1
|
de Winter EP, Wilschut ED, Plasmans K, Eefting DE, van der Steenhoven TJ, Putter H, Rotmans JI, van der Bogt KEA. Intraoperative Transit Time Flow Measurement Predicts Maturation of Radiocephalic Arteriovenous Fistulas. J Vasc Surg 2024:S0741-5214(24)00405-1. [PMID: 38432488 DOI: 10.1016/j.jvs.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20-50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFM) on AVF maturation failure. METHODS In this retrospective cohort study, the intraoperative blood flow, measured using TTFM, was compared to AVF maturation after 6 weeks in 55 patients. Due to its significantly higher prevalence and risk of non-maturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cut-off point for high versus low intraoperative blood flow was determined for RCAVFs, using an ROC curve. RESULTS The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cut-off point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared to patients with a higher intraoperative blood flow (P < .001). CONCLUSION The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF non-maturation 6 weeks after surgery. For RCAVFs, a cut-off point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.
Collapse
Affiliation(s)
- E P de Winter
- Haaglanden Medical Centre, the Hague, the Netherlands,; Leiden University Medical Centre, Leiden, the Netherlands
| | - E D Wilschut
- Haaglanden Medical Centre, the Hague, the Netherlands
| | - K Plasmans
- Haaglanden Medical Centre, the Hague, the Netherlands
| | - D E Eefting
- Haaglanden Medical Centre, the Hague, the Netherlands,; Leiden University Medical Centre, Leiden, the Netherlands,; University Vascular Center Leiden, The Hague, The Netherlands
| | - T J van der Steenhoven
- Haaglanden Medical Centre, the Hague, the Netherlands,; University Vascular Center Leiden, The Hague, The Netherlands
| | - H Putter
- Leiden University Medical Centre, Leiden, the Netherlands
| | - J I Rotmans
- Leiden University Medical Centre, Leiden, the Netherlands
| | - K E A van der Bogt
- Haaglanden Medical Centre, the Hague, the Netherlands,; Leiden University Medical Centre, Leiden, the Netherlands,; University Vascular Center Leiden, The Hague, The Netherlands.
| |
Collapse
|
2
|
Guo FW, Chen H, Dong YL, Shang JN, Ruan LT, Yan Y, Song Y. The Value of Left Internal Mammary Artery Flow Velocity in Predicting the Prognosis of Patients After Coronary Artery Bypass Grafting. Cardiol Res 2023; 14:396-402. [PMID: 37936630 PMCID: PMC10627374 DOI: 10.14740/cr1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Background The purpose of this study was to explore the value of the left internal mammary artery flow velocity (LIMAV) measured by ultrasound before coronary artery bypass grafting (CABG) in predicting the prognosis of patients after left internal mammary artery (LIMA) bypass grafting. Methods One hundred and four patients who underwent CABG with LIMA as the bridge vessel in the cardiovascular surgery department of our hospital between May 2018 and June 2019 were selected. All patients underwent transthoracic Doppler ultrasonography to measure LIMAV preoperatively. Intraoperatively, mean graft flow (MGF) and pulsatility index (PI) of the LIMA bridge were measured using transit time flow measurement (TTFM). The primary endpoint event in this study was cardiac death within 18 months after surgery. Results The Cox survival analysis showed that the MGF, the LIMAV and left ventricular ejection fraction (LVEF) were risk factors for death after CABG. The cut-offs of MGF, LIMAV and LVEF for the prediction of death after CABG were ≤ 14 mL/min (area under the curve (AUC): 0.830; sensitivity: 100%; specificity: 65.6%), ≤ 60 cm/s (AUC: 0.759; sensitivity: 65.5%; specificity: 85.3%), and ≤ 44% (AUC: 0.724; sensitivity: 50%; specificity: 88.5%), respectively. Compared with the use of MGF, MGF + LIMAV, combination of the MGF + LIMAV + LVEF (AUC: 0.929; sensitivity: 100%; specificity: 81.1%) resulted in a stronger predictive value (MGF vs. MGF + LIMAV + LVEF: P = 0.02). Conclusion LIMAV measured by preoperative transthoracic ultrasound combined with intraoperative MGF and LVEF may have a greater value in predicting patients' risk of cardiac death after CABG.
