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Ann Thorac Surg 2004;78:1290-1294
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Flow Dynamics of the Internal Thoracic and Radial Artery T-Graft

David G. Affleck, MDa, Hendrick B. Barner, MDa,*, Marci S. Bailey, RNa, Loretta A. Perry, RNa, Hersh Maniar, MDa, Sunil M. Prasad, MDa, Ralph J. Damiano, Jr, MDa

a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA

Accepted for publication March 2, 2004.

* Address reprint requests to Dr Barner, Division of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 3108 Queeny Tower, St. Louis, MO 63110, USA
barnerh{at}msnotes.wustl.edu

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: Complex use of arterial conduits has resurrected concerns about the adequacy of conduit flow. The T-graft is the extreme example of this trend. Our purpose was to identify the limitation of single source inflow and to compare flow capacity with completion coronary flow.

METHODS: Between February 1999 and November 2001, 372 patients underwent total arterial revascularization with the T-graft alone. Intraoperative flows were recorded for each limb of the T-graft before and after distal anastomoses in 204 patients. Independent predictors of T-graft flow were identified by multivariate analysis.

RESULTS: Free flow for the radial arterial (RA) limb was 161 ± 81 mL/min, the internal thoracic artery (ITA) limb 137 ± 57 mL/min (combined 298 ± 101 mL/min) versus simultaneous limb flow of 226 ± 84 mL/min giving a flow restriction of 24% ± 14%. Completion coronary flow was 88 ± 49 mL/min for the RA, 60 ± 45 mL/min for the ITA, and 140 ± 70 mL/min for both limbs simultaneously to give a flow reserve (vs simultaneous free flow) of 160% or 1.6. Independent predictors of completion RA limb flow are RA proximal diameter (p = 0.005), number of anastomoses (p = 0.018), and target stenosis (p = 0.005).

CONCLUSIONS: A flow reserve of 1.6 compares favorably with an ITA flow reserve of 1.8 at 1-month postoperatively and 1.8 for both the ITA T-graft and the ITA/RA T-graft at 1-week postoperatively as reported by others. Proximal RA diameter and competitive coronary flow influence completion T-graft flow. These data quantitate the limitation of single source inflow of the T-graft configuration and support its continued use.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
The long-term success of coronary bypass grafting (CABG) depends on the longevity and patency of the conduits. Many centers report vein graft patency of 50% at 10 years [1]. In patients with three vessel coronary disease, CABG with the left internal thoracic artery (ITA) to the left anterior descending artery and saphenous vein for the other coronaries will improve survival over that obtained with veins only [2, 3]. Further, bilateral ITA grafting has been reported to improve patient survival and decrease the need for reintervention [1, 4].

In spite of these results, the ITA has not been universally adapted. In 1975, only 5.7% of CABG was performed using the left ITA increasing to 13% in 1980 and 75% in 1997 [5].

Although some have been skeptical [6, 7] of the ability of the left ITA to provide adequate flow, particularly in the face of significant left ventricle hypertrophy, this has not been routinely demonstrated. One group documented angiographic hypoperfusion after total arterial coronary revascularization (TACR) [8]. Nevertheless, there have not been reports to support such limitations on a consistent basis.

The trend more than 15 years has been that of increasing use of arterial conduits to achieve TACR. The return of the radial artery (RA) has aided this strategy [9]. Another approach of greater complexity has been use of only two conduits to achieve TACR [10, 11]. As an alternative to bilateral ITA harvest, the RA T-graft shortens harvest time and reduces sternal complications to that of single ITA harvest [12]. This may be especially applicable in the overweight diabetic patient [13, 14].

