Guo-Wei He (Ed.) Arterial Grafting for Coronary Artery Bypass Surgery Second Edition

Guo-Wei He (Ed.) Arterial Grafting for Coronary Artery Bypass Surgery

Second Edition

Guo-Wei He (Ed.)

Arterial Grafting

for Coronary Artery Bypass Surgery

Second Edition

Foreword by Denton A. Cooley, Houston, USA

Contributions by

Floyd D. Loop, Cleveland, USA Bruce W. Lytle, Cleveland, USA Joseph F. Sabik, Cleveland, USA Hendrick B. Barner, St. Louis, USA Michael J. Mack, Dallas, USA Hartzell V. Schaff, Rochester, USA John Pym, Philadelphia, USA Alfred J. Tector, Milwaukee, USA David P. Taggart, Oxford, UK

Gianni D. Angelini, Bristol, UK Antonio M. Calafiore, Torino, Italy Christophe Acar, Paris, France Brian F. Buxton, Melbourne, Australia James Tatoulis, Melbourne, Australia Hisayoshi Suma, Tokyo, Japan Masashi Komeda, Kyoto, Japan Anthony P.C. Yim, Hong Kong and Other World Experts

With 148 Figures in 205 Parts and 77 Tables

Guo-Wei He (Ed.) Arterial Grafts for Coronary Bypass Surgery First published by Springer-Verlag Ltd., Singapore, 1999

ISBN 3-540-30083-X Springer-Verlag Berlin Heidelberg New York Library of Congress Control Number: 2005935948

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THE EDITOR: Professor Guo-Wei He, MD, PhD, DSc Clinical Professor of Surgery

Oregon Health and Science University (2002 –) and Director,

Cardiovascular Research, Albert Starr Academic Center for Cardiac Surgery, Providence Heart and Vascular Institute (1994 –), Portland, Oregon, USA Cardiac Surgeon-in-Chief

Department of Cardiac Surgery and Director,

Wuhan Heart Institute, The Central Hospital of Wuhan, China (2003 –) Research Professor of Surgery and Director

Cardiovascular Surgical Research,

The Chinese University of Hong Kong, Hong Kong (2000 –) Professor, Chair of Cardiothoracic Surgery

The University of Hong Kong, Hong Kong (1995 – 2000)

Foreword

Denton A. Cooley

Dr. Cooley is President and Surgeon-in-Chief, Texas Heart Institute, and Clinical Professor, University of Texas Medical School at Houston, Houston, Texas, USA Ischemic heart disease is the leading cause of death in the world today, and its inci- dence is likely to increase as the average age of the population continues to rise, par- ticularly in industrialized nations. In the 1950s, the prevalence and seriousness of is- chemic heart disease and the advent of effective cardiopulmonary bypass technology spurred surgeons to develop coronary artery bypass grafting (CABG) procedures.

Later, in the 1970s, percutaneous coronary interventions were devised as a less inva- sive alternative to CABG, and the number of these performed annually now sur- passes that of CABG surgery. Nonetheless, CABG remains among the most common cardiac surgical procedures, with more than 500,000 performed each year in the United States alone.

For these reasons, advances in CABG techniques have tremendous potential to save lives and improve their quality. This is particularly true for improvements in the durability of arterial conduits, the use of which is the central and most technically demanding portion of the CABG procedure. This book is meant to be a comprehen- sive resource for cardiac surgeons concerning arterial grafting and graft materials in CABG.

Many renowned cardiac surgeons and cardiovascular researchers have contribut- ed to this volume, which has been compiled by Guo-Wei He, MD, PhD, DSc.

Dr. He has published a huge body of literature about arterial grafting in CABG, and his extensive experience in, and deep understanding of, this subject has earned him global recognition. He currently serves as Director of Cardiovascular Research Pro- grams at the Chinese University of Hong Kong and the Providence Heart Institute in Portland, Oregon, and he is Clinical Professor of Surgery at the Oregon Health & Sci- ence University. Additionally, Dr. He directs the Wuhan Heart Institute in China, where he is also Chief of Cardiac Surgery.

The first edition of this book was written in 1999 to provide a detailed review of existing knowledge about the nature and selection of graft materials for CABG and the techniques used to harvest them and anastomose them to the coronary arteries.

Rapid progress in this field during the last 5 years has stimulated Dr. He to publish this updated edition. Not only has new material been added to the existing chapters, but there are also new chapters on venous grafts, reoperative CABG, and the recently developed practice of internal thoracic artery and radial artery T-grafting.

Readers will find this book valuable both as a practical guide and as a stimulus for further improvement of arterial grafting techniques and technology. I commend Dr. He and the many authors of this volume for the diligence and expertise they have demonstrated in its creation and revision.