Collapse
Affiliation(s)
- Feng Wei Guo
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Hong Chen
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Ya Ling Dong
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Jia Nan Shang
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Li Tao Ruan
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Yang Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Yan Song
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| |
Collapse
|
3
|
Daubenspeck DK, Balkhy HH, Jeevanandam V, Chaney MA. Commentary: You want to do WHAT with my patient?!? J Thorac Cardiovasc Surg 2023; 165:1202-1203. [PMID: 34563369 DOI: 10.1016/j.jtcvs.2021.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Danisa K Daubenspeck
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Ill
| | - Husam H Balkhy
- Robotic and Minimally Invasive Cardiac Surgery, Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Ill
| | - Valluvan Jeevanandam
- Cardiac Surgery, Section of Cardiac Surgery, Department of Surgery, Heart and Vascular Center, University of Chicago Medical Center, Chicago, Ill
| | - Mark A Chaney
- Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Ill.
| |
Collapse
|
4
|
Ramírez JK, Nafeh-Abi-Rezk M, Tamargo-Barbeito TO, Colao-Jiménez Y, García-Nocetti DF, Contreras-Arvizu JA. FluxCABG: flujometría intraoperatoria en la cirugía de revascularización miocárdica como factor pronóstico de eventos cardiacos mayores. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
5
|
Trachiotis GD, Napolitano MA, Rosenfeld ES, Taggart DP. Intraoperative Graft Patency Assessment: Time to Recognize the Elephant Outside the Operating Room? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:223-226. [PMID: 34002644 DOI: 10.1177/15569845211015892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory D Trachiotis
- 9813919986 Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, USA
| | - Michael A Napolitano
- 9813919986 Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, USA.,8367 Department of Surgery, George Washington University, Washington, DC, USA
| | - Ethan S Rosenfeld
- 9813919986 Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, USA.,8367 Department of Surgery, George Washington University, Washington, DC, USA
| | - David P Taggart
- 6396 Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, UK
| |
Collapse
|
6
|
Patient and haemodynamic factors affecting intraoperative graft flow during coronary artery bypass grafting: an observational pilot study. Sci Rep 2020; 10:12968. [PMID: 32737380 PMCID: PMC7395102 DOI: 10.1038/s41598-020-69924-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
Transit-time flow measurement (TTFM) is frequently used to evaluate intraoperative quality control during coronary artery bypass grafting (CABG) and has the ability to assess graft failure intraoperatively. However, perioperative factors affecting TTFM during CABG remain poorly understood. Patients who underwent CABG at a single institution between July 2016 and May 2018 were prospectively evaluated. TTFM and blood viscosity were measured haemodynamically, while mean flow (mL/min), pulsatility index, and diastolic filling were recorded. Arterial blood gas was analysed immediately after left internal mammary artery to left descending artery anastomosis and before sternal closure. Factors associated with TTFM were assessed using multiple linear regression analysis. We evaluated 57 of the 62 patients who underwent CABG during the study period, including 49 who underwent off-pump and 8 who underwent on-pump surgeries. Blood viscosity was not significantly associated with TTFM (p > 0.05). However, TTFM was significantly associated with body mass index, systolic blood pressure, and cardiac index (p < 0.05 each). In conclusion, maintaining the SBP in the perioperative period and maintaining the CI with inotropic support or fluid resuscitation can be important in improving blood flow of graft vessels after surgery.
Collapse
|
7
|
Xie J, Xie DX, Gan YR, Li J, Wang YZ, Kou ZK, Mao R, Liang TX, Zhang YL. The curative effect of synthetic treatment for refractory acute myocardial infarction. J Thorac Dis 2018; 10:1732-1737. [PMID: 29707327 DOI: 10.21037/jtd.2018.03.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aims to investigate the curative effect of synthetic treatment for refractory acute myocardial infarction (AMI). Methods A total of 76 patients with coronary AMI accompanied by shock, who were treated with combined therapy from August 1999 to April 2017, were included into this study. Sixty patients received emergency percutaneous coronary intervention (PCI). Among these patients, 39 patients received intra-aortic balloon counterpulsation (IABP), eight patients had failed PCI underwent emergency off-pump coronary artery bypass (E-OPCAB), and eight patients were treated by hybrid cardiac surgery. Results All patients were successfully rescued. However, two patients died afterward due to postoperative complications. Conclusions For AMI patients complicated with shock, especially when emergency PCI fails or is difficult to perform, PCI + IABP, emergency E-OPCAB and hybrid cardiac surgery should be carried out, in order to achieve a good outcome and improve the success rate of rescue for this group of patients. Keywords Acute myocardial infarction (AMI); emergency percutaneous coronary intervention (PCI); intra-aortic balloon counterpulsation (IABP); emergency off-pump coronary artery bypass (E-OPCAB); hybrid cardiac surgery.
