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J Thorac Cardiovasc Surg 2001;122:687-690
© 2001 The American Association for Thoracic Surgery
Surgery for Aquired Cardiovascular Disease (ACD) |
From the Department of Cardiac Surgery, G. D&'Annunzio University, Chieti, Italy.
Received for publication Jan 8, 2001. Revisions requested Feb 26, 2001; revisions received March 26, 2001. Accepted for publication March 28, 2001. Address for reprints: Antonio Maria Calafiore, MD, G. D&'Annunzio University, Department of Cardiac Surgery, S. Camillo de&' Lellis Hospital, Via C. Forlanini, 50, 66100 Chieti, Italy (E-mail: calafiore@ unich.it).
Abstract
Background: We sought to evaluate the long-term patency rate of composite lengthened conduits.
Methods and Results: From December 1991 to April 2000, 43 patients had a composite lengthened arterial conduit. There was a mean of 2.83 ± 1.23 anastomoses per patient. No 30-day mortality occurred. Five patients died from 3 to 84 months after the operation (mean, 38.6 ± 34.6 months). After a mean follow-up of 57.0 ± 32.3 months (range, 3-99 months), all the survivors are asymptomatic. The only cardiac major events recorded were 2 (4.6%) late acute myocardial infarctions in the patients who died. Eight-year survival and event-free survival were both 80.4% ± 9.1% (range, 3%-93%). In the early period (13.5 ± 4.8 days) in 26 patients, 26 arterial composite lengthened conduits and 37 distal anastomoses had postoperative angiographic control; all the anastomoses were rates as grade A, according to Fitzgibbon classification. In the late period (29 ± 30 months) in 23 patients, 23 arterial composite lengthened conduits and 34 distal anastomoses were checked; the patency rate was 22 (95.6%) of 23 for the composite lengthened conduits and 33 (97%) of 34 for the distal anastomoses.
Conclusions: In particular situations, when the length of an arterial conduit is not enough to allow a correct use of the graft, lengthening of an arterial conduit can be a safe and effective technique.
Composite arterial grafting has been described by many authors
1-4 but mainly as a T or Y graft. The possibility of lengthening an arterial conduit (AC) with another AC (composite lengthened conduit [CLC]) has seldom been explored and only when related to the technical feasibility in the left anterior small thoracotomy procedure. 5
We reviewed our long-term experience with this strategy, which, in selected cases, represents an effective solution to reach distant target anastomotic sites.
Patients and methods
From December 1991 to April 2000, 43 patients (1.3% of the patients submitted to myocardial revascularization in the same period of time) underwent isolated myocardial revascularization through a median sternotomy by using a composite arterial lengthened conduit. Indications to this strategy were mainly the impossibility for an arterial graft (in situ or anastomosed to the proximal aorta) to reach the target coronary vessel because of reduced length or because of injury during harvesting that forced exclusion of part of the graft.
Preoperative data are shown in Table 1.
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Surgical technique
Harvesting of the ITA and of the radial and epigastric arteries was previously described. 6 The lengthening conduit was connected to the donor conduit with an end-to-end anastomosis before starting the procedure. The surgical technique has been previously reported. 5,7
It is necessary to put the CLC over the heart to avoid any distortion of the graft. As a result of inner pressure, the graft will always be suitably oriented. If there is any doubt, methylene blue can be used to mark the right direction. As soon as the aorta was unclamped (or when the last anastomosis was accomplished without cardiopulmonary bypass [CPB]), a continuous infusion of diltiazem or nitroglycerin was begun and continued up to the first postoperative day, when oral diltiazem was started (60 mg 3 times a day for 4 weeks).
From the operating theater, the patients were transferred to the intensive care unit, where they generally remained up to the first postoperative day, after which they were moved to the general ward.
Follow-up
All the patients were followed up in our outpatients clinic at 3, 6, 12 months after the operation and every year thereafter. Clinical follow-up was 100% complete. Survival and survival free from cardiac events (ie, acute myocardial infarction or need to repeat interventional or surgical revascularizion) were considered. In all but one of the patients, angiography was performed electively.
Statistical analysis
Results are expressed as means ± standard deviation unless otherwise indicated. Survival and event-free survival curves were obtained with the Kaplan-Meier method (SPSS software; SPSS, Inc, Chicago, Ill).