Houston, Texas, USA Denton A. Cooley

Preface

Guo-Wei He

“Some books are to be tasted, others to be swallowed, and some few to be chewed and digested.“

Francis Bacon ( 1561–1626)

“Isn’t it a pleasure to study and practice what you have learned?“

Confucius (551–479 b.c.) Coronary artery disease remains the major cause of mortality worldwide. Despite aggressive application of percutaneous coronary interventions, the surgical ap- proach, namely coronary artery bypass grafting (CABG), remains a major approach for the treatment of coronary artery disease. Usage of arterial grafting has been well accepted as the main approach to increasing the long-term patency of the graft and long-term survival. However, the use of arterial grafts is not a simple issue. This is re- flected by the diversity in practice among most experienced cardiac surgeons around the world as to the choice of conduit, the combined use of various arterial grafts, pedicle versus free grafting, etc. The issue is further complicated by the usage of these grafts during conventional cardiopulmonary bypass or on beating hearts, the usage of minimally invasive surgery in CABG, and, moreover, by the fact that most surgeons are still using vein grafts in combination with arterial grafts. With all these concerns, a comprehensive book on CABG using arterial grafts has become essential for cardiac surgeons and related professionals such as cardiologists, cardiac anesthe- siologists, nurses, and other allied professionals for daily reference.

The first edition of this book was published in 1999 by Springer-Verlag. Since then, much experience has been obtained regarding arterial grafting in CABG. The princi- pal role of the left internal mammary artery (IMA) as the first choice of arterial graft stands without argument and the use of alternative arterial grafts has become more mature in the hands of most cardiac surgeons. However, various methods of using the left IMA in combination with alternative grafts are being used since the role of the lat- ter is defined differently among even most experienced cardiac surgeons. For example, use of the radial artery is routine practice by some surgeons but is ignored by others.

A similar attitude is held by surgeons as to the use of the gastroepiploic artery and in- ferior epigastric artery. This issue exists in the use of the second IMA, namely the right IMA. In addition, the use of complex arterial grafts remains subject to diverse opin- ions. Furthermore, much attention has been paid to the logical use of the minimally invasive technique. For example, the roles of minimally invasive direct coronary artery bypass (MIDCAB) and port-access technology have been redefined.

This second edition is an effort to provide the reader with the most advanced knowledge regarding the issues such as those mentioned above from world-renowned experts. To best reflect the current status of arterial grafting worldwide, new contribu- tors have been invited to write in their areas of expertise. I would particularly mention the contribution by these new authors and their colleagues in the second edition: Dr.

Bruce Lytle and Joseph Sabik from the Cleveland Clinic; Dr. Hendrick Barner from St.

Louis; Dr. Hartzell Schaff from the Mayo Clinic; Dr. Alfred Tector from Milwaukee; Dr.

Matthew Slater from Portland; Dr. Piet Boonstra from The Netherlands; Professor Gianni Angelini, Professor David Taggart, and Dr. Jamie Jeremy from the UK; and Professors Masashi Komeda, Masami Ochi, and Tohru Asai from Japan. I would also acknowledge the contribution of my colleagues Professor Anthony Yim, Dr. Song Wan, and Dr. Qin Yang at the Chinese University of Hong Kong. In addition to all the con- tributors for the first edition, they have made the book more complete.

The successful use of arterial grafts, i.e., the arterial conduit with a diameter of

around 2 mm, is largely related to the method of overcoming the vasospasm of the

graft in the perioperative period. With a more advanced understanding of the basic physiology and pharmacology of the arteries and veins used for grafting, this edition provides the newest information on the endothelial function and the method of overcoming vasospasm in the arterial grafts. The advancement of our basic knowl- edge of myocardial protection is also reflected in this edition.

There are a few chapters for which the original contributors are not contactable due to retirement or other reasons. In these cases where no new contributors could be identified, I did the relevant literature searches and updated the chapter myself.

These chapters are „Histology and Comparison of Arterial Grafts Used for Coronary Surgery,“ „Splenic Artery Grafting,“ and „Use of Subscapular-Thoracodorsal Artery for CABG.“ There is no new literature about inferior mesenteric artery grafting and I therefore wrote an update note for the chapter.

For the chapter on the comparison of unilateral and bilateral IMA grafting, after discussion with the original author, I rewrote the chapter with updated information to better reflect the current view.

On the other hand, to best reflect the use of vein grafts in combination with arteri- al grafts in most surgeons’ practice, this edition also includes a chapter on the role of vein grafts in CABG by myself, a chapter on gene therapy for vein graft disease, and a chapter on the prevention of vein graft failure. The use of arterial grafting in reope- rative CABG is included by presenting the large experience from the Cleveland Clin- ic. In the minimally invasive technique of arterial grafting, Dr. Michael Mack has combined his three chapters in the first edition into a new concise one with updated information. Two chapters on port access of CABG have been reduced to one in order to reflect the new trend in this area.

As one of the most pressing and controversial issues in coronary surgery today, the indications and results of coronary intervention and CABG are attracting the at- tention of all cardiac surgeons and cardiologists. The second edition therefore in- cludes a new chapter on the comparison between coronary intervention and CABG.

