JTCS Email Content Delivery
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Yoshiyuki Takami
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Takami, Y.
Right arrow Articles by Masumoto, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Takami, Y.
Right arrow Articles by Masumoto, H.
Related Collections
Right arrow Coronary disease

J Thorac Cardiovasc Surg 2004;128:629-631
© 2004 The American Association for Thoracic Surgery

Brief communication

Transit-time flow measurement cannot detect wrong anastomosis of an internal thoracic artery with the cardiac vein in coronary artery surgery

Yoshiyuki Takami, MDa,*, Hiroshi Masumoto, MD

a Division of Cardiovascular Surgery, Kasugai Municipal Hospital, Kasugai, Japan

Received for publication January 29, 2004; accepted for publication February 23, 2004.

* Address for reprints: Yoshiyuki Takami, MD, Division of Cardiovascular Surgery, Kasugai Municipal Hospital, 1-1-1 Takagi-cho, Kasugai City 486-8510 Japan
cvs{at}hospital.kasugai.aichi.jp

In coronary artery surgery transit-time flow measurement is useful to determine graft patency and to detect graft failure intraoperatively. Previous reports have demonstrated the accuracy and reproducibility of this noninvasive and simple procedure.1-5 In this report, however, we describe a case of wrong anastomosis of the left internal thoracic artery (LITA) with the cardiac vein, which could not be detected with transit flow measurement.

Clinical summary

A 72-year-old man with effort angina was referred for coronary artery surgery. His coronary angiograms revealed occlusion of the distal right coronary artery and significant stenosis of the left main stem, the proximal left anterior descending artery, and the proximal left circumflex artery. He underwent triple coronary artery bypass grafting during cardiopulmonary bypass. The LITA was grafted to the left anterior descending artery, the left radial artery to the obtuse marginal branch of the left circumflex artery, and the saphenous vein to the atrioventricular branch of the right coronary artery. The result of transit-time flow measurement of the LITA graft is demonstrated in Figure 1. The mean flow (Qm) was 48 mL/min, the pulsatility index ([Maximal flow – Minimal flow]/Qm) was 1.6, and the percentage of insufficiency (Volume of backward flow/Volume of forward flow) was 0%. The postoperative angiogram revealed that the LITA had been anastomosed with the cardiac vein (Figure 1, B), although both aorta-coronary grafts (radial artery and saphenous vein) were patent.



View larger version (59K):
[in this window]
[in a new window]
  		Figure 1. A, An intraoperative flow tracing of an in situ LITA grafted to the left anterior descending artery (LAD) in a 72-year-old man. The mean flow was 48 mL/min, the pulsatility index was 1.6, the percentage of insufficiency was 0%, and the flow was predominantly diastolic, forming a trapezoid-shaped waveform with a short systolic peak. B, A postoperative angiogram showing the LITA anastomosed wrongly with the cardiac vein.

 
Discussion

In the transit-time method it is neither necessary to know the vessel diameter nor to perform any complex calibrating procedures. Therefore intraoperative transit-time flow measurement has become increasingly popular to check the anastomotic quality in coronary artery bypass grafting.5 As we have already demonstrated in the quantitative angiographic evaluation,2,3 intraoperative Qm is closely related to the degree of the stenosis at the most stenotic portion of the anastomosis. However, we cannot completely rely on the Qm value to determine the anastomotic quality of the graft. It is possible to have a patent anastomosis with a low Qm because the optimal Qm varies with the dynamic character, including blood pressure, heart rate, coronary resistance, and graft diameter.1,5 We cannot necessarily judge a graft with a Qm of less than 20 mL/min as nonpatent in the operating room. In contrast, surgeons can consider a graft with a Qm of greater than 20 mL/min as patent.1 In addition, on the basis of the specific physiology of coronary circulation, patent graft flow is predominantly diastolic, forming a trapezoid-shaped waveform with a short systolic peak, as demonstrated in Figure 2. On the contrary, there is no diastolic flow in an occluded graft.2-4



View larger version (62K):
[in this window]
[in a new window]
  		Figure 2. A, An intraoperative flow tracing of an in situ LITA grafted to the left anterior descending artery (LAD) in a 62-year-old man. The mean flow was 48 mL/min, the pulsatility index was 1.4, the percentage of insufficiency was 0%, and the flow was predominantly diastolic, forming a trapezoid-shaped waveform with a short systolic peak. B, A postoperative angiogram showing the patent LITA anastomosed correctly to the left anterior descending artery.

 
In the patient in this report, the intraoperative Qm of the LITA was 48 mL/min, and its flow pattern was diastolic dominant. We considered the LITA as patent in the operating room. However, the postoperative angiogram revealed that the LITA had been accidentally anastomosed with the cardiac vein and not with the left coronary artery that we had intended to use for anastomosis. The arteriovenous flow pattern is similar to the arterioarterial flow pattern in coronary circulation. Although it is uncommon to perform incorrect grafting of the LITA to the cardiac vein, we should know that the transit-time flow measurement cannot differentiate the wrong anastomosis.

References

  1. Jaber SF, Koenig SC, BhaskerRao B, et al. Role of graft flow measurement technique in anastomotic quality assessment in minimally invasive CABG. Ann Thorac Surg. 1998;66:1087–1092[Abstract/Free Full Text]
  2. Takami Y, Ina H. A simple method to determine anastomotic quality of coronary artery bypass grafting in the operating room. Cardiovasc Surg. 2001;9(5):499–503[Medline]
  3. Takami Y, Ina H. Relation of intra-operative flow measurement with post-operative quantitative angiographic assessment of coronary artery bypass grafting. Ann Thorac Surg. 2001;72:1270–1274[Abstract/Free Full Text]
  4. Morota T, Duhaylongsod FG, Burfeind WR, Huang CT. Intraoperative evaluation of coronary anastomosis by transit-time ultrasonic flow measurement. Ann Thorac Surg. 2002;73:1446–1450[Abstract/Free Full Text]
  5. Schmitz C, Ashraf O, Schiller W, et al. Transit time flow measurement in on-pump and off-pump coronary artery surgery. J Thorac Cardiovasc Surg. 2003;126:645–650[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
Y. Takami and H. Masumoto
The answer is an intra-aortic balloon pump
J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 1195 - 1196.
[Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Yoshiyuki Takami
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Takami, Y.
Right arrow Articles by Masumoto, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Takami, Y.
Right arrow Articles by Masumoto, H.
Related Collections
Right arrow Coronary disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS