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J Thorac Cardiovasc Surg 1995;110:952-962
© 1995 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

HIGH FLOW DEMAND ON SMALL ARTERIAL CORONARY BYPASS CONDUITS PROMOTES GRAFT SPASM

Louisville, Ky.

Supported in part by a grant from the Jewish Hospital Heart and Lung Institute.

Received for publication Dec. 19, 1994. Accepted for publication March 6, 1995. Address for reprints: Paul Spence, MD, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, KY 40292.

Abstract

Despite the superior long-term patency of arterial grafts, surgeons are often reluctant to use arterial grafts on coronary vessels that supply large areas of myocardium because postoperative shock may occur. We hypothesized that supramaximal flow through small arterial conduits would decrease distal intraluminal pressure, thereby reducing afterload on the smooth muscle and rendering the arterial graft vulnerable to spasm. Fourteen internal thoracic and eight gastroepiploic arteries were harvested from adult pigs (220 to 250 pounds). Arteries were mounted on a computer-controlled perfusion system with inflow pressure at 80 mm Hg and outflow resistance adjusted to simulate normal (in situ) or supramaximal (coronary artery bypass graft) flow demands. Artery pressures and flow rates were measured at baseline and after norepinephrine was added to the system. Internal thoracic arteries had no hemodynamic response to norepinephrine at normal flow. Under supramaximal flow demands, large internal thoracic arteries (2.5 to 3.0 mm) had no hemodynamic response to norepinephrine. However, for small internal thoracic arteries (2.1 to 2.9 mm), norepinephrine reduced distal internal thoracic arterial pressure (63.2±2.2 to 27.0±1.9 mm Hg) and flow rate (99.4±5.0 to 45.4±2.7 ml/min, median effective dose = 9.12 x 10 ^-9 mol/L). Under normal flow demands, the flow rate in gastroepiploic arteries (1.0 to 2.0 mm diameter) decreased (14.1±0.5 to 4.8±0.8 ml/min, p<0.05) only at high concentrations of norepinephrine (median effective dose = 1.26 x 10 ^-6 mol/L). Supramaximal flow demandsreduced distal gastroepiploic arterial pressure (77.5±0.5 to 49.5±3.8 mm Hg, p <0.05), which resulted in a greater decrease in flow rate (80.0±3.7 to 6.8±1.6 ml/min, p <0.05) at lower concentrations of norepinephrine, (median effective dose = 3.24 x 10 ^-8 mol/L, p <0.05). In four studies in internal thoracic arteries and eight in gastroepiploic arteries, arteries were cut in half, reattached, and reperfused. The proximal half of the internal thoracic artery did not respond to norepinephrine, but the distal half had a 53%±7% decrease in flow. Both gastroepiploic artery halves reacted and flow rate decreased by 88%±2% (proximal half) and 89%±3% (distal half). In conclusion, small arterial conduits develop large transconduit pressure gradients under supramaximal flow demands. Under these conditions, arteries are very sensitive to vasoconstrictors and flow may cease with higher drug concentrations. Myocardial failure after arterial bypass grafting to coronary vessels supplying large amounts of myocardium may result from an increased sensitivity to vasoconstriction leading to graft spasm and myocardial ischemia. (J THORAC CARDIOVASC SURG 1995;110:952-62)

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