This edition also has an added section on quality control of arterial grafting by presenting the method of measuring the blood flow in the arterial graft. Further- more, to better reflect the American experience at large in arterial grafting, in addi- tion to the new chapter from Cleveland mentioned above on the use of arterial grafts in reoperative CABG, the experience on T-graft and internal thoracic artery-radial artery-T-graft from other centers is described in detail.

I would like to extend my great gratitude to the original contributors of the first edition who remain so in the second. These authors have made great efforts to pro- vide updates to their experience and have kept the book in step with the advance- ment of science and medicine. They have made the book a valuable addition to the reference library of cardiac surgeons, cardiologists, anesthesiologists, and all other professionals and scientists working in cardiovascular science and medicine.

As I mentioned above, our aim with the second edition is to make this book one of the few to be chewed and digested, as Francis Bacon said, and to make it a pleasure to study and be helpful in practice, as indicated by Confucius. It is up to the reader to judge whether this goal has been fulfilled.

Finally, I am deeply indebted to Dr. Albert Starr for his continual support and en- couragement to my work, not to mention that I have been the Director of Cardiovas- cular Research since 1994 at the Albert Starr Academic Center for Cardiac Surgery, the Providence Heart Institute, Portland, Oregon. I am also extremely grateful to Dr. Denton Cooley for the useful personal communications and for the foreword he warmly wrote for this edition. The secretarial assistance of Miss Ching-Yan Ng is greatly appreciated.

Portland, Oregon, USA Professor Guo-Wei He

Wuhan and Hong Kong SAR, China

X Preface

Contents

Foreword by Denton A. Cooley . . . VII Preface . . . IX

I Biological Characteristics of Arterial Grafts 1 Histology and Comparison of Arterial Grafts

Used for Coronary Surgery

J.A.M. van Son, F.M.M. Smedts, C.-Q. Yang,

G.-W. He . . . 3

1.1 Internal Mammary Artery . . . 3

1.2 Right Gastroepiploic Artery . . . 7

1.3 Inferior Epigastric Artery . . . 8

1.4 Radial Artery . . . 9

1.5 Intercostal Artery . . . 10

1.6 Comment . . . 11

References . . . 14

2 Endothelial Function and Interaction Between the Endothelium and Smooth Muscle in Arterial Grafts G.-W. He . . . 17

2.1 Endothelium-Derived Relaxing Factors . . . 17

2.2 Endothelium-Derived Contracting Factors . . . . 17

2.3 Vasoconstrictors and Vasospasm in Arterial Grafts . . . 17

2.4 Vasoconstrictor-Stimulated EDRF Release in Arterial Grafts . . . 19

2.5 Endothelium-Dependent Relaxation and Hyperpolarization in Arterial Grafts . . . 20

2.6 The Balance Between EDRFs and EDCFs . . . 21

References . . . 22

3 Clinical Physiology and Related Biological Characteristics G.-W. He . . . 24

3.1 Differences in Biological Characteristics Between Venous and Arterial Grafts . . . 24

3.2 Are There Any Differences Among Arterial Grafts? . . . 24

3.3 Biological Characteristics . . . 25

References . . . 29

4 Clinical Classification of Arterial Grafts G.-W. He, C.-Q. Yang . . . 31

4.1 Introduction . . . 31

4.2 Clinical Classification . . . 31

References . . . 34

II Use of Vasodilators for Arterial Grafts in Coronary Bypass Surgery 5 Pharmacological Studies and Guidelines for the Use of Vasodilators for Arterial Grafts G.-W. He, C.-Q. Yang . . . 39

5.1 Pharmacological Studies . . . 39

5.2 Factors Determining the Effects of Vasodilator Substances . . . 42

5.3 Guidelines for the Use of Vasodilators for Arterial Grafts in CABG . . . 44

References . . . 44

III Myocardial Protection During Coronary Bypass Surgery Using Arterial Grafts 6 Myocardial Management in Arterial Revascularization B.S. Allen, G.D. Buckberg . . . 51

6.1 Cardioplegic Prerequisites . . . 51

6.2 Cardioplegic Composition . . . 52

6.3 Blood Cardioplegia . . . 52

6.4 Operative Strategy . . . 53

6.5 Cardioplegia Pressure . . . 57

6.6 Retrograde Cardioplegia . . . 57

6.7 Specific Issues with all Arterial Conduits . . . . 59

6.8 Reperfusion . . . 59

6.9 Topical Hypothermia . . . 60

6.10 Conclusions . . . 61

References . . . 61

7 Cardiac Protection from the Viewpoint of Coronary Endothelial Function Q. Yang, G.-W. He . . . 63

7.1 Possible Mechanisms Underlying the Damage

of Cardioplegia and Organ Preservation

on Endothelial Function . . . 64

7.2 Influence of Cardioplegic and Organ

Preservation Solutions on Individual EDRFs 65 7.3 Influence of Different Components in

Cardioplegic and Organ Preservation

Solutions on Endothelial Function . . . 65

7.4 Effect of Different Additives to Cardioplegic or Organ Preservation Solutions on Endo- thelial Function . . . 66

References . . . 68

IV Percutaneous Coronary Interventions Versus Coronary Artery Bypass Surgery 8 Needle or Knife? A Comparison Between Percutaneous Coronary Interventions (Includ- ing Plain Balloon Angioplasty and Coronary Stenting) and Coronary Artery Bypass Surgery D.J. Drenth, P.W. Boonstra . . . 73

