Patency of saphenous vein coronary artery bypass grafts from the vascular prosthesis of the ascending aorta.

BACKGROUND: Patients who have Stanford type A aortic dissection with impaired coronary arteries or who have aneurysms from the ascending aorta to the aortic arch with coronary artery disease need coronary artery bypass grafting (CABG) with tube graft replacement of the ascending aorta simultaneously. When vein grafts are used for CABG in these patients, the proximal anastomoses of vein grafts are attached to the prosthetic tube graft of the ascending aorta. However, the validity of proximal anastomoses of vein grafts to the prosthetic tube graft of the ascending aorta has not been confirmed. PATIENTS AND METHODS: We retrospectively analyzed patients who underwent venous coronary bypass grafting with prosthetic graft replacement of the ascending aorta. Between January 1984 and October 2002, 35 patients underwent CABG using saphenous vein grafts at the time of tube graft replacement of the ascending aorta, and the proximal anastomoses of the vein grafts were attached to the tube graft of the ascending aorta. Thirty-three venous bypass grafts were analyzed in 24 survivors. RESULTS: The postoperative catheterization showed only one early vein graft occlusion of 16 vein grafts anastomosed distally to the left anterior descending artery (LAD). All 14 venous grafts anastomosed to the right coronary artery (RCA) and 3 to the left circumflex artery (LCX) were patent. Therefore, the postoperative patency rate at discharge was 97.0% (32/33). Spiral computed tomography performed for long term follow-up revealed occlusion of two vein grafts (3.5 years and 9.7 years) anastomosed to the LAD. CONCLUSIONS: The patency rate of vein grafts anastomosed from prosthetic grafts of the ascending aorta to the native coronary arteries was similar to that of conventional CABG using saphenous vein grafts.     

Optimal patency rates obtained in coronary artery grafting with circular vein grafts.

Twenty-two patients underwent coronary artery grafting with a circular vein graft comprising four or five distal coronary anastomoses. Postoperative angiographic evaluation showed patency in 90 (95.7 percent) of the 94 coronary anastomoses fashioned in this manner. All four occlusions occurred in the one patient whose graft comprised five anastomoses and was occluded beyond the first anastomosis on the right coronary artery (RCA). Eleven of the 94 anastomoses were made onto arteries with limited runoff. Blod flow averaged 214 ml. per minute (range 130 to 320) in the main portion of the graft and 59 ml. per minute (range 35 to 100) in the most distal segment. Flow doubled (averaged 403 ml. per minute) in the 11 grafts injected with papaverine. The technique of circular vein grafting is described in detail and potential pitfalls are outlined. The reasons for the high early patency rate are believed to be the following: (1) high flow in the proximal segment of the graft insuring patency of said segment, (2) termination on the left anterior descending (LAD) coronary artery providing good distal flow and patency. (3) diamond-shaped side-to-side anastomoses (SSA's) preventing angulation of the graft at these crucial points, and (4) nearly equidistant anchoring at the site of the multiple anastomoses giving the graft a smooth, even contour.     

Revascularization of Left Anterior Descending (LAD) Artery with In Situ Left Internal Thoracic Artery (LITA) and Coronary‐Coronary Free LITA Grafts: 12‐Year Patency

Abstract Background: We aim to present a patient with coronary‐coronary bypass grafting (CCBG), left anterior descending‐left anterior descending (LAD‐LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12‐year follow‐up angiogram to confirm the longest reported patency. Methods and Results: A 57‐year‐old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. Conclusions: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long‐term patency.     

Patterns of patency of 596 vein grafts up to seven years after aorta-coronary bypass.

