Arterial Grafting for Coronary Artery Bypass Surgery (eBook)

Foreword 6
Preface 7
Contents 9
List of Contributors 15
I Biological Characteristics of Arterial Grafts 18
Histology and Comparison of Arterial Grafts Used for Coronary Surgery 19
1.1 19
Internal Mammary Artery 19
1.2 23
Right Gastroepiploic Artery 23
1.3 24
Inferior Epigastric Artery 24
1.4 25
Radial Artery 25
1.5 26
Intercostal Artery 26
1.6 27
Comment 27
References 30
Endothelial Function and Interaction Between the Endothelium and Smooth Muscle in Arterial Grafts 33
2.1 33
Endothelium-Derived Relaxing Factors 33
2.2 33
Endothelium-Derived Contracting Factors 33
2.3 33
Vasoconstrictors and Vasospasm in Arterial 33
Grafts 33
2.4 35
Vasoconstrictor-Stimulated EDRF Release 35
in Arterial Grafts 35
2.5 36
Endothelium-Dependent Relaxation 36
and Hyperpolarization in Arterial Grafts 36
2.6 37
The Balance Between EDRFs and EDCFs 37
References 38
Clinical Physiology and Related Biological Characteristics 40
3.1 40
Differences in Biological Characteristics 40
Between Venous and Arterial Grafts 40
3.2 40
Are There Any Differences Among Arterial 40
Grafts? 40
3.3 41
Biological Characteristics 41
References 45
Clinical Classification of Arterial Grafts 47
4.1 47
Introduction 47
4.2 47
Clinical Classification 47
References 50
II Use of Vasodilators for Arterial Grafts in Coronary Bypass Surgery 52
Pharmacological Studies and Guidelines for the Use of Vasodilators for Arterial Grafts 53
5.1 53
Pharmacological Studies 53
5.2 56
Factors Determining the Effects of Vasodilator 56
Substances 56
5.3 58
Guidelines for the Use of Vasodilators 58
for Arterial Grafts in CABG 58
References 58
III Myocardial Protection During Coronary Bypass Surgery Using Arterial Grafts 62
Myocardial Management in Arterial Revascularization 63
6.1 63
Cardioplegic Prerequisites 63
6.2 64
Cardioplegic Composition 64
6.3 64
Blood Cardioplegia ( Table 6.3) 64
6.4 65
Operative Strategy 65
6.5 69
Cardioplegia Pressure 69
6.6 69
Retrograde Cardioplegia 69
6.7 71
Specific Issues with all Arterial Conduits 71
6.8 71
Reperfusion 71
6.9 72
Topical Hypothermia 72
6.10 73
Conclusions 73
References 73
Cardiac Protection from the Viewpoint of Coronary Endothelial Function 75
7.1 76
Possible Mechanisms Underlying the Damage 76
of Cardioplegia and Organ Preservation 76
on Endothelial Function 76
7.2 77
Influence of Cardioplegic and Organ 77
Preservation Solutions on Individual EDRFs 77
7.3 77
Influence of Different Components in 77
Cardioplegic and Organ Preservation Solutions 77
on Endothelial Function 77
7.4 78
Effect of Different Additives to Cardioplegic 78
or Organ Preservation Solutions on Endothelial 78
Function 78
References 80
IV Percutaneous Coronary Interventions Versus Coronary Artery Bypass Surgery 83
Needle or Knife? A Comparison Between Percutaneous Coronary Interventions ( Including Plain Balloon Angioplasty and Coronary Stenting) and Coronary Artery Bypass Surgery 84
8.1 84
Introduction 84
8.2 84
Percutaneous Coronary Interventions 84
8.3 84
Coronary Artery Bypass Grafting 84
8.4 85
PCI Versus CABG 85
8.5 86
Drug Eluting Stents 86
8.6 87
Revascularization Strategy 87
References 87
V Clinical Choice of Arterial Grafts 89
Considerations in the Choice of Arterial Grafts 90
9.1 91
General Condition of the Patient 91
9.2 91
Biological Characteristics 91
9.3 93
Anatomy of the Coronary Artery 93
9.4 93
Vessel Match Between the Graft and the 93
Coronary Artery 93
9.5 93
Technical Considerations 93
9.6 93
Conclusion 93
References 93
VI Internal Thoracic Artery Grafting 96
History of Internal Thoracic Artery Grafting and Alternative Arterial Grafts 97
10.1 98
Early Direct Arterial Revascularization 98
Techniques 98
10.2 99
Coronary Arteriography 99
10.3 100
Saphenous Vein Coronary Artery Bypass 100
10.4 100
Internal Thoracic Artery Grafting 100
10.5 100
Expanded Use of the ITA Graft 100