8.1 Introduction . . . 73

8.2 Percutaneous Coronary Interventions . . . 73

8.3 Coronary Artery Bypass Grafting . . . 73

8.4 PCI Versus CABG . . . 74

8.5 Drug Eluting Stents . . . 75

8.6 Revascularization Strategy . . . 76

References . . . 76

V Clinical Choice of Arterial Grafts 9 Considerations in the Choice of Arterial Grafts G.-W. He . . . 81

9.1 General Condition of the Patient . . . 82

9.2 Biological Characteristics . . . 82

9.3 Anatomy of the Coronary Artery . . . 84

9.4 Vessel Match Between the Graft and the Coronary Artery . . . 84

9.5 Technical Considerations . . . 84

9.6 Conclusion . . . 84

References . . . 84

VI Internal Thoracic Artery Grafting 10 History of Internal Thoracic Artery Grafting and Alternative Arterial Grafts M. Durairaj, B. Buxton . . . 89

10.1 Early Direct Arterial Revascularization Techniques . . . 90

10.2 Coronary Arteriography . . . 91

10.3 Saphenous Vein Coronary Artery Bypass . . . . 92

10.4 Internal Thoracic Artery Grafting . . . 92

10.5 Expanded Use of the ITA Graft . . . 92

10.6 Alternative Arterial Grafts . . . 93

10.7 ITA Grafts and Minimally Invasive Coronary Artery Bypass Grafting . . . 93

10.8 The Future . . . 93

References . . . 94

11 Surgical Techniques for Internal Thoracic Artery Grafting S. Seevanayagam, B. Buxton . . . 97

11.1 Introduction . . . 97

11.2 Anatomy . . . 97

11.3 Harvesting . . . 97

11.4 Histology . . . 100

11.5 Goals of Arterial Grafting . . . 100

11.6 Grafting Strategy . . . 101

11.7 Grafting Techniques . . . 101

11.8 Beating Heart Bypass Surgery . . . 103

11.9 Less Invasive Surgical Techniques . . . 103

11.10 Conclusions . . . 104

References . . . 104

12 Long-Term Results of Internal Thoracic Artery Grafting J.F. Sabik III, F.D. Loop . . . 105

12.1 Introduction . . . 105

12.2 History . . . 105

12.3 Patency . . . 105

12.4 Survival . . . 107

12.5 Freedom from Recurrent Ischemic Events 109 12.6 Conclusions . . . 110

References . . . 110

13 Bilateral Versus Unilateral Internal Thoracic Artery in Coronary Bypass Grafting E. Berreklouw, G.-W. He . . . 113

13.1 Introduction . . . 113

13.2 History . . . 113

13.3 Indications for Use of Bilateral ITAs . . . 113

13.4 Relative Contraindications . . . 114

13.5 Early Mortality . . . 114

13.6 Myocardial Infarction . . . 115

13.7 Late Results . . . 119

13.8 Postoperative Flow Measurements . . . 123

13.9 Late ECG-Stress Testing . . . 123

13.10 Late Blood Flow Studies . . . 123

13.11 Late Patency Rates . . . 124

13.12 Conclusions . . . 125

References . . . 125

14 Left-Sided Myocardial Revascularization with Bilateral Skeletonized Internal Thoracic Artery R. Mohr, A. Kramer . . . 130

14.1 Introduction . . . 130

14.2 Harvesting and Preparation of the Skeletonized ITA . . . 131

14.3 Strategies of Left-Sided Arterial Revascularization . . . 132

14.4 Clinical Results . . . 137

14.5 Comments . . . 137

References . . . 138

XII Contents

15 Free Compared with Pedicled Right Internal Thoracic Arteries for Coronary Artery Bypass Grafting

J. Tatoulis, B.F. Buxton, J.A. Fuller . . . 140

15.1 Introduction . . . 140

15.2 Materials and Methods . . . 140

15.3 Indications . . . 141

15.4 Surgical Technique . . . 141

15.5 Follow-up . . . 143

15.6 Results . . . 143

15.7 Discussion . . . 144

15.8 Conclusion . . . 146

References . . . 146

VII Radial Artery Grafting 16 History and Operative Technique C. Acar . . . 151

16.1 History . . . 151

16.2 Preoperative Assessment . . . 151

16.3 Operative Technique . . . 153

References . . . 155

17 Radial Artery Grafting: Clinical Antispastic Protocols G.-W. He . . . 156

17.1 GWH Protocol (Previously University of Hong Kong Protocol) . . . 157

17.2 Discussion . . . 160

References . . . 162

18 Radial Artery: Clinical Results C. Acar . . . 165

18.1 Early Results . . . 165

18.2 Late Results . . . 166

18.3 Conclusion . . . 169

References . . . 169

19 Angiographic Studies of the Radial Artery Graft C.A. Dietl . . . 171

19.1 Introduction . . . 171

19.2 Patients and Methods . . . 171

19.3 Surgical Technique . . . 171

19.4 Results . . . 172

19.5 Angiographic Studies . . . 172

19.6 Discussion . . . 174

References . . . 176

VIII Gastroepiploic Artery Grafting 20 Right Gastroepiploic Artery Grafting: History and Operative Techniques J. Pym . . . 181