The long-term behavior of vein grafts and their effect on the native circulation were studied by examining 596 vein grafts in 343 patients at a mean follow-up of 15.4 months, range zero to 84 months. Serial studies were performed on 27 patients with 38 grafts. The over-all graft patency rate was 84 per cent, and the rate after more than 5 years was 89 per cent. The patency rate in asymptomatic patients was 91 per cent compared with 81 per cent in the remainder. The patency of grafts attached distal to total occlusions was 82 per cent (78/82). The angle of origin of the grafts from the aorta did not appear to influence patency or the severity of intimal proliferative changes. In 76 patients with 126 grafts, pre- and postoperative cineangiograms were compared, and changes in the graft and underlying coronary artery classified as Groups 1 to to 6: Group 1, patent graft, bidirectional flow in the grafted vessel, proximal lesion unchanged; Group 2, patent graft, bidirectional flow, proximal lesion progressed to occlusion locally; Group 3; patent graft, distal flow only, occlusion of lesion and segment between graft and lesion; Group 4, graft occluded, native artery unaltered; Group 5, graft occluded, native artery now occluded at lesion and region of anastomosis; Group 6, new distal lesion. Results were as follows; Group 1, 58 per cent; Group 2, 21.2 per cent; Group 3, 5 per cent, Group 4, 12.5 per cent; Group 5, 2.5 per cent; and Group 6, 0.8 per cent. Native coronary arteries undergoing closure (Group 2) had lesions 95 per cent or greater in 93 per cent of patients. The rate of closure of ungrafted lesions was 2 per cent. We believe these results encourage the continued used of vein bypass grafts.     

Mid-term angiographic comparison of sequential and individual anastomosis techniques for diagonal artery

OBJECTIVE: The mid-term patency rates for individual and sequential grafts as coronary bypass conduits for diagonal arteries were angiographically compared; the impact of native coronary vessel and type of the conduit characteristics are investigated. METHODS: Between March 1992 and April 2000, we performed a total number of 811 distal anastomosis on diagonal arteries of left anterior descending (LAD) artery in 296 patients who underwent coronary artery bypass surgery (CABG) distal anastomosis in our clinic. The patients were divided into two groups in this prospective study. In group A (n = 195) individual anastomosis technique, in group B (n = 101) sequential anastomosis technique was chosen as the myocardial revascularization strategy. At an average of 49.4 +/- 13.2 months after coronary revascularization procedure coronary angiographies were evaluated. Individual and sequential grafting techniques were compared by graft patency rates. RESULTS: The patency rates of sequential conduits were markedly higher than those of individual conduits (66.7% vs. 89.2%, p = 0.0001). This difference was also clear in coronary arteries with poor quality and small (<1.5 mm) diameter (49.1% vs. 66.6%, p = 0.032). Also, the patency rates of sequential radial artery conduits were higher than sequential saphenous vein graft (SVG) conduits (sequential radial artery; 94.1%, sequential SVG; 85.3%, p = 0.043). CONCLUSIONS: Sequential grafting for diagonal artery is technically more demanding but the mid-term results are better than individual grafting especially in coronary arteries with poor quality. Using radial artery as a sequential graft increases the mid-term graft patency rates.     

Two cases of left main trunk lesion treated with coronary artery bypass grafting the proximal circumflex coronary artery (# 11)

Two cases are reported of coronary artery bypass graft (CABG) surgery to the proximal left circumflex artery (LCX) system and left anterior descending artery (LAD) system. Both patients suffered from unstable angina due to left main trunk (LMT) lesions and required semi-emergent coronary revascularization. In both cases, the obtuse marginal branch and postero-lateral branch were too small to be grafted, although there are the usual target branches in the LCX system. CABG to the proximal portion (# 11) of LCX in the atrioventricular groove using saphenous vein grafts was performed and good blood flow rates were seen intra-operatively. Both patients recovered uneventfully and had no recurrence of anginal attacks. Postoperative coronary angiography confirmed good graft patency and an adequate coronary blood supply. CABG to LCX (# 11) is feasible without special techniques or tools. This method seems to be useful in patients with LMT lesions or with proximal lesions of LCX in which the branches are too small to be grafted.     

