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Rosenfeld ES, Trachiotis GD, Napolitano MA, Sparks AD, Wendt D, Kieser TM, Puskas JD, DiGiammarco G, Taggart DP. Intraoperative transit-time flow measurement and high-frequency ultrasound in coronary artery bypass grafting: impact in off versus on-pump, arterial versus venous grafting and cardiac territory grafted. Eur J Cardiothorac Surg 2021; 61:204-213. [PMID: 34166508 DOI: 10.1093/ejcts/ezab239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/13/2021] [Accepted: 04/13/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Despite society guideline recommendations, intraoperative high-frequency ultrasound (HFUS) and transit-time flow measurement (TTFM) use in coronary artery bypass grafting (CABG) has not been widely adopted worldwide. This retrospective review of the REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study assesses the impact of protocolled high-frequency ultrasound/TTFM use in specific technical circumstances of CABG. METHODS Three REQUEST study sub-analyses were examined: (i) For off-pump (OPCAB) versus on-pump (ONCAB) procedures: strategy changes from preoperative plans for the aorta, conduits, coronary targets and graft revisions; and for all REQUEST patients, revision rates in: (ii) arterial versus venous grafts; and (iii) grafts to different cardiac territories. RESULTS Four hundred and two (39.6%) of 1016 patients undergoing elective isolated CABG for multivessel disease underwent OPCAB procedures. Compared to ONCAB, OPCAB patients experienced more strategy changes regarding the aorta [14.7% vs 3.4%; odds ratios (OR) = 4.03; confidence interval (CI) = 2.32-7.20], less regarding conduits (0.2% vs 2.8%; OR = 0.09; CI = 0.01-0.56), with no differences in coronary target changes or graft revisions (4.1% vs 3.5%; OR = 1.19; CI = 0.78-1.81). In all REQUEST patients, revisions were more common for arterial versus venous grafts (4.7% vs 2.4%; OR = 2.05; CI = 1.29-3.37), and inferior versus anterior (5.1% vs 2.9%; OR = 1.77; CI = 1.08-2.89) and lateral (5.1% vs 2.8%; OR = 1.83; CI = 1.04-3.27) territory grafts. CONCLUSIONS High-frequency ultrasound/TTFM use differentially impacts strategy changes and graft revision rates in different technical circumstances of CABG. Notably, patients undergoing OPCAB experienced 4 times more changes related to the ascending aorta than ONCAB patients. These findings may indicate where intraoperative assessment is most usefully applied. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT02385344.
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Affiliation(s)
- Ethan S Rosenfeld
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Michael A Napolitano
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Teresa M Kieser
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - Gabriele DiGiammarco
- Department of Cardiac Surgery, Università degli Studi "G. D'Annunzio" Chieti-Pescara, Chieti, Italy
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Chan SM, Brahmandam A, Cardella JA, Elefteriades J, Setaro JF, Mangi AA, Ochoa Chaar CI. Aortic remodeling and competitive flow after surgical treatment of aortic dissection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:404-407. [PMID: 34278070 PMCID: PMC8261546 DOI: 10.1016/j.jvscit.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022]
Abstract
Aortic remodeling after dissection is poorly understood and remains a focus of current research. In the present report, we have described the cases of two patients with acute lower extremity ischemia related to malperfusion from aortic dissection treated with extra-anatomic axillobifemoral bypass. During long-term follow-up, aortic remodeling led to reinstitution of flow through the native aorta. This resulted in competitive flow, leading to complete thrombosis of the extra-anatomic conduits. These cases highlight the occurrence of spontaneous aortic recanalization and subsequent competitive flow, two vascular phenomena that are not well understood but can significantly affect patient outcomes.
