA were 186. The mean CPB and aortic cross-clamp times were 53.8 ± 7.7 and 38.6 ± 6.7 minutes, respectively.
Follow-up
Clinical follow-up data were obtained in all patients and was collected at 1-, 6-, 12-, and 36-months after surgery. The first control visit was performed at 1-month after hospital discharge by our cardiologists staff; when patients had problems in reaching our department, data were collected by direct contact with the referring cardiologist.
Any cardiac events after discharge from hospital, including myocardial infarction, angina, arrhythmia and congestive heart failure requiring hospitalization, native coronary artery or graft stenosis requiring any type of coronary intervention, and sudden death were considered and counted as a cardiac-related event.
Postoperative angiographic control was randomly performed in 81 patients (55%) in operating room using the General Electric angiograph (series 9800; GE Medical Systems, Waukesha, WI), or during the in-hospital stay period with the patient’s permission. Follow-up angiographic control was proposed for all patients followed at our institution and performed in 82 patients (56%) and 48 patients (32.6%), within 1 and 3 years, respectively.
Statistical analysis
Continous variables are summarized as the mean ± standard deviation, and categorical variables are summarized as the absolute frequency or as a percentage. Postoperative patient survival, event-free rate, and long-term graft patency were calculated using the Kaplan-Meier method. All statistical analyses were performed using a Statview II software package (Abacus Concepts, Berkeley, CA).
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Results
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The demographic details of the patients are given in Table 1. A total of 147 patients were included in this study. There were 113 men and 34 women, with a mean age of 56 ± 12.6 years.
In-hospital results
The operative data and outcomes are listed in Tables 2 and 3.
We had no in-hospital mortality in our series (0%). Postoperative complications as new Q-wave or values of CK-MB (> 50 IU/L) indicative for myocardial infarction were not observed. After surgery, the mean peak of CK-MB and CK was 32 ± 12 IU/L and 653 ± 358 IU/L, respectively. Sternal infection was present in 2 patients (1.4%). Reexploration for bleeding was needed in 2 patients (1.4%). Low cardiac output syndrome occurred in 2 patients (1.4%) treated pharmacologically with inotropic agents support. Pneumonia occurred in 5 patients (3.4%). Respiratory failure was observed in 7 patients (4.7%) needing prolonged mechanical ventilation (> 7 days). Acute renal failure was present in 1 patient (0.7%) and treated by dialysis. No signs of limb ischemia were observed after harvesting of the DLFCA; however, a transient dysesthesia of the thigh was noted in 6 patients (4%), which was probably due to surgical trauma of the superficial branches of the quadriceps nerve. Transient muscular tone deficit of the thigh was observed in 3 patients (2%) during the first 6 months postoperatively, probably due to muscle/nerve manipulation and stretching during surgery. There were no additional DLFCA wound complications, including delayed healing and superficial wound infection; no compartment syndrome was observed in our series.
Follow-up results
Postoperative follow-up was completed in all patients. Late sudden death occurred in 1 patient (0.7%). Duration of follow-up ranged from 1 to 52 months (mean, 22.09 ± 16.8 months). During this follow-up period, cardiac events occurred in 14 patients (9.5%), including angina pectoris recurrence in 6 patients (4%), arrhythmia requiring hospitalization in 4 patients (2.7%), congestive heart failure in 2 patients (1.4%), percutaneous transluminal angioplasty in 1 patient (0.7%), and sudden death in 1 patient (0.7%). All patients underwent color flow Doppler echocardiography at 6 months, 1 year, and 3 years after surgery. The mean New York Heart Association (NYHA) functional class and the mean left ventricular ejection fraction (LVEF) at 6 months, 1 year, and 3 years, were 1.8 ± 0.6/50.2% ± 12.2%, 1.6 ± 0.2/55% ± 8.2%, and 1.1 ± 0.5/56% ± 9.3%, respectively.
Actuarial 1- and 3-year survival rates after surgery were 100% and 99.3%, respectively. Actuarial 1- and 3-year event-free rates were 97.3% and 90.5%, respectively.
Angiographic study results
An early angiographic control was randomly performed in 81 patients (55%) at the end of surgery in the operating room; the patency rate was 100% and no spasm was observed. All patients were treated with calcium-channel blockers intravenously at the end of CPB. Eighty-two patients (56%) were controlled angiographicaly within 1 year (mean, 9.1 ± 2.2 months) after surgery. The patency rate was 97.5%. Two patients had a DLFCA graft occlusion; 1 patient had all distal anastomoses occluded, including the LIMA to the LAD artery. Forty-eight patients (32.6%) underwent angiographic control within 3 years (mean, 29 ± 6.1 months) after surgery; 6 of these patients had angina recurrence. The patency rate was 93.7%; occlusion of the DLFCA graft was observed in 1 patient, but in 2 patients stenosis at the distal anastomosis side was observed. The cumulative patency rate is illustrated in Figure 1.
String sign of the DLFCA was not observed in our series. Regarding the reactivity, we did not observe catheter-induced or spontaneous spasm neither on the early angiograms nor at the late controls (Fig 2).
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Fig 2. Angiographic controls of the descending branch of the lateral femoral circumflex artery (DLFCA) as Y graft with the left internal mammary artery (LIMA) at 32 months after surgery. (DIAG = diagonal artery; LDA = left descending anterior artery.)