Collapse
Affiliation(s)
- Jing Xie
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | | | - Yi-Rong Gan
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | - Jiong Li
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | - Yan-Zhen Wang
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | - Zong-Ke Kou
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | - Rui Mao
- Gansu Cardiovascular Institute, Lanzhou 730050, China
| | | | | |
Collapse
|
8
|
Amin S, Werner RS, Madsen PL, Krasopoulos G, Taggart DP. Influence of coronary territory on flow profiles of saphenous vein grafts. J Cardiothorac Surg 2018; 13:23. [PMID: 29463268 PMCID: PMC5819683 DOI: 10.1186/s13019-018-0709-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Differing perfusion of the left and right ventricular coronary territory may influence flow-profiles of saphenous vein grafts (SVGs). We compared flow parameters, measured by transit-time flowmetry (TTFM), in left- and right-sided SVGs during coronary artery by-pass grafting (CABG). Methods Routine TTFM measurements were obtained in 167 SVGs to the left territory (55%) and 134 SVGs to the right territory (total of 301 SVGs in 207 patients). The four standard TTFM parameters, [mean graft flow (MGF), pulsatility index (PI), percentage diastolic filling (%DF), and percentage backward flow (%BF)] were compared. Differences in flow parameters were also examined according to surgical technique (on- vs. off-pump). Results No significant difference between coronary territories was found for MGF, PI and %BF. However, a higher %DF was noted in left-sided SVGs in the overall cohort as well as in the on-pump (both p < 0.001) and the off-pump cohorts (p = 0.07). Further, a significantly higher %BF was found in SVGs performed off-pump to the left territory (1.2 ± 2.5 vs. 2.3 ± 3.0, p = 0.023). In a multivariate regression analysis, anastomosing a SVG to the left territory was weakly associated with higher PI (OR = 0.36, p = 0.026) and strongly associated with higher %DF (OR = 5.1, p < 0.001). No significant association was found for MGF, PI, %DF or %BF in either the on-pump nor the off-pump cohorts. Conclusions Although statistically significant, the established differences in TTFM parameters between left- and right-sided vein grafts were small and unlikely to be of clinical relevance.
Collapse
Affiliation(s)
- Sanaz Amin
- University of Oxford, Oxford, UK. .,Department of Cardiovascular Surgery, Oxford University Hospitals Trust, Oxford, UK.
| | - Raphael S Werner
- Department of thoracic surgery, Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Per Lav Madsen
- Department of Cardiology, Copenhagen University Hospital, Herlev, Denmark
| | - George Krasopoulos
- University of Oxford, Oxford, UK.,Department of Cardiovascular Surgery, Oxford University Hospitals Trust, Oxford, UK
| | - David P Taggart
- University of Oxford, Oxford, UK.,Department of Cardiovascular Surgery, Oxford University Hospitals Trust, Oxford, UK
| |
Collapse
|
9
|
Ryu YG, Lee DK, Baek MJ, Kim H. Clinical Value of Intraoperative Transit-Time Flow Measurement for Autogenous Radiocephalic Arteriovenous Fistula in Patients with Chronic Kidney Disease. Ann Vasc Surg 2016; 35:53-9. [DOI: 10.1016/j.avsg.2016.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 02/09/2016] [Accepted: 02/14/2016] [Indexed: 11/28/2022]
|
10
|
Amin S, Pinho-Gomes AC, Taggart DP. Relationship of Intraoperative Transit Time Flowmetry Findings to Angiographic Graft Patency at Follow-Up. Ann Thorac Surg 2016; 101:1996-2006. [PMID: 26876343 DOI: 10.1016/j.athoracsur.2015.10.101] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/29/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Abstract
Early and late graft occlusion remains a significant complication of coronary artery bypass grafting. Transit time flowmetry is the most commonly used imaging technique to assess graft patency intraoperatively. Although the value of transit time flowmetry for intraoperative quality control of coronary anastomosis is well established, its standard variables for predicting eventual graft failure remain controversial. This review readdresses the issue of intraoperative transit time flowmetry, with a particular emphasis on defining cutoff values for standard variables and correlating them with the ability to predict midterm and long-term graft patency for arterial and venous conduits. Further research is warranted to support clinically useful recommendations on the intraoperative application and interpretation of transit time flowmetry.