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Affiliation(s)
| | - Anand Brahmandam
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Jonathan A Cardella
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - John Elefteriades
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - John F Setaro
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Abeel A Mangi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Influence of Diabetes on Long-Term Coronary Artery Bypass Graft Patency. J Am Coll Cardiol 2017; 70:515-524. [DOI: 10.1016/j.jacc.2017.05.061] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/20/2022]
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4
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Numerical modeling of hemodynamics scenarios of patient-specific coronary artery bypass grafts. Biomech Model Mechanobiol 2017; 16:1373-1399. [DOI: 10.1007/s10237-017-0893-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/27/2017] [Indexed: 11/26/2022]
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Mao B, Wang W, Zhao Z, Zhao X, Li L, Zhang H, Liu Y. On the relationship between competitive flow and FFT analysis of the flow waves in the left internal mammary artery graft in the process of CABG. Biomed Eng Online 2016; 15:129. [PMID: 28155726 PMCID: PMC5259820 DOI: 10.1186/s12938-016-0260-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During coronary artery bypass grafting (CABG), the ratio of powers of the fundamental frequency and its first harmonic (F0/H1) in fast Fourier transformation (FFT) analysis of the graft's flow waves has been used in the field of evaluation of the patency in anastomosis. But there is no report about using the FFT method to evaluate the magnitude of competitive flow. This study is aiming at exploring the relationship between competitive flow and FFT analysis of the flow waves in left internal mammary artery (LIMA) graft, and finding a new method to evaluate the magnitude of competitive flow. METHODS At first, establishing the CABG multiscale models of different stenosis in left anterior descending artery (LAD) to get different magnitude of competitive flows. Then, calculating the models by ANSYS-CFX and getting the flow waves in LIMA. Finally, analyzing the flow waves by FFT method and comparing the FFT results with the magnitude of competitive flow. RESULTS There is no relationship between competitive flow and F0/H1. As for F0/H2 and F0/H3, they both increase with the reduction of the stenosis in LAD. But the increase of F0/H3 is not obviously enough and it can't identify the significant competitive flow clearly, so it can't be used as the evaluation index. It is found that F0/H2 increases obviously with the increase of the competitive flow and can identify the significant competitive flow. CONCLUSION The FFT method can be used in the evaluation of competitive flow and the F0/H2 is the ideal index. High F0/H2 refers to the significant competitive flow. This method can be used during CABG to avoid the risk of competitive flow.
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Affiliation(s)
- Boyan Mao
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Wenxin Wang
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Zhou Zhao
- Peking University People’s Hospital, Beijing, China
| | - Xi Zhao
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Lanlan Li
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Huixia Zhang
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Youjun Liu
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
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Ferguson Jr TB. Physiology of in-situ arterial revascularization in coronary artery bypass grafting: Preoperative, intraoperative and postoperative factors and influences. World J Cardiol 2016; 8:623-637. [PMID: 27957249 PMCID: PMC5124721 DOI: 10.4330/wjc.v8.i11.623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/29/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
Surgical revascularization with coronary artery bypass grafting (CABG) has become established as the most effective interventional therapy for patients with moderately severe and severe stable ischemic heart disease (SIHD). This recommendation is based on traditional 5-year outcomes of mortality and avoidance of myocardial infarction leading to reintervention and/or cardiac death. However, these results are confounded in that they challenge the traditional CABG surgical tenets of completeness of anatomic revascularization, the impact of arterial revascularization on late survival, and the lesser impact of secondary prevention following CABG on late outcomes. Moreover, the emergence of physiologic-based revascularization with percutaneous cardiovascular intervention as an alternative strategy for revascularization in SIHD raises the question of whether there are similar physiologic effects in CABG. Finally, the ongoing ISCHEMIA trial is specifically addressing the importance of the physiology of moderate or severe ischemia in optimizing therapeutic interventions in SIHD. So it is time to address the role that physiology plays in surgical revascularization. The long-standing anatomic framework for surgical revascularization is no longer sufficient to explain the mechanisms for short-term and long-term outcomes in CABG. Novel intraoperative imaging technologies have generated important new data on the physiologic blood flow and myocardial perfusion responses to revascularization on an individual graft and global basis. Long-standing assumptions about technical issues such as competitive flow are brought into question by real-time visualization of the physiology of revascularization. Our underestimation of the impact of Guideline Directed Medical Therapy, or Optimal Medical Therapy, on the physiology of preoperative SIHD, and the full impact of secondary prevention on post-intervention SIHD, must be better understood. In this review, these issues are addressed through the perspective of multi-arterial revascularization in CABG, which is emerging (after 30 years) as the “standard of care” for CABG. In fact, it is the physiology of these arterial grafts that is the mechanism for their impact on long-term outcomes in CABG. Moreover, a better understanding of all of these preoperative, intraoperative and postoperative components of the physiology of revascularization that will generate the next, more granular body of knowledge about CABG, and enable surgeons to design and execute a better surgical revascularization procedure for patients in the future.