With the T-graft, all conduit flow is through the single conduit proximal to the T-anastomosis (usually the left ITA). If there was reason to doubt the adequacy of ITA flow when supplying a single coronary, there is obvious reason to question the adequacy of flow through the proximal T-graft segment. There are few data regarding intraoperative T-graft flow [15]. Wendler and associates [16] have provided definitive data on T-graft flow at 1 week and 6 months postoperatively. With this report, we provide free flow and completion flow measurements in a large number of patients receiving the ITA/RA T-graft.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Study Population
Between February 1999 and November 2001, 372 patients underwent total arterial revascularization with the ITA/RA T-graft alone. Intraoperative flows were recorded for each limb of the T-graft before and after anastomosis in 204 patients. Table 1 describes the patient demographics in terms of age, comorbidities, and New York Heart Association (NYHA) classification. All patients were enrolled after informed consent was obtained per standard Washington University Institutional Review Board specifications.


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  		Table 1. Patient Demographics

 
Patient Characteristics
Operative characteristics, severity of disease, case mix and number of anastomoses are depicted in Table 2. Ninety-one percent of the patients underwent "elective" CABG and 94% of those were CABG-only procedures. Over 70% of the patients had three-vessel disease and 18% had left main disease. Cardiopulmonary bypass time was 134 ± 31 minutes with an average of 1.5 distal ITA anastomoses and 2.1 distal RA anastomoses.


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  		Table 2. Operative Data

 
Radial Artery Harvest
Radial artery harvesting was performed as previously described [17]. The RA pedicle was harvested maintaining the paired, parallel venous branches with the use of the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). After harvest, the graft was placed in a dilute papaverine and blood solution to neutralize the acidic nature of the papaverine.

T-Graft Preparation
The ITA/RA anastomoses were performed before cannulation, but after systemic heparin and after a midline pericardial incision and a second incision from the pulmonic valve into the "bare area" (no fat) of the pericardium to the phrenic nerve. The ITA was harvested as a pedicled graft in all patients. The RA was spatulated 2 mm and anastomosed to a 4- to 5-mm incision in the pleural aspect of the ITA at the level where the ITA enters the pericardial space anterior to left atrial appendage (Fig 1). The two limbs of the T-graft were gently filled with blood-papaverine (2 mg/mL) solution and soft vascular bulldogs placed distally. The graft was allowed to dilate for at least 10 minutes while preparations were made for cardiopulmonary bypass.



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  		Fig 1. The radial artery is harvested as described and placed in blood/papaverine solution. It is anastomosed to the left ITA where it enters the pericardial space after incising the pericardium from the level of the pulmonic valve to the phrenic nerve to expose the atrial appendage (A). Before initiation of cardiopulmonary bypass, an end to side anastomosis is created with the pedicled ITA serving as the sole inflow to both limbs of the graft. We create a classic Y-anastomosis with a 5-mm incision in the ITA and a 2- to 3-mm spatulation of the radial artery (B, C). We call this a T-anastomosis not because of the perpendicular course of the radial artery to the ITA, but because the attached limb supplies all of the territory not supplied by the left ITA [10, 11]. Both limbs are gently filled with a blood/papaverine solution (2 mg/mL) and allowed to dilate for 10 minutes while exposed to arterial pressure. Free limb flow and total T-graft free flow are then measured against zero resistance for 30 seconds. (ITA = internal thoracic artery.)

 
T-Graft Free Flow
Before institution of cardiopulmonary bypass, free flow through each limb of the T-graft was measured while the other limb was occluded and then concomitant flow through both limbs was measured (timed collection for 30 seconds). Mean blood pressure was recorded and if not in a "physiologic range," volume was added from the pump or rarely a vasodilator infused and when blood pressure was stable the flow measurements were obtained. The length of the RA and proximal and distal internal diameter were measured with probes having increments of 0.5 mm.

Target Vessel Characteristics
Target vessel stenosis was graded as moderate (< 70% stenosis), severe (70% to 89% stenosis), and critical (> 90% stenosis). Target vessel location was recorded as right coronary, left anterior descending, or circumflex arteries. The quality of the coronary at the anastomotic site was reported as normal/mild intimal disease, moderate or severe intimal disease. The coronary artery at the anastomotic site was sized with probes in 0.5-mm gradations.

Surgical Technique
Cardiopulmonary bypass was instituted and the temperature allowed to drift to 34°C and blood cardioplegia at the same temperature was administered. Radial artery distal anastomoses were performed first followed by ITA anastomoses.