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Comment
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The benefits correlated with the excellent long-term patency of arterial grafts for CABG, particulary the IMA and include improved long-term patient survival, thus attempting to minimize the use of vein grafts that have higher occlusion rates [1–3]. In the last decade, total arterial CABG has become more popular and the results of using various arterial conduits have been extensively discussed and published [7–9, 14–19]. Although we can use different arterial conduits in many strategic operations today, the type of arterial graft and the coronary site where to do the anastomosis is still an individual surgeon’s choice. This implies that when we use the arterial conduits we should follow some principles. The most important one is to give the patient as many blood sources as possible. Several authors report that the ideal conduits in multivessels coronary disease are in situ bilateral IMA for the left territory, and in situ right gastroepiploic artery for the right territory [14, 18, 19]. The skeletonized LIMA can be used as sequential conduits to graft diagonal, intermedius, and LAD coronary artery. The skeletonized RIMA can be used to graft the branch of the circumflex artery, as composite graft or in situ, through the aortic trasvers sinus. Moreover, the LIMA can be used to graft the circumflex branches and in situ crossover RIMA to graft LAD [20]. The other arterial conduits, such as the radial and epigastric artery, should be used in composite graft. However, for the progressive increase of young patients with multivessels disease and of those who undergo cardiac reoperation, the continous research of alternative arterial conduits is still actual.
The DLFCA was first described by Tatsumi and coworkers [13, 21], and consecutively used in our routine surgery as Y graft. Histologically, the DLFCA is classified as a muscular artery, which is known to be liable to vasospasm. To avoid graft injury, harvesting of the DLFCA was performed by the use of scissors for dissection and metal clips to control homeostasis. For the prophilaxis of spasm, papaverine is used topically while calcium-channel blockers, such as diltiazem, were administred systemically after surgery and continued postoperatively by oral administration for a minimum of 3 months. In our surgical experience spasm of the DLFCA was rarely observed and, if present, was completly resolved after chemical and mechanical antivasospastic care. This is mandatory to optimize the graft patency. In this study, the target of the DLFCA graft was usually the branch of circumflex artery; details are listed in Table 3. The proximal anastomoses of the DLFCA was performed in all cases with the IMA to improve long-term graft patency. We think that the proximal anastomoses of the free arterial graft to the ascending aorta gives poor long-term results, which is in agreement with other reports [9, 19]. During the first year of our experience we used the DLFCA to bypass an occluded or tightly stenosed (> 90%) coronary artery with a large perfusion territory, supported by the results obtained with the use of the radial artery [22]. Subsequently, encouraged by the low incidence of spasm and the high capacity of adaptation of the DLFCA observed in angiographic controls, we extended the use of the DLFCA to graft all stenosed coronary artery (> 70%). One of the limits of the DLFCA is its length (mean, 14.3 ± 2.3 cm), which is not always sufficient to revascularize the left ventricular territory. Emergency surgery is not a contraindication for DLFCA grafting, because the harvesting can be performed easily in a short time. The DLFCA can be used safely in diabetic patients and in those with chronic pulmonary obstructive disease when harvesting of both IMA is not indicated. The wound resulting from DLFCA harvesting usually heals rapidly and local infection and compartment syndrome are not observed. Transient sensory deficit, usually due to surgical manipulation of the superficial branches of the quadriceps nerve, occurred in 6 patients (4%).
In our study, no DLFCA graft-related complications were observed. No postoperative myocardial infarction was noted. Two patients (1.4%) had a low cardiac output syndrome postoperatively, probably due to preoperative poor left ventricular function and poor run-off of native coronary artery.
The DLFCA graft was examined by angiography in randomized patients. Although the angiographic follow-up period was relatively short, the graft patency was excellent. Data are illustrated in Table 4. The DLFCA patency rate was 97.5% at 1 year and 93.7% at 3 years. These patency rates compared well with the patency of the other arterial graft conduits, such as the IMA, GEA, and RA [1, 7, 10, 22]. Moreover, the event-free rates were 97.3% and 90.5% at 1 and 3 years, respectively. Late death was observed in only 1 patient (0.7%). The cause of late death was unknown, referred to by relatives as sudden death. Six patients with recurrence of angina were angiographicaly studied; none of them had a DLFCA graft failure, but 1 patient had radial graft stenosis treated by percutaneous angioplasty. Arrhythmia requiring hospitalization occurred in 4 patients; these patients were also studied by angiography and patency of the graft was observed.
In our series, a string sign, which was defined as a severe and extensive narrowing of the whole body of the graft, was never observed. Moreover, we studied the vasoreactivity of the DLFCA in 12 consecutive patients, at a mean of 387 ± 42 days after operation. Serotonin was selectively injected into the LIMA and into the DLFCA. In accordance with the protocol used by Spetri and colleagues [23], an increasing dose was used (10-6 and 10-5 M at an infusion rate of 3 mL/min, for 3 minutes). No vasoconstriction response was observed for the LIMA and the DLFCA; these data were not conclusive and more reactivity studies must be performed.
In conclusion, no adverse effects were noted after CABG using the DLFCA graft in our series, and the patency rates of the DLFCA graft were excellent and similar to the other arterial conduits. We think that the use of the DLFCA bypass contributed to increasing total arterial myocardial revascularization and improves life expectancy and the quality of life of patients undergoing CABG because of the improved long-term graft patency of this arterial conduit with respect to the saphenous vein. We conclude that arterial revascularization with the DLFCA is technically feasible and safe with a low morbidity and mortality rate; the midterm results allow us to extend our surgical strategy of myocardial revascularization.
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References
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Abstract
Introduction
