Total Arterial Off-Pump Coronary Revascularization with Only Internal Thoracic Artery and Composite Radial Artery Grafts

Authors

  • Junjiro Kobayashi
  • Osamu Tagusari
  • Ko Bando
  • Kazuo Niwaya
  • Hiroyuki Nakajima
  • Michiko Ishida
  • Satsuki Fukushima
  • Soichiro Kitamura

DOI:

https://doi.org/10.1532/hsf.969

Abstract

Objective: Total arterial off-pump coronary artery bypass (OPCAB) grafting with only internal thoracic artery (ITA) and composite radial artery (RA) grafts has been applied extensively to avoid cerebral complications and late vein graft failure. We evaluated the initial experience with this method by clinical and angiographic study.

Methods: Between April 2000 and May 2002, 257 patients underwent OPCAB grafting with this technique. The range of ages at operation was 42 to 86 years (mean, 66.1 ± 8.6 years). On average, 3.28 ± 0.86 grafts per patient were completed. More than 4 distal anastomoses were performed in 88 patients (34%). For coronary revascularization, 289 ITA and 555 RA grafts were used. The RA was used as a Y graft in 211 patients, as an I graft (for ITA extension) in 52 patients, and as a K graft (the side of the RA attached to the side of the left ITA) in 28 patients. Sequential bypass grafting was performed with 190 RA and 7 ITA grafts. The sites of distal anastomoses were 256 left anterior descending arteries (30%), 236 posterolateral branches (28%), 144 posterior descending arteries (17%), 106 diagonal branches (13%), 82 obtuse marginal branches (10%), and 19 right coronary arteries (2%).

Results: There were 1 operative death (0.4%) due to cerebral hemorrhage and 2 episodes of stroke (0.8%) during postoperative angiography. There were no clinical underperfusion syndromes or new intra-aortic balloon pump insertions. Perioperative myocardial infarction occurred in 12 patients (4.7%), sternal dehiscence in 5 (1.9%), and early coronary intervention in 4 (1.6%). There was no deep wound infection, reexploration for bleeding, or hand ischemia. The actuarial survival rate and the cardiac event-free rate at 2 years were 98.6% ± 2.4% and 94.2% ± 0.8%, respectively. Early postoperative angiography revealed a 97.8% (264/270) graft patency of ITAs and 97.9% (512/523) graft patency of RAs in 238 patients. Flow competition of the RA graft was recognized in 22 patients and, as indicated by follow-up angiographic study, did not cause late graft occlusion.

Conclusions: OPCAB grafting with ITAs and composite RAs provides excellent early and intermediate clinical results and graft patency.

References

Bal-El Y, Goor DA. 1992. Clamping of the atherosclerotic ascending aorta during artery bypass operation: its cost in stroke. J Thorac Cardiovasc Surg 102:469-74.nBedi HS, Suri A, Kalkat MS, et al. 2000. Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion. Ann Thorac Surg 69:156-64.nBhan A, Choudhary SK, Mathur A, et al. 2000. Surgical myocardial revascularization without cardiopulmonary bypass. Ann Thorac Surg 69:1216-21.nBorger M, Rao V, Weisel R, et al. 1998. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 65:1050-6.nCalafiore AM, Di Mauro M, Teodori G, et al. 2002. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg 73:1387-93.nCalafiore AM, Giammarco G, Teodori G, et al. 1995. Radial artery and epigastric artery in composite grafts: improved midterm angiographic results. Ann Thorac Surg 60:517-23.nKobayashi J, Sasako Y, Bando K, et al. 2002. Multiple off-pump coronary revascularization with "aorta no-touch" technique using composite and sequential methods. Heart Surg Forum 5:114-8.nKramer A, Mastsa M, Paz Y, et al. 2000. Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older. J Thorac Cardiovasc Surg 120:290-7.nLoop FD, Lytle BW, Cosgrove DM, et al. 1986. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 314:1-6.nLytle BW, Blackstone EH, Loop FD, et al. 1999. Two internal thoracic arteries are better than one. J Thorac Cardiovasc Surg 117:855-72.nMills NL, Everson CT. 1991. Atherosclerosis of the ascending aorta and coronary artery bypass: pathology, clinical correlates and operative management. J Thorac Cardiovasc Surg 102:546-53.nPick AW, Orszulak TA, Anderson BJ, Schaff HV. 1997. Single versus bilateral internal mammary artery grafts: 10-year outcome analysis. Ann Thorac Surg 64:599-605.nPossati G, Gaudino M, Alessandrini F, et al. 1998. Midterm clinical and angiographic results of radial artery grafts used for myocardial revascularization. J Thorac Cardiovasc Surg 116:1015-21.nRonan JW, Perry LA, Barner HB, Sundt TM III. 2000. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 69:113-4.nRoyse AG, Royse CF, Ramen JS. 1999. Exclusive Y graft operation for multivessel coronary revascularization. Ann Thorac Surg 68:1612-8.nRoyse AG, Royse CF, Tatoulis J, et al. 2000. Postoperative radial artery angiography for coronary artery bypass surgery. Eur J Cardiothorac Surg 17:294-304.nTashiro T, Nakamura K, Iwakura A, et al. 1999. Inverted T graft: novel technique using composite radial and internal thoracic arteries. Ann Thorac Surg 67:629-31.nTatoulis J, Royse AG, Buxton BF, et al. 2002. The radial artery in coronary surgery: a 5-year experience--clinical and angiographic results. Ann Thorac Surg 73:143-8.nTector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. 1994. Total revascularization with T grafts. Ann Thorac Surg 57:33-9.nAcar C, Jebara VA, Portoghese M, et al. 1992. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 54:652-60.nAcar C, Ramsheyi A, Pagny J-Y, et al. 1998. The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 116:981-9.nAguero OR, Navia JL, Navia JA, Mirtzovian E. 1999. A new method of myocardial revascularization with the radial artery. Ann Thorac Surg 67:1817-8.nArom FV, Flavin TF, Emery RW, Kshettry VR, Janey PA, Petersen BS. 2000. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 69:704-10.nCartier R, Brann S, Dagenais F, Martineau R, Couturier A. 2000. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 119:221-9.nChavanon O, Carrier M, Cartier R, et al. 2001. Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery? Ann Thorac Surg 71:117-21.nDiegeler A, Hirsch R, Schneider F, et al. 2000. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg 69:1162-6.nEckstein FS, Bonilla LF, Englberger L, et al. 2002. The St Jude Medical symmetry aortic connector system for proximal vein graft anastomosis in coronary artery bypass grafting. J Thorac Cardiovasc Surg 123:777-82.nHartman G, Yao F, Bruefach M, et al. 1996. Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery surgery: a prospective study. Anesth Analg 83:701-8.nHe GW, Acuff TE, Ryan WH, Mack MJ. 1994. Risk factors for operative mortality in elderly patients undergoing internal mammary artery grafting. Ann Thorac Surg 57:1453-60.nWeinschelbaum EE, Macchia A, Caramutti VM, et al. 2000. Myocardial revascularization with radial and mammary arteries: initial and mid-term results. Ann Thorac Surg 70:1378-83.n

Published

2005-02-02

How to Cite

Kobayashi, J., Tagusari, O., Bando, K., Niwaya, K., Nakajima, H., Ishida, M., Fukushima, S., & Kitamura, S. (2005). Total Arterial Off-Pump Coronary Revascularization with Only Internal Thoracic Artery and Composite Radial Artery Grafts. The Heart Surgery Forum, 6(1), 30-37. https://doi.org/10.1532/hsf.969

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