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Marek Gwozdziewicz, MD, PhD, Petr Nemec, MD, PhD, Martin imek, MD,
Roman Hajek, MD, and Martin Troubil, MD
Department of Cardiac Surgery, University Hospital, Olomouc, Czech Republic
Background. The sequential bypass technique is a (individual bypass; D1) was 37.4 mL/min, and this was
routine method of myocardial revascularization. The aim not significantly influenced by the creation of a proximal
of this study was to determine flow characteristics of sequential anastomosis (D2, 39.0 mL/min). In 32% of the
individual and sequential bypass grafts created on the patients, the sequential bypass was unwittingly con-
beating heart. nected proximally to a larger coronary bed; despite this,
Methods. Between January 2003 and February 2004, a the flow in its distal segment was not less than that in the
consecutive series of 50 patients underwent off-pump individual bypass.
coronary bypass surgery with at least one venous sequen- Conclusions. The blood flow through an individual
tial coronary graft. During the procedure, flow values and bypass is comparable with that through the distal seg-
pulsatility indexes were measured in both segments of ment (end-to-side anastomosis) of a sequential bypass.
the sequential graft using a CardioMed transit time flow The grafting of a sequential bypass proximally to the
meter (CM 4008; Medi-Stim, Oslo, Norway). The flow larger artery (coronary bed) in sequence does not appear
values were simultaneously compared with those of to have a significant effect on the blood flow in the distal
individual venous grafts sutured to the same coronary segment of a sequential bypass.
arteries. (Ann Thorac Surg 2006;82:620 3)
Results. The mean flow through the distal anastomosis 2006 by The Society of Thoracic Surgeons
Table 1. Clinical Profile of Patients surements were repeated after the administration of 6 mg
saline-diluted papaverine (p) into the graft when the
No. (%) of
Variable Patients maximal flow (D1p, D2p, Pp, Tp) was estimated. This
provided assessment of the flow reserve. To test the
Coronary artery disease quality of the sutured anastomoses, in addition to flow
CARDIOVASCULAR
Left main 11 (22) measurement, PIs were recorded [9, 10]. The PI equals
Triple vessel 40 (80) the difference between the maximum (systolic) and min-
Hypertension 41 (82) imum (diastolic) blood flows divided by the mean flow,
Hyperlipidemia 29 (58) and its value should not exceed 5.0, in the case of a
Diabetes mellitus 22 (44) well-constructed bypass [10].
Stroke 7 (14) For each recording, attempts were made to maintain
Obesity 10 (20) the mean arterial pressure at 70 mm Hg.
Previous percutaneous coronary 4 (8) The recorded data were statistically analyzed using
intervention Statistica 6.0 software (StatSoft, Tulsa, Oklahoma). The
Left ventricular ejection fraction 52% (30%65%) recorded variables were compared using analysis of
variance (ANOVA) for dependent measurements, and
pairs of flow values and PIs were subsequently tested
rior descending artery (LAD) bypass, the construction of using Scheffes test. Differences among the pairs were
a venous sequential graft was commenced. assessed by the Sign test. Correlations between variables
To create an individual venous aortocoronary bypass, a were evaluated by Pearsons correlation coefficient.
distal (end-to-side) coronary anastomosis was per-
formed, followed by a proximal vein-to-ascending aorta
Results
anastomosis. At the same time, the first measurement
(D1) of coronary flow through the distal anastomosis A mean of 3.6 grafts per patient were completed in our 50
(individual bypass) was made using the CardioMed tran- patients. All grafted vessels had significant (70%) prox-
sit time flow meter (CM 4008; Medi-Stim, Oslo, Norway imal stenosis. Because both an individual bypass and the
[Fig 1]). distal segment of a sequential graft were anastomosed to
The operation continued with suturing of the proximal, the same coronary arteries, no attempt was made to
sequential, side-to-side anastomosis to another coronary statistically evaluate the effect of the degree of stenosis or
artery. This transformed the previous individual bypass the diameter of native coronary arteries on differences in
into a sequential one. At that point, blood flow through flow.
the distal (D2) and proximal (P) anastomoses and the Each patient received an individual mammary artery-
whole sequential graft (T) was measured. All the mea- to-LAD bypass as one of the grafts. Table 2 lists the types
Fig 1. Diagrams of the flow measurements. (A) Individual graft with the measurement of the flow through the distal anastomosis (D1, D1p).
(B) Sequential bypass graft with flow measurements in the distal (D2, D2p) and proximal (P, Pp) anastomoses, and total bypass flow assess-
ment (T, Tp). The flow was recorded before and after the administration of papaverine (p). The proximal flows (P, Pp) were measured after
clamping the vein with a bulldog clamp behind the side-to-side anastomosis (not shown).
622 GWOZDZIEWICZ ET AL Ann Thorac Surg
OPCABG SEQUENTIAL CORONARY BYPASS 2006;82:620 3
Table 2. Types of Sequential Graft Used in 50 Patients ration of the right ventricle during the intramyocardial
preparation of the LAD. One patient required repeat
No. (%) of
Coronary Arteries Patients surgery owing to bleeding. There were five wound com-
plications, two with complete sternum dehiscence. One
Circumflex and obtuse marginal 3 (6) patient suffered a mild pulmonary embolism. The post-
CARDIOVASCULAR
Circumflex and diagonal 5 (10) operative course in the remaining 45 patients was
Obtuse marginal 1 and obtuse marginal 2 6 (12) uneventful.
Obtuse marginal and high marginal 9 (18)
Obtuse marginal and diagonal 21 (42)
Comment
Diagonal and high marginal 1 (2)
Posterior descending and high marginal 1 (2) The advantages of the sequential bypass technique over
Posterior descending and obtuse marginal 1 (2) individual bypass conduit surgery have been reported
Posterior descending and right posterolateral 1 (2) previously [13].