Completion T-Graft Flow
After discontinuation of CPB, and achieving hemodynamic stability, flow was measured using a hand-held, transonic flow probe (Transonic Systems Inc., Ithaca, NY). Flow was usually measured 15 to 20 minutes after discontinuation of cardiopulmonary bypass and only when the blood pressure was stable and within normal limits. Flow was measured in each limb and in the ITA proximal to the T-anastomosis. The anesthesiologist determined use of vasopressor and inotropic drugs and specific drugs were not used to treat conduit spasm other than the initial exposure to papaverine.

Statistical Analysis
Data were represented as frequency distributions and percentages. Values of continuous variables were expressed as a mean ± SD. Univariate analysis (X2 test) and multivariate stepwise logistic regression analysis were used to determine the preoperative and operative variables that were significant, independent predictors to influence free or completion flow (SPSS 11.0 for Windows; SPSS Inc., Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
Of the 372 patients having TACR during the study period, 204 had complete intraoperative flow data. Free flow for the RA limb was 161 ± 81 mL/min with a mean arterial pressure (MAP) of 78 ± 9 mm Hg. The ITA free flow was 137 ± 57 mL/min, MAP 79 ± 10 mm Hg. Combined this gives a free flow for both limbs of 298 ± 101 mL/min. This compares with a simultaneous limb free flow of 226 ± 84 mL/min, MAP 77 ± 9 mm Hg demonstrating a flow restriction of 24% ± 14% (Fig 2).



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  		Fig 2. Free flow from the T-graft, after dilation with papaverine is depicted by the bars. The ITA limb free flow was 137 ± 57 and for the radial artery was 161 ± 81 mL/min. By addition, this gives a free flow of 298 mL/min. Simultaneous flow through both limbs is 226 ± 84 mL/min. The difference represents a flow restriction of 24% ± 14% imposed by the proximal ITA segment supplying both limbs of the T-graft. (ITA = internal thoracic artery; RA = radial artery.)

 
Completion conduit flow after discontinuation of cardiopulmonary bypass was 88 ± 49 mL/min, MAP 80 ± 10 mm Hg for the RA limb and 60 ± 45 mL/min, MAP 80 ± 10 mm Hg for the ITA limb with the other limb occluded. Combining the two limb flows gives a flow of 148 mL/min, which is slightly greater than the measured T-graft flow of 140 ± 70 mL/min, MAP 80 ± 10 mm Hg, because there may be overlapping of flow territories. When the completion T-graft flow of 140 ± 70 mL/min is compared with the free T-graft flow (226 ± 84 mL/min) a flow reserve of 160% or 1.6 is obtained (Fig 3).



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  		Fig 3. Transonic flow measurement 15 to 20 minutes after discontinuation of cardiopulmonary bypass is depicted by the three bars to the left. The ITA limb flow was 60 ± 45 and the radial artery 88 ± 49 mL/min when the other limb was occluded. The T-graft flow with both limbs open was 140 ± 70 mL/min. Comparison with the measurement of T-graft free flow (Fig 2) gives a conduit flow reserve of 1.6. It should be noted that the T-graft flow (140 ± 70 mL/min) is slightly less than the sum of the limb flows (148 ± 71 mL/min) because clamping of one limb may increase flow in the other limb if they both have the potential to supply the same territory. (ITA = internal thoracic artery; RA = radial artery.)