10.6 101
Alternative Arterial Grafts 101
10.7 101
ITA Grafts and Minimally Invasive Coronary 101
Artery Bypass Grafting 101
10.8 101
The Future 101
References 102
Surgical Techniques for Internal Thoracic Artery Grafting 105
11.1 105
Introduction 105
11.2 105
Anatomy 105
11.3 105
Harvesting 105
11.4 108
Histology 108
11.5 108
Goals of Arterial Grafting 108
11.6 109
Grafting Strategy 109
11.7 109
Grafting Techniques 109
11.8 111
Beating Heart Bypass Surgery 111
11.9 111
Less Invasive Surgical Techniques 111
11.10 112
Conclusions 112
References 112
Long- Term Results of Internal Thoracic Artery Grafting 113
12.1 113
Introduction 113
12.2 113
History 113
12.3 113
Patency 113
12.4 115
Survival 115
12.5 117
Freedom from Recurrent Ischemic Events 117
12.6 118
Conclusions 118
References 118
Bilateral Versus Unilateral Internal Thoracic Artery in Coronary Bypass Grafting 121
13.1 121
Introduction 121
13.2 121
History 121
13.3 121
Indications for Use of Bilateral ITAs 121
13.4 122
Relative Contraindications 122
13.5 122
Early Mortality 122
13.6 123
Myocardial Infarction 123
13.7 127
Late Results 127
13.8 131
Postoperative Flow Measurements 131
13.9 131
Late ECG-Stress Testing 131
13.10 131
Late Blood Flow Studies 131
13.11 132
Late Patency Rates 132
13.12 133
Conclusions 133
References 133
Left- Sided Myocardial Revascularization with Bilateral Skeletonized Internal Thoracic Artery 138
14.1 138
Introduction 138
14.2 139
Harvesting and Preparation of the Skeletonized 139
ITA [16] 139
14.3 140
Strategies of Left-Sided Arterial 140
Revascularization 140
14.4 145
Clinical Results [35, 36] 145
14.5 145
Comments 145
References 146
Free Compared with Pedicled Right Internal Thoracic Arteries for Coronary Artery Bypass Grafting 148
15.1 148
Introduction 148
15.2 148
Materials and Methods 148
15.3 149
Indications 149
15.4 149
Surgical Technique 149
15.5 151
Follow-up 151
15.6 151
Results 151
15.7 152
Discussion 152
15.8 154
Conclusion 154
References 154
VII Radial Artery Grafting 156
History and Operative Technique 157
16.1 157
History 157
16.2 157
Preoperative Assessment 157
16.3 159
Operative Technique 159
References 161
Radial Artery Grafting: Clinical Antispastic Protocols 162
17.1 163
GWH Protocol (Previously University of Hong 163
Kong Protocol) 163
17.2 166
Discussion 166
References 168
Radial Artery: Clinical Results 171
18.1 171
Early Results 171
18.2 172
Late Results 172
18.3 175
Conclusion 175
References 175
Angiographic Studies of the Radial Artery Graft 177
19.1 177
Introduction 177
19.2 177
Patients and Methods 177
19.3 177
Surgical Technique 177
19.4 178
Results 178
19.5 178
Angiographic Studies 178
19.6 180
Discussion 180
References 182
VIII Gastroepiploic Artery Grafting 184
Right Gastroepiploic Artery Grafting: History and Operative Techniques 185
20.1 185
Introduction 185
20.2 185
Anatomy 185
20.3 185
History 185
20.4 188
Harvesting Technique 188
20.5 191
Preparation of the Artery 20.6 191
Routing the Pedicle 191
20.7 192
Anastomotic Technique 192
20.8 195
Perioperative Management 195
20.9 195
Conclusion 195
References 195
The Right Gastroepiploic Artery Graft 197
21.1 197
Introduction 197
21.2 197
Clinical Results 197
References 199
Technique and Results for Skeletonized GEA Using the Harmonic Scalpel in Combination with Other Arterial Grafts in Off- Pump Coronary Bypass Surgery 200
22.1 200
History of GEA Skeletonization 200
22.2 201
A Technique for Skeletonizing GEA Using 201
the Harmonic Scalpel 201
22.3 203
Results of Skeletonized GEA in Combination 203
with Skeletonized IMA in OPCAB 203
22.4 204
Comments 204
References 204
IX Inferior Epigastric Artery Grafting 205
Inferior Epigastric Artery Grafting: History, Anatomy and Surgical Techniques 206
23.1 206
Historical Note 206
23.2 206
Inferior Epigastric Artery 206
23.3 206
Anatomy of the Epigastric Artery 206
23.4 207