Right posterolateral and obtuse marginal 2 (4) To assess the quality of sequential bypasses performed
on the beating heart, and to determine whether a con-
struction of a proximal side-to-side anastomosis alters
of sequential bypass used. None of the sequential grafts flow across the distal end-to-side anastomosis, we mea-
required revision owing to technical errors. sured the blood flow and PI in an individual bypass, and
Table 3 lists the blood flow values in relation to then in both segments of a sequential graft. An individual
hemodynamic parameters in a group of 50 consecutive bypass was first constructed using the off-pump tech-
patients. The mean flow through the distal anastomoses nique, which was subsequently transformed into a se-
(individual bypass) before papaverine administration quential type by creating side-to-side anastomosis. That
(D1) was 37.4 mL/min. After the creation of a proximal allowed us to maintain the same pathophysiologic con-
side-to-side anastomosis, the blood flow through the ditions in relation to vascular resistance, which was
distal anastomosis (D2) was 39.0 mL/min (p 0.9). A crucial for measuring the blood flow.
similar relationship between the groups of flow values Our main goal in coronary surgery is to provide a
was found after papaverine administration (D1p and long-lasting reconstruction of the coronary artery system
D2p). The mean flow through the proximal anastomoses with good graft patency. One of the recommended prin-
(P) of the sequential bypass was 36.9 mL/min. The mean ciples that should guarantee good patency of sequential
total flow through the sequential graft (T) was 69.4 grafts is suturing the last anastomosis in the sequence
mL/min. onto the largest vessel (coronary bed). That was not the
The increase in blood flow through the proximal anas- case in 32% of our patients. The flow capacity of a
tomosis of the sequential bypass after papaverin admin- coronary bed observed during papaverine-induced flow
istration was larger than the increase in flow through its measurement was not consistent with prior angiographic
distal anastomosis in 32% of the patients. We believe that estimation in these patients. Despite this, the blood flow
the measurement /degreeof the flow increase may be in the distal segment of the sequential bypass was not
related to the capacity of the coronary bed (which is less than that in the individual bypass.
responding to papaverine) supplied by the grafted coro- In our 50 consecutive patients, we have proved that the
nary artery. flow through an individual bypass was comparable with
All PI values remained within the normal range, thus that through the distal segment (end-to-side anastomo-
confirming the good patency of the sutured anastomoses. sis) of a sequential bypass (p 0.9), and this remained
No deaths occurred in our cohort. One patient had to unchanged after papaverine administration. The experi-
be converted to the on-pump procedure owing to perfo- mental studies of Rittgers and coworkers [11] and Mey-
Table 3. Blood Flow Through Anastomoses of Individual and Sequential Bypass, and Related Hemodynamic Variables in 50
Consecutive Patients
Flow SD MAP SD HR SD
(mL. min1) PI SD (mm Hg) (min1)
D1, D1p, D2, D2p, P, Pp, T, Tp flows through the anastomoses of the individual and sequential grafts without and with papaverine (p); HR heart
rate; MAP mean arterial pressure; mean value; PI pulsatility index.
Ann Thorac Surg GWOZDZIEWICZ ET AL 623
2006;82:620 3 OPCABG SEQUENTIAL CORONARY BYPASS
erson and colleagues [12] have shown that it is bypass sequential grafting as coronary bypass. Kokyu To Junkan
flow (namely, the wall shear stress) that determines the 1993;41:577 80.
4. Kieser TM, FitzGibbon GM, Keon WJ. Sequential coronary
degree of intimal proliferation, which may lead to bypass
bypass grafts. Long-term follow-up. J Thorac Cardiovasc
closure. Comparable blood flows through an individual Surg 1986;91:76772.
bypass with those across end-to-side anastomosis of the
CARDIOVASCULAR
5. Kim KB, Lim C, Lee C, et al. Off-pump coronary artery
sequential graft performed on a beating heart might bypass may decrease the patency of saphenous vein grafts.
predict similar patency of both types of bypass. Ann Thorac Surg 2001;72(Suppl):10337.
6. Kobayashi J, Tagusari O, Bando K, et al. Total arterial
The long-term patency of sequential off-pump by-
off-pump coronary revascularization with only internal tho-
passes has not been reported yet. A meticulous operative racic artery and composite radial artery grafts. Heart Surg
technique and intraoperative blood flow measurement in Forum 2002;6:30 7.
sutured grafts may disclose the presence of insufficient 7. Kobayashi J, Sasako Y, Bando K, et al. Multiple off-pump
flow due to technical errors, and prevent early bypass coronary revascularization with aorta no-touch technique
using composite and sequential methods. Heart Surg Forum
closure. The grafting of a sequential bypass proximally to
2002;5:114 8.
the larger artery in sequence does not appear to have a 8. Bergsland J, Karamanoukian HL, Soltoski PR, Salerno TA.
significant effect on the blood flow in the distal segment Single suture for circumflex exposure in off-pump coro-
of a sequential bypass. nary artery bypass grafting. Ann Thorac Surg 1999;68:1428
30.
9. Walpoth BH, Bosshard A, Kipfer B, Berdat PA, Althaus U,
We gratefully acknowledge the contribution of Zdenka Carrel T. Failed coronary artery bypass anastomosis de-
Michalikov, who prepared the diagrams for this article. tected by intraoperative coronary flow measurement. Eur
J Cardiothorac Surg 1998;14:S76 81.
10. DAncona G, Karamanoukian HL, Bergsland J. Is intraoper-
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