Endarterectomy, vein patch, and mammary bypass of the anterior descending artery

Occasionally the left anterior descending (LAD) coronary artery contains such diffuse calcific atherosclerosis that an area suitable for distal anastomosis with the internal mammary artery (IMA) cannot be found. Additionally, the LAD of some patients contains multiple areas of stenosis, which would prevent free outflow from the IMA graft. In these cases the potentially increased operative risk of LAD endarterectomy is justified to avoid leaving poorly revascularized areas of anteroseptal heart. In an effort to provide the long-term patency benefits of IMA grafting for these patients without the technical difficulty of a lengthy IMA to LAD anastomosis, we have combined saphenous vein patch reconstruction with IMA bypass when LAD endarterectomy is required.     

A Modified Reconstruction Technique After Extended Anterior Descending Artery Endarterectomy

A bstract An increasing number of patients with advanced coronary artery disease and diffusely complex atherosclerotic lesions are referred for coronary artery bypass surgery (CABG). Under these circumstances, complete myocardial revascularization with an adequate distal runoff can only be achieved by extensive manual endarterectomy and a reconstructive procedure prior to conduit placement. Because of the numerous septal and diagonal branches of the left anterior descending artery (LAD), an extended and meticulous endarterectomy is warranted. Placement of the internal mammary artery (IMA) on such a widely opened vessel requires reconstruction with a vein patch and the IMA. A modified technique of extended manual endarterectomy, distal vein patch, and proximal IMA reconstruction and revascularization is described. This technique was used in six patients between October 1990 and December 1992 with 100% early survival. This technique is less time consuming and more importantly allows for a direct artery-to-artery anastomosis with the potential for a better long-term patency.     

Further Evaluation of the Circular Sequential Vein Graft Technique of Coronary Artery Bypass

Our study reports a series of circular sequential vein grafts in 21 patients with highly symptomatic triple-vessel coronary artery disease. Four or more distal anastomoses were done in each patient. Thirteen of the patients were restudied, and the results revealed a 97% patency rate for distal anastomoses (58 out of 60) at 4 to 13 months after operation. One patient died 2 months after operation. Postmortem examination revealed a desmoplastic, fibrotic reaction at the proximal anastomosis of the circular graft, with 3 of 4 distal anastomoses patent. Twenty of the 21 patients in this series are now alive with asymptomatic cardiac status 14 to 22 months after operation.The finding by Grondin and associates [1] of increased patency rate with this technique for distal anastomoses is confirmed. The circular sequential vein graft represents a particularly advantageous technique for patients in whom 4 to 6 distal anastomoses are needed for complete revascularization and in whom one or more vessels have limited runoff. The obvious disadvantage of this technique is that all distal anastomoses depend on a single proximal anastomosis.     

Results of Coronary Artery Bypass Grafting in Myocardial Bridging of Left Anterior Descending Artery

Background

We aimed to evaluate the graft patency rate following coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD) with proximal myocardial bridging (MB). While MB is generally a benign coronary abnormality, ischemia, stunning, and sudden death have been reported. In symptomatic patients with proximal LAD systolic compression of >50%, positive for ischemic noninvasive testing and noneffective optimal medical therapy, coronary intervention could be indicated. Few studies of CABG in myocardial bridging have been reported. The influence of high flow in coronaries with MB on graft patency is cause for concern.

Methods

We retrospectively studied 39 patients operated on for isolated MB of proximal LAD with >50% systolic compression. All patients were severely symptomatic despite optimal medical therapy and positive noninvasive tests for myocardial ischemia. CABG was performed through the midsternotomy with cardiopulmonary bypass and cardioplegia. Patients were divided into two groups: in 20 patients, LAD was bypassed with left internal mammary artery (LIMA) (Group 1) and in 19 patients with saphenous vein graft (SVG) (Group 2). All patients underwent follow‐up coronary angiography.

Results

Demographics and degree of systolic compression of the LAD were similar in both groups. There was no mortality or major morbidity. Freedom from angina was 68% in Group 1 and 94% in Group 2 at 18 months postoperatively (p = 0.58). Twelve LIMA grafts and three SVGs were found occluded (p = 0.002).

Conclusions

LIMA patency in myocardial bridging of the LAD can be low. SVGs should be considered in cases of CABG for myocardial bridging. doi: 10.1111/jocs.12101 (J Card Surg 2013;28:218–221)     

Reoperative off-pump coronary revascularization via left thoracotomy using the PAS-Port system to the descending thoracic aorta: report of a case

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.     