Surgical Technique 207
23.5 209
Postoperative Angiography 209
23.6 209
Remodeling of the IEA 209
23.7 210
Clinical Experience 210
References 210
Inferior Epigastric Artery Grafting: Clinical Results 211
24.1 211
Introduction 211
24.2 211
Indications, Perioperative Mortality and 211
Myocardial Infarction Rate 211
24.3 211
Morbidity Related to IEA Harvesting 211
24.4 212
Patency Rates 212
24.5 213
Composite Grafts Using the IEA 213
24.6 213
Conclusion 213
References 214
X Rarely or Possibly Used Arterial Grafting 215
Splenic Artery Grafting 216
25.1 216
Case Report 216
25.2 216
Technique 216
25.3 217
Use of the Splenic Artery Under Other 217
Situations 217
25.4 218
Discussion 218
25.5 218
Conclusion 218
References 218
Use of the Subscapular- Thoracodorsal Artery for Coronary Artery Bypass Grafting 219
26.1 219
Anatomical Notes 219
26.2 219
Historic Notes 219
26.3 220
Harvest of the Subscapular Artery 220
26.4 221
Cannulation 221
26.5 221
Clinical Notes 221
26.6 222
Comment 222
References 223
Inferior Mesenteric Artery Grafting 224
Update Note by the Editor 224
27.1 224
Introduction and Anatomic Considerations 224
27.2 225
Physiopathologic Considerations 225
27.3 226
Harvesting of Inferior Mesenteric Artery 226
27.4 227
Clinical Experience 227
27.5 227
Closing Comments 227
References 227
Ulnar Artery as a Coronary Artery Bypass Graft: Five- Year Experience 228
28.1 228
Introduction 228
28.2 228
Anatomy 228
28.3 229
Patterns of Arterial Supply to the Forearm 229
and Hand 229
28.4 229
Surgical Technique 229
28.5 231
Results 231
28.6 232
Discussion 232
References 233
Descending Branch of Lateral Circumflex Femoral Artery Grafting 234
29.1 234
Introduction 234
29.2 234
Anatomy 234
29.3 235
Surgical Procedure 235
29.4 235
Results 235
29.5 236
Comment 236
References 238
The Intercostal Artery: An “ Ideal” Arterial Graft Awaiting Clinical Application 239
30.1 239
History 239
30.2 239
Potential Advantages of Intercostal Arteries 239
30.3 240
Feasibility Studies 240
30.4 240
The Future 240
References 241
XI Arterial Grafting Using Complex Grafts 242
Complex Arterial Grafts: Operative Techniques 243
31.1 243
Internal Mammary Artery 243
31.2 245
Right Gastroepiploic Artery 245
31.3 245
Inferior Epigastric Artery and Radial Artery 245
31.4 245
Inferior Epigastric Artery 245
31.5 246
Radial Artery 246
References 246
Complex Arterial Grafts: Clinical Results 248
32.1 248
End-to-Side 248
32.2 248
End-to-End 248
32.3 248
End-to-Side/End-to-End 248
32.4 249
BIMA Y Graft 249
32.5 250
Radial Artery 250
32.6 252
Inferior Epigastric Artery 252
32.7 252
Conclusion 252
Internal Thoracic Artery T- Grafting: Operative Technique and Long- Term Results 253
33.1 253
Introduction 253
33.2 253
Developments Leading to T-Graft Technique 253
33.3 253
Advantages of ITA Grafts 253
33.4 254
Operative Technique 254
33.5 256
Failure of ITA Grafts 256
33.6 257
Demographics of T-Graft Patients 257
33.7 257
Results 257
33.8 259
Comparison of Results 259
33.9 259
Comment 259
References 260
Internal Thoracic Artery and Radial Artery T- Grafting: Operative Technique and Long- Term Results 261
34.1 261
Radial Artery 261
34.2 261
Technique 261
34.3 263
Harvest Complications 263
34.4 263
Hypoperfusion 263
34.5 264
Results 264
34.6 264
Conduit Patency 264
34.7 264
Conclusions 264
References 265
XII Arterial Grafting in Reoperative Coronary Artery Bypass Surgery 266
Role of Internal Thoracic Artery Grafts in Reoperative Coronary Artery Bypass Surgery 267
35.1 267
Introduction 267
35.2 267
Perioperative Risk of Internal Thoracic Artery 267
Grafting at Reoperation 267
35.3 269
Impact of Patent Internal Thoracic Artery Grafts 269
on Perioperative Risk 269
35.4 271
Internal Thoracic Artery Grafts and Survival 271
after Coronary Reoperation 271
35.5 272
Conclusions 272
References 272
XIII Quality Control of Arterial Grafting: Early Detection of Graft Patency and Flow 274
