Technical Aspects of Composite Arterial Grafting With Double Skeletonized Internal Thoracic Arteries*

Background: Complete myocardial revascularization with internal thoracic arteries (ITAs) improves long-term survival and decreases the rate of repeat operations, compared to vein grafts. Adequate length of the graft in coronary artery bypass graft (CABG) surgery is essential for providing complete arterial revascularization. Extra length can be obtained by skeletonization of both ITAs. In cases where the right ITA (RITA) is too short to bridge the distance to the target anastomotic site, it is used as a free graft in "composite" arterial grafting, a surgical technique in which free arterial conduits are proximally anastomosed end-to-side to an intact ITA. Objectives: To describe alternative surgical procedures adapted to accommodate special anatomic requirements. Design: Retrospective study from April 1996 to April 1999. Patients: One thousand fifty patients underwent CABG surgery using bilateral skeletonized ITAs: 650 patients (482 men and 168 women; mean ؎ SD age, 69 ؎ 7 years) underwent composite arterial grafting. Two hundred sixteen patients (33.2%) were diabetics, 87 patients (13.4%) had severe left ventricular dysfunction (ejection fraction < 35%), and 27 patients (4.2%) underwent emergency operations. Interventions: The RITA was used as a free graft connected to the in situ left ITA (LITA) in 618 patients. A free LITA was attached to in situ RITA in 32 patients, and minicomposite grafts (free distal LITA on the LITA or free distal RITA on the RITA) were constructed in 38 patients. The average number of grafts was 3.2 per patient (range, 2 to 6 grafts per patient). Measurements and results: Operative mortality was 2.9% (n ‫؍‬ 19), and there were 11 sternal wound infections (1.7%). Early recatheterization was performed in 41 symptomatic patients. The patency rate was 95%. The mean follow-up was 25 months (range, 14 to 36 months), and the 3-year survival was 92.5%, with 97% of the surviving patients being angina free. Conclusions: Planning CABG surgery using bilateral skeletonized ITAs as arterial conduits affords greater choice in grafting approaches, especially when a composite technique is feasible. (CHEST 2003; 123:1348 -1354

The Bruce Rappaport School of Med-icine (Mr. Domany), the Technion

Objective: A cerebrovascular accident (CVA) is a devastating complication of coronary artery bypass grafting (CABG) and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography (EAUS) would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly. Methods: After undergoing a mid-sternotomy for CABG, 105 patients underwent EAUS with an 8-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS. Results: The preoperative strategy had assigned 105 patients to the "touched aorta" group that was planned for either on-pump or off-pump CABG (OPCAB) with proximal anastomosis to the aorta. Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients (38%), with the lesions detected in 22 patients (21%) by both palpation and EAUS, and in 18 patients (17%) by EAUS alone. The planned surgical strategy was changed in 29 patients (28%): 25 patients (24%) were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping, and proximal anastomosis site in 4 patients (4%). Among the changes in surgical decision making, changes in 11 patients (10%) were based on lesion detection by both manual palpation and EAUS; in 18 patients (17%), changes resulted from pathologic evidence provided by EAUS alone. Conclusions: This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta. This investigation contributes new data on the effect of EAUS on intraoperative surgical approach in the era of OPCAB. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures. (CHEST 2005; 127:60 -65) Key words: cerebrovascular accident; coronary artery bypass; epiaortic ultrasound Abbreviations: CABG ϭ coronary artery bypass grafting; CVA ϭ cerebrovascular accident; EAUS ϭ epiaortic ultrasonography; OPCAB ϭ off-pump coronary artery bypass; PVD ϭ peripheral vascular disease; TEE ϭ transesophageal echocardiography A dverse neurologic sequelae following coronary artery bypass grafting (CABG) are relatively common and are associated with substantial increases in mortality, length of hospitalization, and the need for intermediate or long-term care facilities. 1 Adverse cerebral outcomes have been reported to occur in 6.1% of these patients. Preoperative risk factors to develop ischemic stroke after CABG include age, preexisting cerebrovascular disease, and atherosclerosis of the ascending aorta. 2 Atheroscle