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Computational study of the risk of restenosis in coronary bypasses. Biomech Model Mechanobiol 2016; 16:313-332. [DOI: 10.1007/s10237-016-0818-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/09/2016] [Indexed: 10/21/2022]
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Sabik JF. Should Coronary Artery Bypass Grafting Be Performed in Patients With Moderate Stenosis of the Left Anterior Descending Coronary Artery? Circulation 2016; 133:111-3. [PMID: 26647081 DOI: 10.1161/circulationaha.115.020084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph F Sabik
- From the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, OH.
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Buch AN, Chen C, Ferguson TB. Revascularization for stable ischemic heart disease: are there new parallels between percutaneous coronary intervention and coronary artery bypass grafting? Interv Cardiol 2015. [DOI: 10.2217/ica.14.76] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Swillens A, De Witte M, Nordgaard H, Løvstakken L, Van Loo D, Trachet B, Vierendeels J, Segers P. Effect of the degree of LAD stenosis on "competitive flow" and flow field characteristics in LIMA-to-LAD bypass surgery. Med Biol Eng Comput 2012; 50:839-49. [PMID: 22707228 DOI: 10.1007/s11517-012-0927-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 05/28/2012] [Indexed: 11/30/2022]
Abstract
The long-term patency of the left internal mammary artery (LIMA) in left anterior descending (LAD) coronary stenosis bypass surgery is believed to be related to the degree of competitive flow between the LAD and LIMA. To investigate the effect of the LAD stenosis severity on this phenomenon and on haemodynamics in the LIMA and anastomosis region, a numerical LIMA-LAD model was developed based on 3D geometric (obtained from a cast) and hemodynamic data from an experimental pig study. Proximal LAD pressure was used as upstream boundary condition. The model counted 13 outlets (12 septal arteries and the distal LAD) where flow velocities were imposed in systole, while myocardial conductance was imposed in diastole via an implicit scheme. LAD stenoses of 100 (total occlusion), 90, 75 and 0 % area reduction were constructed. Low degree of LAD stenosis was associated with highly competitive flow and low wall shear stress (WSS) in the LIMA, an unfavourable hemodynamic regime which might contribute to WSS-related remodelling of the LIMA and suboptimal long-term LIMA bypass performance.
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 575] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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12
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Zacho M, Damgaard S, Lilleoer NT, Kelbaek H, Steinbrüchel D, Nielsen MB, Kofoed KF. Long-term internal thoracic artery bypass graft patency and geometry assessed by multidetector computed tomography. Int J Cardiovasc Imaging 2011; 28:1577-83. [DOI: 10.1007/s10554-011-9962-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 10/07/2011] [Indexed: 10/16/2022]
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Yi G, Youn YN, Song SW, Yoo KJ. Off-Pump Right Coronary Artery Bypass With Saphaneous Vein or In-Situ Right Internal Thoracic Artery. Ann Thorac Surg 2010; 89:717-22. [DOI: 10.1016/j.athoracsur.2009.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 11/25/2009] [Accepted: 12/01/2009] [Indexed: 10/19/2022]
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Handa T, Katare RG, Nishimori H, Wariishi S, Fukutomi T, Yamamoto M, Sasaguri S, Sato T. New device for intraoperative graft assessment: HyperEye charge-coupled device camera system. Gen Thorac Cardiovasc Surg 2010; 58:68-77. [PMID: 20155342 DOI: 10.1007/s11748-009-0536-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 09/03/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Our institution developed a new color chargecoupled device (CCD) camera system (HyperEye system) for intraoperative indocyanine green (ICG) angiography. The device consists of a combination of custommade optical filters and an ultra-high-sensitive CCD image sensor with non-Bayer color filter array (i.e., HyperEye technology), which can detect simultaneously color and near-infrared (NIR) rays from 380 to 1200 nm. Here, we demonstrate intraoperative graft assessment using the HyperEye system. METHODS We investigated the intraoperative graft patency using both the HyperEye system and transittime flowmetry (TFM) in 51 patients between April 2007 and April 2009 while ICG dye was injected through a central venous catheter. Each patient signed a consent form before the surgery. RESULTS We obtained intraoperative graft flows and images in 189 anastomoses of 153 grafts. Both the HyperEye system and TFM indicated the patency of the grafts in 129 grafts. Both the HyperEye system and TFM detected the abnormality of the graft in seven grafts. For the competitive flows, the HyperEye system captured to-and-fro flow fluorescence and TFM detected the retrograde waveform in 16 grafts. On the other hand, although TFM indicated the patency of the graft, the HyperEye system suspected nonoccluded graft failure in seven grafts. In contrast, although TFM detected a mean flow of <10 ml/min, the HyperEye system captured the patent perfusion fluorescence in four grafts. CONCLUSION The HyperEye system can visualize any structural and functional failures. Our findings suggest that this device could become a useful tool for intraoperative graft assessment.