Sequential bypass on the beating heart can be achieved without compromising patient safety or regional myocardial blood flow

For some cardiac surgeons, operating on the beating heart is the preferred method of coronary revascularization. In an effort to minimize manipulation of the aorta, we have used, in addition to an internal mammary artery (IMA) graft to the left anterior descending (LAD) coronary artery, a sequential reversed saphenous vein graft (rSVG) to revascularize the lateral, inferior, and posterior myocardium with a single proximal aortic anastomosis. In this report, we retrospectively summarize a recent series of off-pump coronary bypass grafting (OPCABG) cases, including the evaluation of distal conduit blood flow. Between January 1, 2005, and January 1, 2007, a consecutive series of 175 patients underwent OPCABG with 1 IMA graft and 1 sequential rSVG performed by a single surgeon (RLQ). The average number of grafts/patient was 3.4 (range, 3-5). Flow rates were measured in each segment of the sequential graft using a Transonic Flowmeter (HT314, Transonic Systems Inc, Ithaca, NY). All patients were given PO clopidogrel (75 mg/d) for 6 weeks beginning on postoperative day #1. Mean flow through the distal segment of the sequential venous bypass was 36 ml/min, which was not significantly influenced by the number of proximal coronary anastomoses nor by the size of the proximal coronary bed. The 30-day mortality and stroke rate was 0% (0/175). The incidence of postoperative atrial fibrillation in those patients with normal baseline sinus rhythm was 29% (49/169). No postoperative myocardial infarctions [enzyme/electrocardiographic (ECG) criteria] nor renal failure requiring dialysis occurred. As the complexity of the surgical candidate continues to increase, less invasive approaches to coronary revascularization will prevail. The results of this retrospective study indicate that this technique is safe, and that regional coronary blood flow is not compromised by the creation of sequential anastomoses.     

Myocardial revascularization with the left internal thoracic artery Y graft configuration.

BACKGROUND: The proved long-term patency of the left internal thoracic artery (LITA) has made it the conduit of choice for myocardial revascularization. Maximal utilizable LITA length can be achieved by using a semiskeletonizing harvest technique. Expanded LITA use with sequential and Y graft techniques allows for a wider territory of myocardial revascularization. METHODS: A retrospective analysis of 30 patients undergoing coronary artery bypass surgery with a LITA-Y graft between December 1994 and November 1996 was performed. In selected patients the LITA was cut to length and anastomosed to the left anterior descending artery (LAD), with the redundant length of LITA used as a free graft to the lateral circumflex and diagonal systems. The proximal end of the free LITA was anastomosed to the in situ LITA to form the Y graft. Selection criteria included: a) minimal distal disease in the LAD and circumflex systems; and b) graftable circumflex branches proximal to the mid free wall of the left ventricle, allowing total revascularization of the left coronary system with the Y graft. RESULTS: Thirty patients (22 male, 8 female) underwent the LITA-Y graft procedure. There were no deaths or episodes of myocardial infarction. One patient required inotropic and intraaortic balloon pump support. Two patients with isolated coronary ostial stenosis developed recurrence of angina due to occlusion of the free limb of the LITA. CONCLUSIONS: In patients with suitable coronary artery anatomy, the LITA-Y graft can be successfully performed with good short-term outcome, but may be contraindicated in the management of isolated coronary ostial stenosis.     

Spontaneous recanalization of postoperative severe graft stenosis. What is the cause and prognosis of the "string sign" in the internal thoracic artery?