20.1 Introduction . . . 181

20.2 Anatomy . . . 181

20.3 History . . . 181

20.4 Harvesting Technique . . . 184

20.5 Preparation of the Artery . . . 187

20.6 Routing the Pedicle . . . 187

20.7 Anastomotic Technique . . . 188

20.8 Perioperative Management . . . 191

20.9 Conclusion . . . 191

References . . . 191

21 The Right Gastroepiploic Artery Graft H. Suma . . . 193

21.1 Introduction . . . 193

21.2 Clinical Results . . . 193

References . . . 195

22 Technique and Results for Skeletonized GEA Using the Harmonic Scalpel in Combination with Other Arterial Grafts in Off-Pump Coronary Bypass Surgery T. Asai . . . 196

22.1 History of GEA Skeletonization . . . 196

22.2 A Technique for Skeletonizing GEA Using the Harmonic Scalpel . . . 197

22.3 Results of Skeletonized GEA in Combination with Skeletonized IMA in OPCAB . . . 199

22.4 Comments . . . 200

References . . . 200

IX Inferior Epigastric Artery Grafting 23 Inferior Epigastric Artery Grafting: History, Anatomy and Surgical Techniques L. Boro Puig, S. Almeida de Oliveira . . . 203

23.1 Historical Note . . . 203

23.2 Inferior Epigastric Artery . . . 203

23.3 Anatomy of the Epigastric Artery . . . 203

23.4 Surgical Technique . . . 204

23.5 Postoperative Angiography . . . 206

23.6 Remodeling of the IEA . . . 206

23.7 Clinical Experience . . . 207

References . . . 207

24 Inferior Epigastric Artery Grafting: Clinical Results F. Dagenais, L.P. Perreault, M. Carrier 208 24.1 Introduction . . . 208

24.2 Indications, Perioperative Mortality and Myocardial Infarction Rate . . . 208

24.3 Morbidity Related to IEA Harvesting . . . 208

24.4 Patency Rates . . . 209

24.5 Composite Grafts Using the IEA . . . 210

24.6 Conclusion . . . 210

References . . . 211

Contents XIII

X Rarely or Possibly Used Arterial Grafting 25 Splenic Artery Grafting

B. Blakeman, J. Pickleman, G.-W. He . . . . 215

25.1 Case Report . . . 215

25.2 Technique . . . 215

25.3 Use of the Splenic Artery Under Other Situations . . . 216

25.4 Discussion . . . 217

25.5 Conclusion . . . 217

References . . . 217

26 Use of the Subscapular-Thoracodorsal Artery for Coronary Artery Bypass Grafting G.-W. He, N.L. Mills . . . 218

26.1 Anatomical Notes . . . 218

26.2 Historic Notes . . . 218

26.3 Harvest of the Subscapular Artery . . . 219

26.4 Cannulation . . . 220

26.5 Clinical Notes . . . 220

26.6 Comment . . . 221

References . . . 222

27 Inferior Mesenteric Artery Grafting P. Shatapathy, B.K. Aggarwal . . . 223

27.1 Introduction and Anatomic Considerations . . 223

27.2 Physiopathologic Considerations . . . 224

27.3 Harvesting of Inferior Mesenteric Artery . . . 225

27.4 Clinical Experience . . . 226

27.5 Closing Comments . . . 226

References . . . 226

28 Ulnar Artery as a Coronary Artery Bypass Graft: Five-Year Experience A. Newcomb, E. Oqueli, B.F. Buxton . . . 227

28.1 Introduction . . . 227

28.2 Anatomy . . . 227

28.3 Patterns of Arterial Supply to the Forearm and Hand . . . 228

28.4 Surgical Technique . . . 228

28.5 Results . . . 230

28.6 Discussion . . . 231

References . . . 232

29 Descending Branch of Lateral Circumflex Femoral Artery Grafting T.O. Tatsumi, S. Minohara, K. Kondoh . . 233

29.1 Introduction . . . 233

29.2 Anatomy . . . 233

29.3 Surgical Procedure . . . 234

29.4 Results . . . 234

29.5 Comment . . . 235

References . . . 237

30 The Intercostal Artery: An “Ideal” Arterial Graft Awaiting Clinical Application L.C.H. John . . . 238

30.1 History . . . 238

30.2 Potential Advantages of Intercostal Arteries 238 30.3 Feasibility Studies . . . 239

30.4 The Future . . . 239

References . . . 240

XI Arterial Grafting Using Complex Grafts 31 Complex Arterial Grafts: Operative Techniques A.M. Calafiore, M. Di Mauro . . . 243