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Affiliation(s)
- Takemi Handa
- Department of Surgery 2, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan.
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Berger A, MacCarthy PA, Siebert U, Carlier S, Wijns W, Heyndrickx G, Bartunek J, Vanermen H, De Bruyne B. Long-term patency of internal mammary artery bypass grafts: relationship with preoperative severity of the native coronary artery stenosis. Circulation 2005; 110:II36-40. [PMID: 15364835 DOI: 10.1161/01.cir.0000141256.05740.69] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Internal mammary artery conduits (IMA) have an excellent long-term patency rate. Nevertheless, graft closure does occur and significantly limits future revascularization options. We sought to investigate the relationship between the long-term patency of IMA with clinical and angiographic parameters. Particularly, the preoperative degree of stenosis of the relevant bypassed coronary vessel was assessed to analyze the importance of chronic competitive flow on the arterial graft closure rate. METHODS AND RESULTS Consecutive patients in whom occlusion of at least 1 IMA had been documented at angiography (OCC group) were compared with a group of patients with patent IMA grafts (PAT group). The degree of stenosis in the native coronary artery on which the IMA was placed was analyzed by off-line quantitative coronary angiography. Multivariate stepwise logistic regression was used to identify independent clinical and angiographic predictors of occlusion. The OCC group comprised 96 patients (67+/-10 years) with 103 native bypassed arteries analyzed. The PAT group comprised 127 patients (69+/-8 years) with 170 native bypassed arteries analyzed. Both groups were similar except for gender (42% versus 32% female; P=0.04), height (166+/-8 versus 169+/-8 cm; P=0.006), minimum lumen diameter (0.76+/-0.7 versus 0.51+/-0.5; P=0.001), and diameter stenosis of the native artery (73+/-25% versus 84+/-16%; P<0.0001) in OCC versus PAT, respectively. In the multivariate analysis, only percent diameter stenosis was an independent and statistically significant predictor for graft patency. Among IMA placed on coronary arteries with a diameter of stenosis <50% (n=28), the occlusion rate was very high (79%). CONCLUSIONS The degree of stenosis in the native vessel is a major predictor of internal mammary artery bypass graft patency. The association between nonsignificant stenosis of the native artery and high occlusion rate of the arterial bypass conduit raises concerns about the use of IMA in the treatment of native vessels with only mild or moderate stenosis.