Collapse
Affiliation(s)
- Sanaz Amin
- Department of Cardiovascular Surgery, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - David P Taggart
- Department of Cardiovascular Surgery, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Department of Cardiac Surgery, Oxford University Hospitals Trust, Oxford, United Kingdom
| |
Collapse
|
11
|
Hinz J, Mansur A, Hanekop GG, Weyland A, Popov AF, Schmitto JD, Grüne FFG, Bauer M, Kazmaier S. Influence of isoflurane on the diastolic pressure-flow relationship and critical occlusion pressure during arterial CABG surgery: a randomized controlled trial. PeerJ 2016; 4:e1619. [PMID: 26966644 PMCID: PMC4783760 DOI: 10.7717/peerj.1619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/02/2016] [Indexed: 11/20/2022] Open
Abstract
The effects of isoflurane on the determinants of blood flow during Coronary Artery Bypass Graft (CABG) surgery are not completely understood. This study characterized the influence of isoflurane on the diastolic Pressure-Flow (P-F) relationship and Critical Occlusion Pressure (COP) during CABG surgery. Twenty patients undergoing CABG surgery were studied. Patients were assigned to an isoflurane or control group. Hemodynamic and flow measurements during CABG surgery were performed twice (15 minutes after the discontinuation of extracorporeal circulation (T15) and again 15 minutes later (T30)). The zero flow pressure intercept (a measure of COP) was extrapolated from a linear regression analysis of the instantaneous diastolic P-F relationship. In the isoflurane group, the application of isoflurane significantly increased the slope of the diastolic P-F relationship by 215% indicating a mean reduction of Coronary Vascular Resistance (CVR) by 46%. Simultaneously, the Mean Diastolic Aortic Pressure (MDAP) decreased by 19% mainly due to a decrease in the systemic vascular resistance index by 21%. The COP, cardiac index, heart rate, Left Ventricular End-Diastolic Pressure (LVEDP) and Coronary Sinus Pressure (CSP) did not change significantly. In the control group, the parameters remained unchanged. In both groups, COP significantly exceeded the CSP and LVEDP at both time points. We conclude that short-term application of isoflurane at a sedative concentration markedly increases the slope of the instantaneous diastolic P-F relationship during CABG surgery implying a distinct decrease with CVR in patients undergoing CABG surgery.
Collapse
Affiliation(s)
- José Hinz
- Department of Anesthesiology, University Medical Center Goettingen , Germany
| | - Ashham Mansur
- Department of Anesthesiology, University Medical Center Goettingen , Germany
| | - Gerd G Hanekop
- Department of Anesthesiology, University Medical Center Goettingen , Goettingen , Germany
| | - Andreas Weyland
- Department of Anesthesiology and Intensive Care Medicine, University of Oldenburg , Oldenburg , Germany
| | - Aron F Popov
- Department of Cardiothoracic Surgery, Transplantation & Mechanical Support, Royal Brompton & Harefield Hospital , London , United Kingdom
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School , Hannover , Germany
| | - Frank F G Grüne
- Department of Anesthesiology, Erasmus University/Rotterdam , Rotterdam , Netherlands
| | - Martin Bauer
- Department of Anesthesiology, University Medical Center Goettingen , Göttingen , Germany
| | - Stephan Kazmaier
- Department of Anesthesiology, University Medical Center Goettingen , Goettingen , Germany
| |
Collapse
|
12
|
Yu Y, Zhang F, Gao MX, Li HT, Li JX, Song W, Huang XS, Gu CX. The application of intraoperative transit time flow measurement to accurately assess anastomotic quality in sequential vein grafting. Interact Cardiovasc Thorac Surg 2013; 17:938-43. [PMID: 24000314 DOI: 10.1093/icvts/ivt398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Intraoperative transit time flow measurement (TTFM) is widely used to assess anastomotic quality in coronary artery bypass grafting (CABG). However, in sequential vein grafting, the flow characteristics collected by the conventional TTFM method are usually associated with total graft flow and might not accurately indicate the quality of every distal anastomosis in a sequential graft. The purpose of our study was to examine a new TTFM method that could assess the quality of each distal anastomosis in a sequential graft more reliably than the conventional TTFM approach. METHODS Two TTFM methods were tested in 84 patients who underwent sequential saphenous off-pump CABG in Beijing An Zhen Hospital between April and August 2012. In the conventional TTFM method, normal blood flow in the sequential graft was maintained during the measurement, and the flow probe was placed a few centimetres above the anastomosis to be evaluated. In the new method, blood flow in the sequential graft was temporarily reduced during the measurement by placing an atraumatic bulldog clamp at the graft a few centimetres distal to the anastomosis to be evaluated, while the position of the flow probe remained the same as in the conventional method. This new TTFM method was named the flow reduction TTFM. Graft flow parameters measured by both methods were compared. RESULTS Compared with the conventional TTFM, the flow reduction TTFM resulted in significantly lower mean graft blood flow (P < 0.05); in contrast, yielded significantly higher pulsatility index (P < 0.05). Diastolic filling was not significantly different between the two methods and was >50% in both cases. Interestingly, the flow reduction TTFM identified two defective middle distal anastomoses that the conventional TTFM failed to detect. Graft flows near the defective distal anastomoses were improved substantially after revision. CONCLUSIONS In this study, we found that temporary reduction of graft flow during TTFM seemed to enhance the sensitivity of TTFM to less-than-critical anastomotic defects in a sequential graft and to improve the overall accuracy of the intraoperative assessment of anastomotic quality in sequential vein grafting.