31.1 Internal Mammary Artery . . . 243

31.2 Right Gastroepiploic Artery . . . 245

31.3 Inferior Epigastric Artery and Radial Artery 245 31.4 Inferior Epigastric Artery . . . 245

31.5 Radial Artery . . . 246

References . . . 246

32 Complex Arterial Grafts: Clinical Results A.M. Calafiore, M. Di Mauro . . . 248

32.1 End-to-Side . . . 248

32.2 End-to-End . . . 248

32.3 End-to-Side/End-to-End . . . 248

32.4 BIMA Y Graft . . . 249

32.5 Radial Artery . . . 250

32.6 Inferior Epigastric Artery . . . 252

32.7 Conclusion . . . 252

33 Internal Thoracic Artery T-Grafting: Operative Technique and Long-Term Results A.J. Tector . . . 253

33.1 Introduction . . . 253

33.2 Developments Leading to T-Graft Technique 253 33.3 Advantages of ITA Grafts . . . 253

33.4 Operative Technique . . . 254

33.5 Failure of ITA Grafts . . . 256

33.6 Demographics of T-Graft Patients . . . 257

33.7 Results . . . 257

33.8 Comparison of Results . . . 259

33.9 Comment . . . 259

References . . . 260

34 Internal Thoracic Artery and Radial Artery T-Grafting: Operative Technique and Long- Term Results H.B. Barner . . . 261

34.1 Radial Artery . . . 261

34.2 Technique . . . 261

34.3 Harvest Complications . . . 263

34.4 Hypoperfusion . . . 263

34.5 Results . . . 264

34.6 Conduit Patency . . . 264

34.7 Conclusions . . . 264

References . . . 265

XIV Contents

XII Arterial Grafting in Reoperative Coronary Artery Bypass Surgery

35 Role of Internal Thoracic Artery Grafts in Reoperative Coronary Artery Bypass Surgery

J.F. Sabik III, B.W. Lytle . . . 269

35.1 Introduction . . . 269

35.2 Perioperative Risk of Internal Thoracic Artery Grafting at Reoperation . . . 269

35.3 Impact of Patent Internal Thoracic Artery Grafts on Perioperative Risk . . . 271

35.4 Internal Thoracic Artery Grafts and Survival after Coronary Reoperation . . . 273

35.5 Conclusions . . . 274

References . . . 274

XIII Quality Control of Arterial Grafting: Early Detection of Graft Patency and Flow 36 Flow Capacity of Arterial Grafts: Internal Thoracic Artery, Gastroepiploic Artery and Other Grafts M. Ochi . . . 279

36.1 Internal Thoracic Arteries . . . 279

36.2 Studies of Flow Reserve of the ITA . . . 279

36.3 Effect of Competitive Flow on the ITA and Remodeling . . . 280

36.4 Capability of ITA to Respond to Flow Demand . . . 280

36.5 Effect of Skeletonization on the Flow Capacity of the ITA . . . 281

36.6 Right Gastroepiploic Artery . . . 281

36.7 Pressure Characteristics of GEA . . . 281

36.8 Adequate Size of the GEA as a Graft . . . 281

36.9 Effect of Skeletonization on the Flow Capacity of the GEA . . . 283

References . . . 283

37 Intraoperative Graft Evaluation in Coronary Artery Bypass Grafting Using a 15-MHz High-Frequency Linear Transducer: Maintaining the Comprehensive Quality of Coronary Surgery H. Nakajima, M. Komeda . . . 285

37.1 Routine Evaluation of Graft, Artery and Anastomosis . . . 285

37.2 Troubleshooting with Anastomosis in OPCAB . . . 286

37.3 Revascularization of Intramuscular Coronary Artery in OPCAB . . . 286

References . . . 288

XIV Role of Venous Grafts in Arterial Grafting 38 Role of Venous Grafts in Combination with Arterial Grafting G.-W. He . . . 291

