J Thorac Cardiovasc Surg 2005;129:1461-1462
© 2005 The American Association for Thoracic Surgery
Caution with twisted arterial grafts
Helmut Mair, MD,
Sabine Daebritz, MD,
Bruno Reichart, MD
Cardiac Surgery, University of Munich, Marchioninistr. 15, Munich 81375, Germany
To the Editor:
Sarma and colleaques1 recently reported a case of an inadvertent clockwise 360° twisted left internal thoracic artery (LITA) graft sequentially anastomosed to the diagonal and left descending coronary arteries (LAD). Angiography 6 months postoperatively revealed a patent graft with good distal runoff. The acceptance of twisting was based on an uneventful course during and after weaning from cardiopulmonary bypass. In addition, the LITA was long, and the spiral course of the twist was in the midportion of the graft.
In our unit we experienced the same thing: as long as twisting is in the midportion of a long arterial graft, it does not seem to affect patency. In contrast, twisting in the end portion of the arterial graft, near the distal anastomosis to the coronary vessel, is clearly hazardous, jeopardizing patency.
As experienced recently, a 70-year-old man underwent off-pump coronary artery bypass surgery with the right internal thoracic artery grafted to the circumflex artery and the LITA grafted to the LAD. Operative course (eg, rhythm, hemodynamics, electrocardiography, and transesophageal echocardiography) was uneventful. However, transit-time flow measurement of the LITA revealed borderline satisfactory results intermittently (Figure 1): the pulsatility index increased from 3.4 to 5.7, and the mean flow curve decreased intermittently from 34 to 12 mL/min (mean, 25 mL/min). On careful inspection of the LITA-to-LAD anastomosis, we noticed that the pedicle, which for safety reasons is fixed to the epicardium near the anastomosis, was fixed at 90° rotation. After revision of the pedicle fixation, transit-time flow measurement improved: pulsatility index decreased to 1.7, and mean flow curve increased to 77 mL/min.
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Figure 1. Before revision of the anastomosis, transit-time flow measurement of the LITA demonstrated low graft flow (mean, 25 mL/min; upper graph). After revision and refixation of the pedicle of the LITA (lower graph), the mean flow rate improved to 77 mL/min.
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Twisting of arterial grafts might occur.2 Although a redo operation is generally recommended, it might not be necessary in all cases. However, it has to be ensured that the graft is long enough and the spiral course of the twist is in the midportion and not near the anastomosis site.
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References
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- Sarma AK, Krishnamurthy SK, Siva VS, Karunakaran J, Sankaran NK. Twisting of pedicled left internal thoracic artery graft three hundred sixty degrees clockwise. does it change the outcome?. J 2004;128:617-618.
- Canver CC, Dame NA. Ultrasonic assessment of internal thoracic artery graft flow in the revascularized heart. Ann Thorac Surg 1994;58:135-138.[Abstract]
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