Flow Capacity of Arterial Grafts: Internal Thoracic Artery, Gastroepiploic Artery and Other Grafts 275
36.1 275
Internal Thoracic Arteries 275
36.2 275
Studies of Flow Reserve of the ITA 275
36.3 276
Effect of Competitive Flow on the ITA 276
and Remodeling 276
36.4 276
Capability of ITA to Respond to Flow Demand 276
36.5 277
Effect of Skeletonization on the Flow Capacity 277
of the ITA 277
36.6 277
Right Gastroepiploic Artery 277
36.7 277
Pressure Characteristics of GEA 277
36.8 277
Adequate Size of the GEA as a Graft 277
36.9 279
Effect of Skeletonization on the Flow Capacity 279
of the GEA 279
References 279
Intraoperative Graft Evaluation in Coronary Artery Bypass Grafting Using a 15- MHz High- Frequency Linear Transducer: Maintaining the Comprehensive Quality of Coronary Surgery 281
37.1 281
Routine Evaluation of Graft, Artery 281
and Anastomosis 281
37.2 282
Troubleshooting with Anastomosis in OPCAB 282
37.3 282
Revascularization of Intramuscular Coronary 282
Artery in OPCAB 282
References 284
XIV Role of Venous Grafts in Arterial Grafting 285
Role of Venous Grafts in Combination with Arterial Grafting 286
38.1 286
Introduction 286
38.2 286
Recent Reports on the Long-Term Patency 286
of SVG 286
38.3 287
Methods to Improve SVG Patency 287
38.4 288
Use of SVG in Combination with Arterial Grafts 288
38.5 288
Use of SVG in Minimally Invasive CABG 288
38.6 288
Surgical Strategy and Technique for the Use 288
of SVG 288
References 291
Minimally Invasive Saphenous Vein Harvesting for Coronary Artery Bypass Grafting 293
39.1 293
Introduction 293
39.2 293
Minimally Invasive Techniques for Saphenous 293
Vein Harvest 293
39.3 294
Limitations of Endoscopic Vein Harvest 294
39.4 296
Evolution and Technique of Endoscopic 296
Technique at Our Institution 296
39.5 296
Conclusion 296
References 297
Novel Strategies for the Prevention of Vein Graft Failure 298
40.1 298
Introduction 298
40.2 298
Mechanisms Underlying Neointima Formation, 298
Graft Thickening and Atherogenesis 298
40.3 300
External Dacron Stents and Biodegradable 300
Sheaths 300
40.4 301
Endothelin- 1A Antagonists 301
40.5 303
Nitroaspirin 303
40.6 303
Antioxidant Therapy 303
40.7 304
Concluding Remarks 304
References 304
Gene Therapy for Vein Graft Disease 306
41.1 306
Gene Therapy 306
41.2 307
Saphenous Vein Graft Disease 307
41.3 308
Vein Graft Gene Therapy 308
41.4 310
Candidate Genes 310
41.5 313
Future Directions 313
41.6 313
Conclusion 313
References 313
XV Minimally Invasive Techniques in Arterial Grafting 316
Minimally Invasive Coronary Artery Bypass Surgery and the Role of Arterial Conduits 317
42.1 317
MIDCAB Procedure 317
42.2 318
Minimally Invasive CAB (Port Access) 318
42.3 318
Off-Pump Coronary Artery Bypass Grafting 318
(OPCAB) 318
42.4 321
Multivessel Off-Pump Limited Access Surgery 321
42.5 321
Hybrid Procedure 321
42.6 321
Facilitating Technology for Minimally Invasive 321
Arterial Grafting 321
References 323
Off- Pump Coronary Artery Bypass Grafting Using Arterial Grafts 325
43.1 325
Extracorporeal Circulation 325
43.2 326
When Can Myocardial Revascularization 326
Without Extracorporeal Circulation Be Performed? 326
43.3 326
Arterial Grafts and Off-Pump Myocardial 326
Revascularization 326
43.4 327
Operative Technique 327
43.5 328
Clinical Experience 328
References 329
Comparison of the Effect of On- Pump and Off- Pump Coronary Artery Bypass Grafting on Neurological Events 331
44.1 331
Introduction 331
44.2 331
Stroke 331
44.3 332
Delirium 332
44.4 332
Cognitive Impairment 332
44.5 333
Conclusions 333
References 334
Closed- Chest Cardiopulmonary Bypass and Cardioplegia for Coronary Artery Bypass Surgery: History and Development 336
45.1 336
Introduction 336
45.2 336
History and Development 336
45.3 339
Closed-Chest Cardiac Surgery and Robotics 339
45.4 342
Conclusions 342
References 342
Subject Index 344