Collapse
Affiliation(s)
- Yang Yu
- Department of Cardiac Surgery, Beijing An Zhen Hospital of Capital Medical University, Beijing, China
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Kim HJ, Lee TY, Kim JB, Cho WC, Jung SH, Chung CH, Lee JW, Choo SJ. The impact of sequential versus single anastomoses on flow characteristics and mid-term patency of saphenous vein grafts in coronary bypass grafting. J Thorac Cardiovasc Surg 2010; 141:750-4. [PMID: 20598321 DOI: 10.1016/j.jtcvs.2010.05.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 04/06/2010] [Accepted: 05/20/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the influence of bypass grafting technique on the flow characteristics and mid-term patency of saphenous vein coronary bypass grafts. METHODS In the present study, 309 patients who underwent either sequential (group A, N = 84 grafts) or individual (group B, N = 244 grafts) saphenous vein coronary bypass grafting between February 2002 and September 2007 were investigated. Individual bypassing only was performed in 212 patients, and sequential bypassing only was performed in 78 patients. The remaining 19 patients received both. A total of 436 distal anastomoses were performed with 328 saphenous vein grafts. The intraoperative flow characteristics and the graft patency were assessed with the transit time flow meter and serial multi-detector computed tomography coronary angiograms, respectively. RESULTS Group A showed a higher mean flow compared with group B at 49.4 ± 27.4 mL/min versus 37.1 ± 20.1 mL/min, respectively (P = .001). The mean flow increased linearly as the number of anastomoses increased per graft (P < .001). Graft patency at 3 years was 93.3% ± 3.4% in group A and 86.5% ± 3.1% in group B (P = .048). After adjustment for baseline characteristics, group A showed a tendency for superior mid-term patency than group B (hazard ratio 0.362; 95% confidence interval, 0.129-1.017; P = .0538). CONCLUSIONS Sequential bypass grafts were associated with higher mean flows and superior mid-term patency compared with individual grafts. These findings suggest the more favorable results of sequential bypass grafting to be attributed to the enhanced flow hemodynamics.
Collapse
Affiliation(s)
- Hee Jung Kim
- Department of Cardiovascular Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Routine Off-Pump Coronary Artery Bypass Grafting Is Safe and Feasible in High-Risk Patients With Left Main Disease. Ann Thorac Surg 2010; 89:1125-30. [DOI: 10.1016/j.athoracsur.2009.12.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 12/17/2009] [Accepted: 12/18/2009] [Indexed: 11/24/2022]
|
15
|
Poston RS, Kwon MH, Gu J. Role of procurement-related injury in early saphenous vein graft failure after coronary artery bypass surgery. Future Cardiol 2009; 2:503-12. [PMID: 19804185 DOI: 10.2217/14796678.2.4.503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Saphenous vein graft thrombosis after coronary artery bypass graft surgery is a poorly understood problem that lessens the benefits of this procedure. Recent studies highlight the importance of injury sustained at the time of saphenous vein graft procurement in the pathogenesis of acute graft thrombosis. In particular, damage to the graft endothelium that occurs secondary to ex vivo pressure distention, a common practice during vein harvest, leads to a loss of antithrombotic factors and increased activity of subendothelial prothrombotic factors. The prothrombotic potential of damaged grafts is further exacerbated by an ischemic storage interval and subsequent exposure to arterial flow conditions after grafting. A clearer understanding of the mechanisms by which endothelial disruption leads to acute saphenous vein graft thrombosis may result in interventions for improving our procurement techniques, interrupting the downstream effects of the damaged saphenous vein graft and/or discriminating damage that is beyond an acceptable threshold of thrombotic risk.
