JTCS KCI
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
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gwozdziewicz, M.
Right arrow Articles by Richter, M.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Gwozdziewicz, M.
Right arrow Articles by Richter, M.
Related Collections
Right arrow Coronary disease

J Thorac Cardiovasc Surg 2008;135:693-694
© 2008 The American Association for Thoracic Surgery

Brief Communication

Arterial coronary revascularization failure as a result of coronary vasospasm

Marek Gwozdziewicz, MD, PhDa,*, Martin Sluka, MDb, Marek Richter, MDb

a Department of Cardiac Surgery, University Hospital, Olomouc, Czech Republic
b Department of Cardiology, University Hospital, Olomouc, Czech Republic

Received for publication September 26, 2007; accepted for publication November 15, 2007.

* Address for reprints: Marek Gwozdziewicz, MD, PhD, University Hospital Olomouc, I. P. Pavlova 6, 775 15 Olomouc, Czech Republic. (Email: gwozdziewicz{at}email.cz).


Figure 1
Dr Gwozdziewicz


Total arterial revascularization (TAR) is an option for the surgical treatment of ischemic heart disease.1Go It provides better long-term patency than do venous aortocoronary bypasses. TAR seems to offer the most benefit to the patient when combined with the off-pump "aorta no-touch" technique.2Go

Kobayashi and collegues3Go described a TAR technique that comprises two in situ internal thoracic arteries (ITAs) and a radial artery (RA) used as an I composite graft. They reported that to avoid the competition phenomenon in the graft, the distal end of the I composite should be placed on the right coronary artery (RCA) when this exhibits at least 80% stenosis.

Clinical Summary

A 76-year-old man was admitted to our department for elective coronary surgery. Preoperative angiography revealed triple-vessel disease with 40% left main coronary artery stenosis, 90% left anterior descending coronary artery stenosis, 90% diagonal artery stenosis, 80% circumflex artery stenosis, and at least 80% proximal RCA stenosis (Go Figure 1). Echocardiography showed good left ventricular function with no valve disease. The patient had extensive varicose veins on both lower extremities and negative results of an Allen test on both hands. A Doppler examination revealed RAs of good quality with adequate collateral flow.


Figure 1
View larger version (128K):
[in this window]
[in a new window]

  		Figure 1. Preoperative coronary angiogram showing at least 80% proximal right coronary artery stenosis (arrow).

 
Quadruple off-pump coronary bypass grafting was performed with the left anterior descending coronary artery bypassed individually by the left ITA. The diagonal artery, obtuse marginal artery, and posterior descending branch of the RCA were sequentially grafted with a crossover I composite composed of the right ITA and left RA. Perioperative flow measurement with a transit-time flow meter showed blood flows of 27 and 71 mL/min in the left and right ITAs, respectively, with respective pulsatility indexes of 1.7 and 1.4.

The postoperative course of the patient was uneventful. Postoperative coronary angiography, performed on postoperative day 6 as part of the study protocol, revealed competitive flow in the distal segment of the I composite (Go Figure 2). All sutured anastomoses were patent. There was 40% stenosis in the proximal RCA, in contrast to at least 80% on preoperative angiography.


Figure 2
View larger version (83K):
[in this window]
[in a new window]

  		Figure 2. Postoperative coronary angiogram showing competitive flow in distal segment of I composite graft (arrows).

 
Discussion

Most coronary arteries onto which bypass conduits are sutured are not completely occluded and maintain some native blood flow. Sometimes the flow competition between a native artery and a bypass conduit may cause reversal of blood flow in the sutured graft, leading to its closure. This phenomenon has been especially noted in arterial bypass.4Go

TAR with composite grafts is becoming more popular, but many surgeons are concerned about blood flow competition when such grafts are placed in the right coronary system. Kobayashi and colleagues3Go attempted to solve the problem of competition by suturing the distal end of a sequential I composite graft composed of the right ITA and RA to the RCA when the RCA exhibited at least 80% stenosis. For stenosis of the RCA less than 80%, they recommended grafting the RCA as the first in the sequence, side-to-side with the composite bypass. This graft orientation should decrease the risk of competition by maintaining the highest blood pressure wave in the anastomosis with the RCA.

Despite our adherence to the recommended rules, our patient had postoperative blood flow competition. This was caused, however, by a coronary vasospasm in the RCA that was misinterpreted as severe stenosis on the preoperative angiogram.

Our experience in this case demonstrates that it is critical for a surgeon who plans to perform the TAR with composite grafts to be aware of the possibility of coronary spasm, leading to overestimation of the degree of stenosis. This is especially important when the lesion is located in the proximal segment of the RCA, where spasm may be provoked by catheter insertion during coronary angiography.

References

  1. Tatoulis J, Buxton BF, Fuller JA, Royse AG. Total arterial coronary revascularization: techniques and results in 3,220 patients. Ann Thorac Surg 1999;68:2093-2099.[Abstract/Free Full Text]
  2. Lev-Ran O, Braunstein R, Sharony R, Kramer A, Paz Y, Mohr R, et al. No-touch aorta off-pump coronary surgery: the effect on stroke. J Thorac Cardiovasc Surg 2005;129:307-313.[Abstract/Free Full Text]
  3. Kobayashi J, Tagusari O, Bando K, Niwaya K, Nakajima H, Ishida M, et al. Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts. Heart Surg Forum 2002;6:30-37.[Medline]
  4. Nakajima H, Kobayashi J, Tagusari O, Bando K, Niwaya K, Kitamura S. Competitive flow in arterial composite grafts and effect of graft arrangement in off-pump coronary revascularization. Ann Thorac Surg 2004;78:481-486.[Abstract/Free Full Text]




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
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gwozdziewicz, M.
Right arrow Articles by Richter, M.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Gwozdziewicz, M.
Right arrow Articles by Richter, M.
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