A 68-year-old female with unstable angina was treated surgically. She was referred to the surgical ward by cardiologists because of a diagnosis of unstable angina with three vessel disease. On a coronary angiogram (CAG), 90% stenoses were found in the left anterior descending coronary artery (LAD), circumflex (CX), and right coronary artery (RCA). She received elective coronary artery bypass grafting (CABG), in which the left internal thoracic artery (LITA) was anastomosed to the LAD and reversed saphenous vein grafts (SVG) were made to segment 12 of the CX, and segment 4PD of the RCA, respectively. The postoperative course was uneventful, but postoperative early graftgraphy revealed distal narrowing of the LITA graft as the so-called "string sign". However, one year post surgery, the LITA string sign was not found and its patency had markedly improved on the second graftgram. It is reported that the LITA "string sign" might cause late graft occlusion. However, this LITA graft evidently enlarged the size and increased the flow of the artery in proportion to myocardial blood demand. To our knowledge, it has not been reported that an in situ LITA string sign on postoperative early graftgram has disappeared in the late phase. We hypothesize that the LITA string sign might be caused by several different factors such as flow competition, spasm, and/or technical problems. In any event, the LITA string sign does not cause graft occlusion in the late postoperative period in every case.     

Off-pump redo coronary artery bypass grafting

BACKGROUND: Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique. METHODS: Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta. RESULTS: Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days. CONCLUSIONS: In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.     

Bilateral internal mammary artery for coronary revascularization. Early experience of 100 cases

One hundred cases are presented in which both right and left internal mammary artery (IMA) were used as coronary bypass grafts. Special indications were thrombosis of previous venous graft (14 cases), poor venous resources (10) and small-vessel (probe less than 1.5 mm) disease (34), but bilateral IMA was used also for routine revascularization (42 cases). The total 212 distal IMA anastomoses included 12 jump grafts, three free grafts and seven thrombendarterectomies. There were 3.8 distal anastomoses per patient, 2.1 with IMA and 1.7 with vein graft. The right IMA was preferably inserted into LAD and the left into diagonal or obtuse marginal coronary artery. Excessive postoperative bleeding was the only major complication attributable to bilateral IMA grafting in the 97 survivors of surgery. In routine revascularization the procedure involved minimal morbidity and no mortality. The superiority of the IMA as regards long-term patency is widely recognized. Since many thrombosed vein grafts will require replacement, we believe that bilateral IMA grafting will become common, and it is also an option when no suitable vein is available.     

Results of bypasses to the anterior tibial artery through the interosseous membrane

The purpose of the present study was to retrospectively evaluate the results of anatomically tunneled grafts to the anterior tibial artery for distal revascularization in terms of patency and limb salvage rates as well as local morbidity, which can lengthen the postoperative hospital stay. Twenty-three patients received 24 bypasses to the anterior tibial artery, with grafts tunneled through the interosseous membrane. The mean age was 67 years; 10 patients were diabetic, 12 were smokers, 9 presented with significant coronary artery disease, and 2 with chronic renal insufficiency. The donor vessel was the common femoral artery in 17 cases, the superficial femoral artery in 4, and the infra-articular popliteal artery in 3. The graft material consisted in the reversed saphenous vein in 4 cases, the non-reversed devalvulated ex situ saphenous vein in 11, composite polytetrafluoroethylene (PTFE) + inversed saphenous vein in 6, and PTFE alone in 3 cases. No postoperative mortality was observed, nor was there postoperative graft occlusion or need for major amputation. The average postoperative length of stay in the hospital was 9.7 days. Two local surgical wound complications were observed, which did not necessitate a postoperative hospital stay exceeding 15 days. Cumulative primary patency and limb salvage rates at 3 years were 50% and 70%, respectively. Anatomic tunneling of grafts to the anterior tibial artery yields patency and limb salvage rates comparable to those reported in the literature for distal bypasses and, considered overall, an acceptably low local morbidity and short hospital stay. Definitive superiority over externally tunneled grafts, however, is not definitely demonstrated by this study and should be prospectively tested. Received: 9 May 1997     

IMA-graft patency control by thermal coronary angiography during coronary bypass surgery.