Collapse
Affiliation(s)
- Robert S Poston
- University of Maryland, School of Medicine, Department of Surgery, Division of Cardiac Surgery, 22 South Greene St, N4W94 Baltimore, MD 21201, USA.
| | | | | |
Collapse
|
16
|
Trunfio R, Demertzis S, van den Berg J, Siclari F. A New Surgical Approach for Exclusion of Renal Artery Aneurysms Avoiding Organ Ischemia. Eur J Vasc Endovasc Surg 2008; 36:559-61. [DOI: 10.1016/j.ejvs.2008.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 06/14/2008] [Indexed: 11/25/2022]
|
17
|
Predicting Midterm Coronary Artery Bypass Graft Failure by Intraoperative Transit Time Flow Measurement. Ann Thorac Surg 2008; 86:532-6. [DOI: 10.1016/j.athoracsur.2008.04.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Revised: 04/08/2008] [Accepted: 04/09/2008] [Indexed: 11/20/2022]
|
18
|
Tokuda Y, Song MH, Ueda Y, Usui A, Akita T. Predicting Early Coronary Artery Bypass Graft Failure by Intraoperative Transit Time Flow Measurement. Ann Thorac Surg 2007; 84:1928-33. [DOI: 10.1016/j.athoracsur.2007.07.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 07/11/2007] [Accepted: 07/12/2007] [Indexed: 10/22/2022]
|
19
|
Lotto AA, Owens WA. Intraoperative Doppler velocity measurements to locate patent ITA grafts at reoperation. Ann Thorac Surg 2006; 82:1108-10. [PMID: 16928554 DOI: 10.1016/j.athoracsur.2006.01.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 12/21/2005] [Accepted: 01/05/2006] [Indexed: 10/24/2022]
Abstract
We are reporting a case of a patient who underwent an aortic valve replacement with previous coronary artery bypass grafting. During the operation we used a Doppler velocity probe to locate the exact position of the bilateral internal thoracic arteries. Once the vessels were identified, a suture was passed widely around each internal thoracic artery and a snare was positioned. With the aid of the Doppler velocity probe, we achieved a gentle occlusion of the vessels, applying enough traction on the snares to abolish the flow through the internal thoracic arteries.
Collapse
Affiliation(s)
- Attilio A Lotto
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
| | | |
Collapse
|
20
|
Manchio JV, Gu J, Romar L, Brown J, Gammie J, Pierson RN, Griffith B, Poston RS. Disruption of graft endothelium correlates with early failure after off-pump coronary artery bypass surgery. Ann Thorac Surg 2006; 79:1991-8. [PMID: 15919298 DOI: 10.1016/j.athoracsur.2004.12.054] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 12/23/2004] [Accepted: 12/28/2004] [Indexed: 11/22/2022]
Abstract
BACKGROUND Saphenous vein graft failure after coronary artery bypass surgery may be as high as 5% to 10% in the first postoperative week. We hypothesized that identifying damage sustained by saphenous vein endothelium before grafting predicts early graft attrition after off-pump coronary artery bypass graft surgery. METHODS Intraoperative graft flow, platelet function, and endothelial integrity were analyzed in 125 patients undergoing off-pump coronary artery bypass graft surgery. Endothelial integrity was assessed in an excess vein segment from each graft using immunohistochemistry (CD31 staining). Platelet function was monitored just before and immediately after revascularization and on postoperative days 1 and 3 using whole blood aggregometry, thrombelastography, and platelet activated clotting time. Platelet activation was monitored using flow cytometry. Intraoperative conduit blood flow, measured by transit time ultrasonography, was used to detect and rectify anastomotic problems. Early graft patency was determined on postoperative day 5 using gated multichannel computed tomography angiography. RESULTS In 106 patients undergoing postoperative computed tomography evaluation, 10 vein grafts in 10 patients were discovered to have developed early thrombosis, representing 4% (10 of 217) of all vein grafts. Endothelial integrity was 10.75% +/- 17.56% in 10 grafts that failed early compared with 51.45% +/- 36.29% in patent grafts (p = 0.04). Perioperative platelet function and graft flow did not differ significantly between the two groups. CONCLUSIONS Although endothelial disruption predicts early failure of bypass grafts, the importance of a hypercoaguable state and low graft flow as a cause of early graft thrombosis after off-pump coronary artery bypass graft surgery was not supported by our preliminary results. A means to assess, prevent, and treat intraoperative vein graft damage will likely improve early graft patency.
