Configurations of Arterial Grafts: In situ vs. composite arterial conduits

Transcription

1 Advanced Techniques for State of the Art CABG Session AATS 2015 Configurations of Arterial Grafts: In situ vs. composite arterial conduits David P Taggart MD PhD FRCS FESC Professor of Cardiovascular Surgery, University of Oxford Conflicts of Interest:None

2 In Situ or Composite ( Y ): BIMA In Situ Composite Advantages Technically easy More Distal Anastomoses No Midline Cross Do not need Distal RIMA Disadvantages Cross Midline 20% too short Uses distal RIMA (spasm) and devascularizes xiphisternum 4 Questions re In Situ or Composite Technically more complex All eggs in one basket 1 Patency? 2 Adequate flow to supply whole heart? 3 Functionality of free IMA (denervation)? 4 Clinical Outcomes?

3 [CIRC 2008] o 304 patients o Anastomoses In situ (2.4) vs Composite (3.2): p<0.001 o 6 month patency 97% of 295 In situ 97% of 464 composite

4 [JTCVS 2010] o 17 composite Y grafts studied at 6 months (RITA 10; SVG 7)

5 locate/ ej cts Endot helium-dependent and endot hel ium-independent vasodilat or response of left and right internal mammary and internal thoracic arteries used as a composite Y-graft Abst ract David Glineur *, Sophia Dj aoudi, William D horre, Olivier Gurne, Ast rid Delouvroy, Laurent de Kerchove, Gebrine El Khoury, Claude Hanet Depart ment of Cardiovascular Medicine and Surgery of t he Universit é Cat holique de Louvain Medical School, Brussels, Belgium 11 patients 3 years after CABG Received 4 August 2010; received in revised form 16 November 2010; accepted 23 November 2010; Available online 28 January 2011 Obj ective: The manner in which a blood vessel is for used as a coronary graft may be important in maintaining a viable and functional endothelial lining. Composite internal thoracic arteries (ITAs) in a Y-graft configuration are characterized by the connection of an in sit u left ITA with preserved innervation and lymphatics and of a free semi-skelet onized right ITA. Methods: To determine whether endothelial function differs between left and right ITA segments in a Y-graft configuration, 11 patients were studied 3 years after surgery. The endothelium-dependent vasodilator substance P was selectively infused ( pmol min 1 in doubling dose increments) in the ostium of ITA Y-grafts. A maximal endot heli um-independent vasodilat ory response was t hen obt ained by int ragraft infusion of 2 mg isosorbide dinit rat e (ISDN). Biplane angiograms obt ained at 3-min int ervals using an aut omat ed cont rast inj ect ion syst em wit h fixed preset volume and pressure paramet ers were analyzed offline using a quant it at ive analysis syst em (CAAS, Pie Medical). Result s: A similar dose-dependent vasodilat ory response to subst ance P was observed in t he left and in t he right ITA. No difference in maximal endot helium- dependent response to subst ance P( %in t he left ITA and %in t he right ITA) or in maximal endot heli um-independent response to ISDN ( %in t he left ITA and %in t he right ITA) was observed. Conclusions: The endot heli um-dependent and t he endot heli um-independent vasodilat or capacit y of t he t wo branches of a Y-graft ITA configuration appear similar 3 years after bypass surgery. This suggests that the preservation of the ITA pedicle does not significantly affect basal vasomotor tone, long-term endothelial function, or vasodilator reserve. # 2010 European Associat ion for Cardio-Thoracic Surgery. Published by Elsevier B.V. All right s reserved. Keywords: Surgery; Bypass; Coronary disease; Endothelial function; Internal thoraci c artery [EJCTS 2011] 1. Introduction The superiority of the internal t horacic artery (ITA) over venous graftshas been demonst rated by several long-term follow-up studies [1,2]. The superior pat ency of the ITA is thought to result from a bet t er capacit y of the endothelium to release dilator substances, particularly nitric oxide (NO) [ 3, 4] and t o prot ect t he graf t against vasospasm and at herot hrombosis [ 5]. Observat ional st udies suggest t hat bilat eral ITA (BITA) could improve long-t erm survival of pat ient s when compared wit h t he associat ion of a single ITA implant ed into t he left ant erior descending (LAD) coronary art ery with one or several saphenous vein graft s (SVGs). A limit ation of the use of BITA as in si tuleft and right graftsis the lengt h of the right ITA that limits t he possibilities to reach distal branches of the left circumflex syst em. To allow more extensive revascularizat ion of the left coronary artery syst em using segments of ITA of sufficient diameter, Barra and Tector [6,7] have proposed the use of composite Y- or T- graft s. In t hese configurat ions, a free proximal segment of the right ITA is connect ed proximally to the in sit u left ITA and dist ally tooneor several branchesof theleft circumflex. In contrast t o the free right ITAsegment, t he innervat ion and the lymphat ic drainage of t he pedicled lef t ITA are preserved. Uncertainties remain whether section and the resulting denervation of the right ITAcould affect basal vasomotor tone, vasodilat or reserve, or endot helial funct ion. The present st udy was designed to compare the endothelium-dependent and endot helium-independent vasodilat or response of the t wo CONCLUSION: RIMA used as free graft does not affect basal vasomotor tone, endothelial function or vasomotor reserve

6 [JTCVS 2014]

7 RI MA BI MA CONFI GURATI ONS LlI MA LI MA RI MA I nt d OM LAD OM LAD OM I nt d Diag RI MA LlI MA LAD OM

8 In situ vs. composite arterial conduits No difference in patency, endothelial function or vasomotor reserve when BIMA used In situ or as Composite Grafts Composite grafts allow more distal anastomoses, avoid the need to use distal RIMA and avoid crossing midline

9 o 43 patients (mortality 5%) o 6 BIMA (mortality 0%) o Graft Flow Measurements (45ml/min (range 30-60ml/min) o Repeat Angiography at 2-3 weeks 97% patency

10 BI MA SKELETONI Z ATI ON Preparat ion: Harvest, divide dist ally and clip Wrap in papaverine swab + increase BP t o 150 f or 5 mins No need t o heparinize!!!! No need t o inj ect ARTERY Longer Wider See Full Lengt h Easier composit es Easier sequent ials CHEST WALL Not denuded Less Bleeding Bet t er Healing

11 224 patients 1 year angio patency 98% SVG and 97% RITA [JTCVS 2014]