38.1 Introduction . . . 291

38.2 Recent Reports on the Long-Term Patency of SVG . . . 291

38.3 Methods to Improve SVG Patency . . . 292

38.4 Use of SVG in Combination with Arterial Grafts . . . 293

38.5 Use of SVG in Minimally Invasive CABG . . . 293

38.6 Surgical Strategy and Technique for the Use of SVG . . . 293

References . . . 296

39 Minimally Invasive Saphenous Vein Harvest- ing for Coronary Artery Bypass Grafting M.S. Slater . . . 298

39.1 Introduction . . . 298

39.2 Minimally Invasive Techniques for Saphenous Vein Harvest . . . 298

39.3 Limitations of Endoscopic Vein Harvest . . . . 299

39.4 Evolution and Technique of Endoscopic Technique at Our Institution . . . 301

39.5 Conclusion . . . 301

References . . . 302

40 Novel Strategies for the Prevention of Vein Graft Failure S. Wan, A.P.C. Yim, G.D. Angelini, J.Y. Jeremy . . . 303

40.1 Introduction . . . 303

40.2 Mechanisms Underlying Neointima Forma- tion, Graft Thickening and Atherogenesis . . 303

40.3 External Dacron Stents and Biodegradable Sheaths . . . 305

40.4 Endothelin-1

Antagonists . . . 306

40.5 Nitroaspirin . . . 308

40.6 Antioxidant Therapy . . . 308

40.7 Concluding Remarks . . . 309

References . . . 309

41 Gene Therapy for Vein Graft Disease D.G. Cable, H.V. Schaff . . . 311

41.1 Gene Therapy . . . 311

41.2 Saphenous Vein Graft Disease . . . 312

41.3 Vein Graft Gene Therapy . . . 313

41.4 Candidate Genes . . . 315

41.5 Future Directions . . . 318

41.6 Conclusion . . . 318

References . . . 318

Contents XV

XV Minimally Invasive Techniques in Arterial Grafting

42 Minimally Invasive Coronary Artery Bypass Surgery and the Role of Arterial Conduits

M.J. Mack . . . 323

42.1 MIDCAB Procedure . . . 323

42.2 Minimally Invasive CAB (Port Access) . . . 324

42.3 Off-Pump Coronary Artery Bypass Grafting (OPCAB) . . . 324

42.4 Multivessel Off-Pump Limited Access Surgery . . . 327

42.5 Hybrid Procedure . . . 327

42.6 Facilitating Technology for Minimally Invasive Arterial Grafting . . . 327

References . . . 329

43 Off-Pump Coronary Artery Bypass Grafting Using Arterial Grafts E. Buffolo, L.R. Gerola . . . 331

43.1 Extracorporeal Circulation . . . 331

43.2 When Can Myocardial Revascularization Without Extracorporeal Circulation Be Performed? . . . 332

43.3 Arterial Grafts and Off-Pump Myocardial Revascularization . . . 332

43.4 Operative Technique . . . 333

43.5 Clinical Experience . . . 334

References . . . 335

44 Comparison of the Effect of On-Pump and Off-Pump Coronary Artery Bypass Grafting on Neurological Events Y. Abu-Omar, D.P. Taggart . . . 337

44.1 Introduction . . . 337

44.2 Stroke . . . 337

44.3 Delirium . . . 338

44.4 Cognitive Impairment . . . 338

44.5 Conclusions . . . 339

References . . . 340

45 Closed-Chest Cardiopulmonary Bypass and Cardioplegia for Coronary Artery Bypass Surgery: History and Development J.I. Fann, T.A. Burdon . . . 342

45.1 Introduction . . . 342

45.2 History and Development . . . 342

45.3 Closed-Chest Cardiac Surgery and Robotics 345 45.4 Conclusions . . . 348

References . . . 348

Subject Index . . . 351

XVI Contents

List of Contributors

Yasir Abu-Omar, MB, ChB, MRCS John Radcliffe Hospital, Oxford, UK Christophe Acar, MD

Department of Cardiac Surgery, Hˆopital La Piti´e Salpˆetri`ere, Paris, France

Bhuvnesh Kumar Aggarwal, MS, MCh

Department of Cardiothoracic Surgery, Kasturba Medical College and Hospital, Manipal, India Bradley S. Allen, MD

Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Memorial Hermann Children’s Hospital, Houston, Texas, USA

Gianni D. Angelini, MD, FRCS

Bristol Heart Institute, University of Bristol, Bristol, UK

Tohru Asai, MD, PhD

Department of Surgery, Division of Cardiovascular Surgery, Shiga University of Medical Science, Seta Tsukinowacho, Otsu, Shiga, Japan Hendrick B. Barner, MD

Forest Park Hospital and the Division of Cardio- thoracic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA Eric Berreklouw, MD, PhD

Catharina Hospital Eindhoven, Eindhoven, ZA, The Netherlands

Bradford Blakeman, MD

Loyola University Medical Center, Maywood, Illinois, USA

Piet W. Boonstra, MD, PhD, FECTS

Department of Cardiothoracic Surgery, University Medical Center of Groningen, Groningen, The Netherlands

Gerald D. Buckberg, MD

Department of Surgery, Dacid Geffen School of Medicine at UCLA, Los Angeles, California, USA

Enio Buffolo

Department of Cardiovascular Surgery, Paulista School of Medicine, Federal University of S˜ao Paulo, S˜ao Paulo, Brazil

Thomas A. Burdon, MD

Department of Cardiothoracic Surgery, Stanford Uni- versity School of Medicine, Stanford, California, USA Veterans Affairs HCS, Palo Alto, California, USA Brian F. Buxton, MBBS, FRACS

Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia

David G. Cable, MD

Cardiovascular Surgery of Alexandria, LLC, Alexandria, Louisiana, USA

Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA Antonio Maria Calafiore, MD

Division of Cardiac Surgery, European Hospital, Rome, Italy

Michel Carrier, MD

University of Montreal, Montreal Heart Institute, Montreal, Canada

Denton A. Cooley, MD

Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA

University of Texas Medical School at Houston, Houston, Texas, USA

Fran¸cois Dagenais, MD

University Laval, Qu´ebec Heart Institute, Qu´ebec City, Canada

S´ergio Almeida de Oliveira, MD

Division of Thoracic and Cardiovascular Surgery, Heart Institute (InCor), University of S˜ao Paulo Medical School, S˜ao Paulo, Brazil