Collapse
Affiliation(s)
- Jeffrey V Manchio
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Kazmaier S, Hanekop GG, Grossmann M, Dörge H, Götze K, Schöndube F, Quintel M, Weyland A. Instantaneous diastolic pressure–flow relationship in arterial coronary bypass grafts. Eur J Anaesthesiol 2006; 23:373-9. [PMID: 16438765 DOI: 10.1017/s0265021505001985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2005] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of this study was to describe the diastolic pressure-flow relationship and to assess critical occlusion pressure in arterial coronary bypass grafts in human beings. METHODS AND RESULTS Fifteen patients were studied following elective surgical coronary artery bypass grafting. Flow in the left internal mammary artery bypass to the left anterior descending artery was measured and simultaneously, aortic pressure, coronary sinus pressure and left ventricular end-diastolic pressure were recorded. The zero-flow pressure intercept as a measure of critical occlusion pressure was extrapolated from the linear regression analysis of the instantaneous diastolic pressure-flow relationship. Mean diastolic flow was 46 +/- 17 mL min(-1), mean diastolic aortic pressure was 60.5 +/- 10.0 mmHg. Diastolic blood flow was linearly related to the respective aortic pressure in all patients (R-values 0.7-0.99). The regression lines had a mean slope of 2.1 +/- 1.2 mL min(-1) mmHg(-1). Mean critical occlusion pressure was 32.3 +/- 9.9 mmHg and exceeded mean coronary sinus pressure and mean left ventricular end-diastolic pressure by factors of 3.1 and 2.6, respectively. CONCLUSIONS Our data demonstrate the presence of a vascular waterfall phenomenon in the coronary circulation after internal mammary artery bypass grafting. Critical occlusion pressure in arterial grafts considerably exceeds coronary sinus pressure as well as left ventricular end-diastolic pressure and should thus be used as the effective downstream pressure when calculating coronary perfusion pressure. Our data further suggest that the slope of diastolic pressure-flow relationships provides a more rational approach to assess regional coronary vascular resistance than conventional calculations of coronary vascular resistance.
Collapse
Affiliation(s)
- S Kazmaier
- Department of Anesthesiology, Emergency Medicine and Intensive Care, Georg-August-University, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Aleksic M, Heckenkamp J, Gawenda M, Brunkwall J. Pulsatility Index Determination by Flowmeter Measurement: A New Indicator for Vascular Resistance? Eur Surg Res 2004; 36:345-9. [PMID: 15591742 DOI: 10.1159/000081642] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Accepted: 06/30/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Peripheral resistance (R) is measured by flow (Q) and a pressure difference (P1-P2), where R equals (P1-P2)/Q. The pulsatility index (PI) has been used to assess peripheral vascular resistance by measuring flow velocities. Alternatively, PI can be expressed by the ratio of the flow volume amplitude and mean flow volume which both are quantified by a flowmeter. While reflected flow due to a distally located stenosis will considerably influence PI, this parameter theoretically could provide a good estimation of resistance. The appropriateness of this presumption has not been evaluated in this setting though, why the correlation of PI in flow recordings was examined by comparing PI with the true R using the stenosis of the internal carotid artery (ICA) as a clinical model. METHODS The volume flow in the ICA was measured by a transit-time flowmeter in 400 patients undergoing carotid endarteriectomy. The pressure in the common carotid artery (CCA) proximal to and in the ICA distal to the stenosis was determined by direct puncture allowing the calculation of a pressure gradient (PG) and R in analogy to Ohm's law. R and PI were then correlated using Spearman's correlation. RESULTS The blood flow in the ICA ranged from 2 to 478 ml/min with a median value of 165. The median PG was 14 mm Hg (0 to 88). Median R was 0.08 mm Hg x min / ml (0-26.5). PI varied between 0.8 and 114.1 with a mean of 1.9. Since a concentration of R and PI values in the lower ranges was observed, a logarithmic transformation was performed. Log PI showed only weak correlation to log R (r = 0.426, p < 0.0001). CONCLUSIONS Log PI was intermediately correlated to log R in carotid artery stenosis, with a low discriminating power in the lower ranges due to the close distribution of measurements. Further studies are required to clarify the role of PI in hemodynamic questions and its general usefulness in other fields of vascular surgery like in peripheral bypass surgery.