 
Radial artery diameter influences RA limb free flow (p = 0.01) and not T-graft free flow. Independent predictors of RA limb completion flow were RA proximal diameter (p = 0.005), number of anastomosis (p = 0.018), and target artery stenosis (p = 0.005). Preoperative risk factors of diabetes, hypertension, and smoking did not significantly influence free or completion flow. Operative variables of coronary diameter and coronary arteriosclerosis at the anastomotic site did not significantly effect completion flows.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
These data demonstrate that the ITA/T-Graft has an intraoperative flow reserve of 160% or 1.6. This flow reserve is comparable to that of the left ITA as an isolated graft at 1-month postoperatively and increases to 2.6 at 1 year with a change in the ITA diameter from 2.4 to 2.9 mm [18]. This remodeling of the ITA to increased (or decreased) flow has been demonstrated experimentally [19]. Similarly, the coronary flow reserve was 1.8 one week postoperatively in both ITA and radial artery T-grafts and at 6 months had increased to 2.7 and 2.5 respectively with a nonsignificant decrease in resting flow and a significant increase in maximum flow (adenosine challenge into the left ITA) [16]. Clinical measurements of the RA used as an in situ arteriovenous dialysis fistula and studied three or more months after creation revealed an increase in RA diameter from 2.4 ± 0.61 mm to 3.31 ± 1.09 mm when flow increased from 22 ± 24 to 126 ± 135 mL/min (p < 0.001) [20].

Thus, there is strong evidence that arterial coronary bypass conduits will remodel to maintain endothelially sensed shear stress in a narrow range of 20 to 40 dyne/cm2 and that this process may be substantially complete by 3 months in man but may require up to 12 months although these data are incomplete [21]. Flow requirements placed on a conduit (or the T-graft) depend on multiple determinants including heart size, the amount of myocardium perfused by the conduit versus that perfused by nonbypassed and patent coronary arteries, the severity of coronary stenosis, and the presence of competitive and collateral coronary flow. These determinants are dynamic and may change both acutely and chronically.

Because the stimulus for remodeling is endothelially sensed shear stress, which is dependent on conduit flow, the rapidity and magnitude of conduit change may vary greatly in each clinical situation. In the presence of moderate coronary stenosis, with competitive coronary flow, remodeling may occur over a longer time interval as coronary disease progresses or regresses.

In 17 patients having an ITA/RA T-graft with papaverine vasodilation of the conduits and a study protocol similar to ours, T-graft free flow was 173 ± 16 mL/min and completion flow was 82 ± 13 mL/min to give a conduit flow reserve of 2.3 [15]. Both flow measurements are substantially less than ours, which could represent the duration of exposure to papaverine, the method of exposure (topical or intraluminal), and differences in systemic blood pressure or competitive coronary flow. Considering these variables, and others not enumerated, these data are consistent with ours and support the observation of hemodynamic adequacy of the ITA/RA T-Graft.

In 27 patients, ITA/RA T-Graft coronary flow reserve was measured using a Doppler guidewire with atrial pacing and adenosine infusion to stimulate flow 5 days postoperatively. Flow reserve was 1.5 for the RA during sinus rhythm and decreased to 1.3 with atrial pacing at 85% of maximum predicted heart rate followed by adenosine infusion [22]. These early postoperative data include pacing-induced stress followed by adenosine infusion to provide classic determination of coronary flow reserve for the ITA/RA T-graft.

Our observations suggest that the T-graft has adequate flow reserve to meet myocardial flow requirements in the perioperative interval and this will only improve over time, which is our clinical experience. Persistent harvest spasm or recurrent spasm, conduit injury (dissection or intimal flap), faulty anastomosis, and conduit kinking/angulation at the anastomoses have all been recognized as causes of hypoperfusion.

Hypoperfusion may result in acute ischemic changes, infarction, low cardiac output, and cardiac failure. Recognition and correction of the problem is essential and with experience this is usually possible although the strategy of placing a "back-up" vein graft is appropriate and perhaps the best approach if one is not confident about the etiology of the hypoperfusion or the feasibility of a corrective action.

We have had a few patients with inadequate free flow or completion flow (we continue to assess the former visually and the latter with the transit time flow meter) which were successfully treated as described. We have not recognized subsequent hypoperfusion. This total experience suggests that the hemodynamics of the ITA/RA T-graft are intrinsically adequate to meet the flow requirements of the heart in the early postoperative period and with remodeling, conduit flow will improve as needed.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR THORALF SUNDT (Rochester, MN): How did you go about controlling for hemodynamics at your two measurement points? In other words, was your completion flow on bypass, and how well did your mean arterial pressures match up at eh times you tested your free flows versus your completion flows?