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Sabik JF, Lytle BW, Blackstone EH, Houghtaling PL, Cosgrove DM. Comparison of Saphenous Vein and Internal Thoracic Artery Graft Patency by Coronary System. Ann Thorac Surg 2005; 79:544-51; discussion 544-51. [PMID: 15680832 DOI: 10.1016/j.athoracsur.2004.07.047] [Citation(s) in RCA: 264] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND We sought to compare saphenous vein and internal thoracic artery graft patency by coronary system. METHODS From 1972 to 1999, 50,278 patients underwent primary coronary surgery; subsequently, 4,333 had angiography of 2,121 internal thoracic artery and 8,733 saphenous vein grafts. Longitudinal analysis was used to model graft occlusion and identify risk factors. Using the model, patency was calculated twice for each graft and compared first as if an internal thoracic artery, and second as if a saphenous vein, were used. RESULTS Unadjusted 1-, 5-, and 10-year patency was 93%, 88%, and 90% for internal thoracic arteries and 78%, 65%, and 57% for saphenous veins. At 10 years, internal thoracic arteries were more likely than saphenous veins to be patent to left anterior descending in 99.1% of cases, to diagonals in 98.3%, to circumflex in 98.3%, to posterior descending artery in 98.5%, and to right coronary arteries in 82.5%. For right coronary arteries, saphenous vein patency was equivalent to or better than internal thoracic artery patency early after surgery. However, by 10 years, internal thoracic artery patency was better in right coronary arteries with 70% stenosis or greater. At all times after surgery and all levels of clinically important coronary stenosis, internal thoracic artery patency surpassed saphenous vein patency in grafts to the left anterior descending, diagonal, circumflex, and posterior descending arteries. CONCLUSIONS Internal thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed right coronary arteries. When bypassing right coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.
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Affiliation(s)
- Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Bolotin G, Kypson AP, Nifong LW, Chitwood WR. A technique for evaluating competitive flow for intraoperative decision making in coronary artery surgery. Ann Thorac Surg 2004; 76:2118-20. [PMID: 14667667 DOI: 10.1016/s0003-4975(03)00652-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The effect of native coronary competitive flow on the patency of arterial and saphenous vein grafts is controversial. We use a simple intraoperative technique to evaluate competitive flow that allows us to make informed intraoperative decisions regarding anastomotic quality, vessel runoff, and competing native coronary blood flow.
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Affiliation(s)
- Gil Bolotin
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.
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Sabik JF, Lytle BW, Blackstone EH, Khan M, Houghtaling PL, Cosgrove DM. Does competitive flow reduce internal thoracic artery graft patency? Ann Thorac Surg 2003; 76:1490-6; discussion 1497. [PMID: 14602274 DOI: 10.1016/s0003-4975(03)01022-1] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In coronary arteries with moderate stenosis, competitive flow may lead to internal thoracic artery (ITA) graft occlusion. The goals of this study were to determine if competitive flow reduces ITA patency, and if there is a degree of coronary stenosis below which ITAs should not be used. METHODS From 1972 to 1999, 50,278 patients underwent primary coronary artery bypass grafting (CABG). Of these, 2,002 had at least one ITA graft and postoperative angiography before coronary reintervention; 2,999 angiograms of 2,121 ITAs were made. Time-related ITA occlusion was modeled using longitudinal analysis to identify its risk factors while accounting for lack of independence introduced by repeated angiography and multiple ITA anastomoses per patient. Proximal coronary stenosis (maximum preoperative stenosis between ITA anastomosis and aorta) was the surrogate for competitive flow. RESULTS Unadjusted ITA patency was 93%, 89%, 90%, and 92% at 1, 5, 10, and 15 years after CABG. Risk factors associated with ITA occlusion were lesser degree of proximal coronary stenosis (p < 0.0001); longer time from CABG in grafts to non-left anterior descending coronary arteries (p < 0.0001); female sex (p = 0.0003); later date of CABG (p = 0.01); right ITA (p < 0.0001); and smoking (p < 0.0001). In all arteries, as preoperative proximal coronary stenosis decreased, ITA patency declined; however, at no degree of stenosis was there a sharp decline. CONCLUSIONS Internal thoracic artery patency decreases as coronary competitive flow increases. However, the nature of this relationship indicates ITAs should not be abandoned at moderate grades of stenosis.