Thermal coronary angiography (TCA) was evaluated for the intraoperative assessment of graft patency and flow in internal mammary artery (IMA) bypass grafts. TCA was performed in 210 patients undergoing 460 vein and 153 IMA bypass grafts after completion of the distal anastomoses. The IMA grafts and the recipient coronary arteries were delineated by the temperature differential between a cold epimyocardium and the perfusing warm blood after bulldog clamp release. TCA provided information about graft and anastomosis patency, initial flow patterns, and native coronary stenoses. TCA was performed in all studied IMA bypass grafts: 142 grafts were patent. Low flow but patency was observed in 24 IMA grafts and 11 IMA grafts showed no flow. Subsequently, 8 anastomotic failures and 3 proximal IMA graft occlusions were encountered. Based on these findings, 8 anastomoses were successfully revised and 7 additional vein grafts were added. One low flow IMA graft was not revised leading to postoperative ST elevation. Thirty-one distal native coronary stenoses were detected in the recipient LADs, 3 of which were not seen in the preoperative cineangiogram. In 20 instances, TCAs were obscured by an excess of fat or myocardium impeding image analysis. In 8 cases, TCA results were confirmed by conventional angiography postoperatively showing an excellent correlation in all cases. We conclude that intraoperative TCA demonstrates early IMA graft function and initial flow patterns. During our study, TCA documented a 7.2% IMA graft early failure rate. Intraoperative decision making was aided by TCA in 9.2% of all IMA grafts; this confirmed the clinical relevance of TCA.     

Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG

Objectives: Arterial grafts have been used to achieve better long-term results and improve graft patency in coronary artery bypass grafting. Composite graft was proposed to overcome inconveniences of proximal anastomoses to the aorta and increase the use and surgical options of arterial grafts. However, lack of prospective randomized studies with this kind of grafts is evident. We compare the results of composite Y-grafts of the radial artery (RA) and the right gastroepiploic artery (RGEA) proximally anastomosed to the left internal thoracic artery (LITA) for CABG, evaluated through angiography, in a prospective randomized study. Methods: Between August 1998 and November 1999, 60 patients were randomly divided into two groups: group I (GI) received RGEA graft and group II (GII), RA graft. LITA was used to graft the left anterior descending artery and RGEA or RA was placed to obtuse marginal or first diagonal branch. The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had ≥75% proximal stenosis and diameter ≥1.5 mm. Results: GI and GII preoperative data were similar, 63 distal anastomoses were performed with the LITA, 32 with the RA and 32 with the RGEA. There were two perioperative deaths (3.3%), one in each group, none related to cardiac causes. Four (6.6%) q-wave myocardial infarctions were found and two (3.3%) patients showed low cardiac output syndrome. Angiography was performed in all surviving patients from the 8th to 15th postoperative day and showed a patency rate of 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025).Conclusions: Radial artery had better early results than right gastroepiploic artery. Use of the LITA as inflow graft seems not to affect its good patency. Use of the RGEA as composite graft should not be encouraged. Long-term follow-up with objective investigation and randomized trials is required to confirm better results of composite conduits.     

Adjunct endarterectomy of the left anterior descending coronary artery

During a three-year period, complete revascularization of diffusely diseased left anterior descending (LAD) coronary arteries was accomplished by extensive endarterectomy in conjunction with bypass grafting in 37 patients in whom conventional bypass was not feasible. This group constituted 7.0% of all patients undergoing nonemergency coronary revascularization during this period. The left internal mammary artery was used to bypass the endarterectomized LAD artery in 22 patients. There was 1 (2.7%) operative death and 1 perioperative myocardial infarction. At follow-up, which was 100% with a mean of 41.4 months, all endarterectomy patients were in New York Heart Association Functional Class I or II. Twenty-four endarterectomy patients underwent first-pass radionuclide angiographic stress testing 20 months after operation. Twenty patients (83%) had excellent postoperative exercise tolerance, achieving 5 to 7 mets on treadmill testing. Left ventricular functional reserve was preserved, as evidenced by an increase of global ejection fraction from 48 +/- 15% at rest to 59 +/- 18% (p less than 0.005) with exercise. A similar increase was measured in the proximal and distal anterior wall segmental ejection fractions. No difference in response to exercise was found between the internal mammary artery and the vein graft groups. Thus, complete revascularization of the diffusely diseased LAD artery can be accomplished by adjunct endarterectomy without added morbidity or mortality and with excellent functional results.