DR AFFLECK: I know you have done these so you know, but the free flows are done before the initiation of cardiopulmonary bypass by measuring the volume into a bucket in each limb as well as simultaneously, and the completion flows are performed after completion of all of the anastomoses off of bypass.

DR SUNDT: And did you control for mean arterial pressure at the two points?

DR AFFLECK: As far as I am aware we did not control for mean arterial pressure at those two points. That is a good question.

DR SUNDT: It might be something worth looking at. Thanks.

DR D. GLENN PENNINGTON (Johnson City, TN): I enjoyed that paper very much. Just a couple of questions. One, are these patients receiving intravenous dilating drugs such as nitroglycerin or calcium-channel-blockers? If they are, is there any influence on flow?

The second question, is there any difference doing this off-pump than on-pump in terms of measurements of flow in the internal thoracic artery (ITA) and the radial artery specifically?

DR AFFLECK: As far as your second question, I can't comment because we have not done this procedure off-pump. In terms of your first question about calcium-channel-blockers or other vasodilators, other than the dilation with papaverine, we have moved away from routinely using calcium-channel-blockers for an extended period of time. Some the patients received intravenous diltiazem, but that is weaned off very early in the perioperative period. We have not done it off-pump.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Tatoulis J, Buxton BF, Fuller JA, Royse AG. Total arterial coronary revascularization: techniques and results in 3,220 patients. Ann Thorac Surg. 1999;68:2093–2099[Abstract/Free Full Text]
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  4. Lytle BW, Blackstone EH, Loop FD. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–872[Abstract/Free Full Text]
  5. Barner HB. The continuing evolution of arterial conduits. Ann Thorac Surg. 1999;68:S1–8
  6. Flemma RJ, Singh HM, Tector AJ. Comparative hemodynamic properties of vein and mammary artery in coronary bypass operations. Ann Thorac Surg. 1975;20:619–627[Abstract]
  7. Vajtai P, Rauichandran PS, Fessler CL, et al. Inadequate internal mammary artery grafts as a cause of postoperative ischemia: Incidence, diagnosis, and management. Eur J Cardiothorac Surg. 1992;6:603–608[Abstract]
  8. Jones EL, Lattouf OM, Weintraub WS. Catastrophic consequences of internal mammary artery hypoperfusion. J Thorac Cardiovasc Surg. 1989;98:902–907[Abstract]
  9. Acar C, Ramshey A, Pagny JY, et al. Five-year results of coronary artery bypass grafting using the radial artery. J Thorac Cardiovasc Surg. 1998;116:981–989[Abstract/Free Full Text]
  10. Sauvage LR, Wu HD, Kowalsky TE. Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries. Ann Thorac Surg. 1986;42:449–465[Abstract]
  11. Tector AJ, Amundsen S, Schmahl T, et al. Total revascularization with T grafts. Ann Thorac Surg. 1994;57:33–38[Abstract]
  12. Barner HB, Sundt TM III, Bailey M, Zang Y. Intermediate term results of complete arterial revascularization in over 1,000 patients using an internal thoracic/radial artery T-graft. Ann Thorac Surg. 2001;234:447–452
  13. Cosgrove DM, Lytle BW, Loop FD. Does bilateral internal mammary artery grafting increase surgical risk? J Thorac Cardiovasc Surg. 1988;95:850–856[Abstract]
  14. Kouchoukos NT, Wareing TH, Murphy SF. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg. 1990;49:210–219[Abstract]
  15. Royse AG, Royse CF, Groves KL, et al. Blood flow in composite arterial grafts and effect of native coronary flow. Ann Thorac Surg. 1999;68:1619–1622[Abstract/Free Full Text]
  16. Wendler O, Hennen B, Markwirth T. T grafts with the right internal thoracic artery to left internal thoracic artery versus the left internal thoracic artery and radial artery: flow dynamics in the internal thoracic artery main stem. J Thorac Cardiovasc Surg. 1999;118:841–848[Abstract/Free Full Text]
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