Results
In 7 patients the myocardial revascularization was performed without CPB. In the remaining patients the CPB time was 64.0 ± 27.0 minutes, and the aortic crossclamp time was 45.5 ± 22.7 minutes. In 43 patients a mean of 2.8 ± 1.2 anastomoses were performed, and in 34 (65%) patients a total arterial myocardial revascularization was carried out.
Table 2 shows the arrangement of lengthened conduits. In 43 patients the CLC was used for 57 distal anastomoses (1.3 ± 0.6); a sequential graft was performed 12 times. The distribution of the distal anastomoses is shown in Table 3.
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No patient died within 30 days from the operation. Only one (2.3%) patient showed ventricular arrhythmias in the postoperative course, and these were treated with drug therapy. One patient had a wound-healing complication and required a surgical revision.
Follow-up
After a mean follow-up period of 57.0 ± 32.3 months (range, 3-99 months), 38 (88.4%) patients are alive and asymptomatic without any major complications, such as acute myocardial infarction, redo operations, or interventional revascularization. Five late deaths were recorded, 2 as a result of cardiac causes (acute myocardial infarction 20 and 84 months after the operation, respectively) and 3 as a result of noncardiac causes (2 patients with gastric bleeding at 5 and 72 months after the operation, respectively, and the 1 patient with leukemia 56 months after the operation). The only major cardiac events recorded in the follow-up period were 2 (4.6%) late acute myocardial infarctions that occurred in the patients who died.
Eight-year survival and event-free survival were both 80.4% ± 9.1% (Figure 1).
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8 Of 23 (60.5%) patients who had late angiographic examinations (29 ± 30 months), only an ITA lengthened with a radial artery on the posterior descending artery was occluded because of progression of coronary disease. This patient had a postoperative angiogram after an abnormal myocardial scintiscan on the inferior wall. The patient at present is asymptomatic with medical treatment. Twenty-two (95.6%) of 23 intermediate and 33 (97.0%) of 34 distal anastomoses were rated as grade A, according to the Fitzgibbon classification. The angiographic results of arterial CLC and of the other grafts used are shown in Table 4.The patency rate of the arterial CLC distal anastomoses in the early (37/37 [100%]) and in the late (33/34 [95.6%]) period are comparable with the ITA&'s patency rate (early, 20/20; late, 17/17; P = not significant).
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In selected patients the possibility of lengthening an AC with another AC can be a technical solution when the donor graft is too short to reach the target coronary vessel. In previous reports, good long-term patency of the Y or T grafts was demonstrated. 1,3,9 To the best of our knowledge, the results of arterial CLC anastomoses have not been evaluated, at least in the long term.
We reported our experience with arterial CLCs in the left anterior small thoracotomy operation, 5 in which the left ITA was lengthened with the inferior epigastric artery. These patients had follow-up angiograms 87.5 ± 23.3 days after the operation, with a satisfying patency rate of 21 (95.4%) of 22.
From this study, it was evident that the intermediate anastomosis between 2 ACs was not a weak point of the strategy of composite grafting and that its failure was rare.
Seldom is the surgeon forced to lengthen another AC because of the great availability of such conduits. However, when an AC is harvested, an injury can force the discarding of part of an in situ conduit, making its lengthening the only possible solution. Our study was able to demonstrate that, if necessary, lengthening of an AC can be a safe and effective technique.
References
This article has been cited by other articles:
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  G. Teodori, P.-P. Caimmi, T. Toscano, and M. Bernardi Use of the inferior epigastric artery for CABG MMCTS, March 15, 2006; 2006(0315): 794. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, L. Weltert, M. D. Mauro, G. Actis-Dato, A. L. Iaco, P. Centofanti, M. L. Torre, and F. Patane Internal mammary artery MMCTS, November 29, 2005; 2005(1129): 1008. [Abstract] [Full Text] [PDF]
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 I. Parvaiz, J. T. Lund, and H. Kelbaek The Arterial Sling Operation: One-Year Follow-Up Ann. Thorac. Surg., October 1, 2005; 80(4): 1375 - 1380. [Abstract] [Full Text] [PDF]
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 R. G. Fuster, J. Estornell, O. Gil, and J. A. Montero Arterial graft extension with radial artery: a method of total arterial revascularization Eur. J. Cardiothorac. Surg., October 1, 2004; 26(4): 839 - 841. [Abstract] [Full Text] [PDF]
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