Collapse
Affiliation(s)
- M Aleksic
- Division of Vascular Surgery, Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
| | | | | | | |
Collapse
|
23
|
Bergsland J, Hol PK, Lingås PS, Lundblad R, Rein KA, Andersen R, Mørk BE, Halvorsen S, Mujanovic E, Kabil E, Svennevig JL, Fosse E. Intraoperative and intermediate-term angiographic results of coronary artery bypass surgery with Symmetry proximal anastomotic device. J Thorac Cardiovasc Surg 2004; 128:718-23. [PMID: 15514599 DOI: 10.1016/j.jtcvs.2004.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the patency in saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices or with a traditional suture technique. METHODS Forty-six patients underwent coronary artery bypass grafting without cardiopulmonary bypass by using one thoracic graft and one or more saphenous vein grafts. Grafts were attached to the aorta with a Symmetry connector (St Jude Medical, Inc, St Paul, Minn) in 23 patients, and partial occlusion of the aorta and sutured anastomoses were used in 23 other patients. Grafts were studied intraoperatively with transit time flowmetry and angiography and revised if necessary. Angiography was repeated after 3 to 5 months. RESULTS Intraoperative graft patency did not differ between the 2 groups. Follow-up angiography demonstrated excellent thoracic graft patency. Vein graft patency decreased to 50% in the Symmetry group, whereas it was 90% in the suture group ( P = .01). Twenty-five percent of the Symmetry grafts had significant stenosis in the connector. CONCLUSION Saphenous vein grafts anastomosed to aorta with the Symmetry proximal connector have low intermediate patency compared with those with traditionally sutured anastomoses. We do not recommend the routine use of this device in coronary artery bypass operations.
Collapse
|
24
|
Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management †. Br J Anaesth 2004; 92:400-13. [PMID: 14970136 DOI: 10.1093/bja/aeh064] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing interest is being shown in beating heart (off-pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high-risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple-vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating-heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data.
Collapse
Affiliation(s)
- P-G Chassot
- Departments of Anaesthesiology and Cardiovascular Surgery, University Hospital Lausanne (CHUV), CH-1011 Lausanne, Switzerland
| | | | | | | | | |
Collapse
|
25
|
Wolfe JA. The coronary artery bypass conduit: II. Assessment of the quality of the distal anastomosis. Ann Thorac Surg 2001; 72:S2253-8; discussion S2258-9, S2267-70. [PMID: 11789849 DOI: 10.1016/s0003-4975(01)03298-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The outcome of coronary artery bypass grafting procedures is highly dependent on the technical adequacy of the distal anastomosis. Various methodologies, including flow measurement and imaging techniques, have been used by the cardiothoracic surgeon to assess the adequacy of the distal anastomosis. The limitations of these techniques outweigh their advantages and limit their widespread clinical applicability. Recent improvements in the technique for online measurement of regional myocardial pH provide a promising new metabolic approach to assessing the adequacy of the distal anastomosis in cardiac surgery.
Collapse
Affiliation(s)
- J A Wolfe
- Peachtree Cardiovascular & Thoracic Surgeons, Atlanta, Georgia 30342, USA.
| |
Collapse
|
26
|
Ricci M, Salerno TA. Off-pump coronary reoperations via left thoracotomy: Reply. Ann Thorac Surg 2001. [DOI: 10.1016/s0003-4975(01)02451-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
27
|
Ricci M, Kaplon R, Barron M, Salerno TA. Acute right ventricular failure during aortic root replacement: intraoperative diagnosis and treatment. J Card Surg 2001; 16:258-9. [PMID: 11824674 DOI: 10.1111/j.1540-8191.2001.tb00518.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The scope of this article is to report on a patient who underwent a Bentall procedure for type A aortic dissection. Right ventricular (RV) failure developed immediately after completion of the operation. The etiology was determined by using transit time flow measurement (TTFM), an ultrasound-based technique which demonstrated the absence of blood flow to the right coronary artery. This allowed for early and effective treatment, which was followed by a successful outcome.
Collapse
Affiliation(s)
- M Ricci
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Florida 33136, USA
| | | | | | | |
Collapse
|