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Affiliation(s)
- Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Gaudino M, Alessandrini F, Nasso G, Bruno P, Manzoli A, Possati G. Severity of coronary artery stenosis at preoperative angiography and midterm mammary graft status. Ann Thorac Surg 2002; 74:119-21. [PMID: 12118741 DOI: 10.1016/s0003-4975(02)03614-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the correlation between the midterm angiographic results of mammary artery grafts and the preoperative stenosis of the target vessel. METHODS We analyzed preoperative and postoperative angiograms of 93 patients who underwent postoperative midterm (> or = 3 years) angiograms of an internal mammary artery (IMA) to left anterior descending artery graft for clinical or study purposes. Patients were divided into three groups on the basis of the percentage of the coronary artery stenosis at preoperative angiography: < 70%, 70% to 90%, and > 90% stenosis. RESULTS Preoperative characteristics were similar in the three groups. The overall incidence of IMA occlusion was 19% in the entire population, without significant differences between groups (19% versus 29% versus 14%). The mean mammary artery diameter significantly increased in direct proportion to the severity of the coronary stenosis (2.0 +/- 0.2 mm in the < 70% versus 2.5 +/- 0.3 mm in the 70% to 90% and 2.7 +/- 0.4 mm in the > 90% series; p < 0.05). CONCLUSIONS Chronic native competitive flow does not significantly affect midterm graft status but does influence mammary graft diameter.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiac Surgery, Catholic University, Rome, Italy.
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21
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Maniar HS, Sundt TM, Barner HB, Prasad SM, Peterson L, Absi T, Moustakidis P. Effect of target stenosis and location on radial artery graft patency. J Thorac Cardiovasc Surg 2002; 123:45-52. [PMID: 11782755 DOI: 10.1067/mtc.2002.118686] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the effect of target vessel characteristics on radial artery patency when used as a composite T graft. METHODS Between October 1993 and March 2001, 1022 patients underwent coronary bypass with the internal thoracic artery-radial artery composite T graft. Of these, angiography has been performed on 109 patients at a mean 27.1 months (range, 2-70 months) postoperatively for symptoms of ischemia. By means of Cox proportional hazard models, the relationships between anastomotic patency and target vessel location, proximal stenosis, target diameter, and quality were assessed. RESULTS A total of 231 radial artery anastomoses were evaluated. The mean stenosis for patent anastomoses was 82% compared with 71% for occluded anastomoses (P <.001). Anastomotic patency for targets with moderate stenosis (< or = 70%) was worse than that for vessels with critical stenosis (> or = 90%; relative risk, 1.7; 95% confidence interval, 1.3-2.2; P <.001). Patency for targets of the right coronary artery was statistically inferior to that for targets of the left anterior descending artery (relative risk, 1.8; 95% confidence interval, 1.2-2.9; P =.01) and bordered on significance versus that for the circumflex artery distribution (relative risk, 1.6; 95% confidence interval, 1.0-2.8; P =.06). When directed toward critically stenosed targets of the left anterior descending or circumflex arteries, radial artery patency was not statistically different that that of the internal thoracic artery (P =.19). CONCLUSION Radial artery patency is sensitive to both target location and proximal target stenosis. Selective use of the radial artery to targets of the left anterior descending and circumflex distributions remains encouraging. Radial artery grafts to targets of the right coronary artery or those with moderate stenosis appear to be at particularly high risk of failure.
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Affiliation(s)
- Hersh S Maniar
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO, USA
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22
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Bertolotti C, Deplano V, Fuseri J, Dupouy P. Numerical and experimental models of post-operative realistic flows in stenosed coronary bypasses. J Biomech 2001; 34:1049-64. [PMID: 11448697 DOI: 10.1016/s0021-9290(01)00027-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
By means of both experimental and finite element methods, we simulated three-dimensional unsteady flows through coronary bypass anastomosis. The host artery includes a stenosis shape located at two different distances of grafting. The inflow rates are issued from in vivo measurements in patients who had undergone coronary bypass surgery a few days before. We provide a comparison between experimental and numerical velocity profiles coupled with the numerical analysis of spatial and temporal wall shear stress evolution. The interaction between the graft and coronary flows has been demonstrated. The phase inflow difference can partly be responsible for specific flow phenomena: jet deflection towards a preferential wall or feedback phenomenon that causes the flapping of the post-stenotic jet during the cardiac cycle. In conclusion, we showed the sensitivity of these typical flows to distance of grafting, inflows waveforms but also to their phase difference.
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Affiliation(s)
- C Bertolotti
- IRPHE UMR no 6594/ESM2 Laboratoire de Biomécanique Cardiovasculaire Technopôle de Château Gombert, 13451 Cedex 20, Marseille, France
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