Charles A. Dietl, MD

Department of Surgery, University of New Mexico,

Albuquerque, New Mexico, USA

Michele Di Mauro, MD

G. D’Annunzio University, San Camillo de Lellis Hospital, Chieti, Italy

Derk J. Drenth, MD, PhD

Department of Cardiothoracic Surgery, University Medical Center of Groningen, Groningen, The Netherlands

Manoj Durairaj, MS, MCh

Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia

James I. Fann, MD

Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, USA Veterans Affairs HCS, Palo Alto, California, USA John A. Fuller, MB, BS, FRACP, FRCP (Edin)

Department of Cardiac Surgery and Cardiology, Epworth Hospital, University of Melbourne, Melbourne, Australia

Luis R. Gerola, MD

Department of Cardiovascular Surgery, Paulista School of Medicine, University of S˜ao Paulo, S˜ao Paulo, Brazil

Guo-Wei He, MD, PhD, DSc

Department of Surgery, Oregon Health and Science University, Providence Heart and Vascular Institute, Portland, OR, USA

Department of Cardiac Surgery, Wuhan Heart Institute, The Central Hospital, Wuhan, China Department of Surgery, The Chinese University of Hong Kong, Hong Kong

Jamie Y. Jeremy, PhD

Bristol Heart Institute, University of Bristol, Bristol, UK

Lindsay C.H. John, MBBS, MS, MD, FRCS

Kings College Hospital, Denmark Hill, London, UK Masashi Komeda, MD, PhD

Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan Keiichiro Kondoh, MD

Department of Thoracic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan

Amir Kramer, MD

Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Floyd D. Loop, MD

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Lyndhurst, Ohio, USA

Bruce W. Lytle, MD

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Michael J. Mack, MD

Cardiopulmonary Research Science and Technology Institute, Medical City Dallas Hospital, Dallas, Texas, USA

Noel L. Mills, MD

Department of Surgery, Tulane University Medical Center, New Orleans, Louisiana, USA

Seiichiro Minohara, MD

Tatsumi Clinic and Hospital, Ikeda, Osaka, Japan Raphael Mohr, MD

Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Hiroyuki Nakajima, MD

Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan Andrew Newcomb, MD, MBBS

Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia

Masami Ochi, MD

Division of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan

Ernesto Oqueli, MD

Epworth Hospital, Melbourne, Victoria, Australia Louis P. Perrault, MD

University of Montreal, Montreal Heart Institute, Montreal, Canada

Jack Pickleman, MD

Loyola University Medical Center, Maywood, Illinois, USA

Luiz Boro Puig, MD

Division of Thoracic and Cardiovascular Surgery, Heart Institute (InCor), University of S˜ao Paulo Medical School, S˜ao Paulo, Brazil

John Pym, MB, BS, FRACS, FRCSC, FACS

Lankenau and Frankford-Torresdale Hospitals and Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA

Joseph F. Sabik III, MD

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Hartzell V. Schaff, MD

Division of Cardiovascular Surgery, Mayo Clinic

College of Medicine, Rochester, Minnesota, USA

XVIII List of Contributors

Siven Seevanayagam, MBBS, MBBS, FRACS

Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia

Pitambar Shatapathy, MS, MCh, FACS, FIACS Department of Cardiothoracic Surgery, Kasturba Medical College and Hospital, Manipal, India Matthew S. Slater, MD, FACS

Department of Surgery, Division of Cardiothoracic Surgery, Oregon Health & Science University, Portland, Oregon, USA

Frank M.M. Smedts, MD, PhD

Department of Pathology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands

Hisayoshi Suma, MD

The Cardiovascular Institute, Roppongi, Minato-ku, Tokyo, Japan

David P. Taggart, MD, PhD, FRCS University of Oxford, Oxford, UK

Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK

James Tatoulis, MB, BS, MS, FRACS

Private Medical Centre, The Royal Melbourne Hospi- tal, University of Melbourne, Melbourne, Australia Takahiko O. Tatsumi, MD

Tatsumi Clinic and Hospital, Tenjin, Ikeda, Osaka, Japan

Alfred J. Tector, MD, MS

Midwest Heart Surgery Institute, Aurora St. Lukes Medical Center, Milwaukee, Wisconsin, USA Jacques A.M. van Son, MD, PhD

Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands

Song Wan, MD, PhD, FRCS(Eng)

Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Cheng-Qin Yang, MD

Starr Academic Center, Providence Heart and Vascu- lar Institute, St. Vincent Hospital, Portland, Oregon, USA

Qin Yang, MD, PhD

Department of Maternal and Fetal Medicine, Oregon Health and Science University, Portland, Oregon, USA and Department of Surgery, The Chinese University of Hong Kong, China

Anthony P.C. Yim, MD, FRCS, FACS, FCCP

Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

List of Contributors XIX