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Eur J Cardiothorac Surg 2007;31:276-282. doi:10.1016/j.ejcts.2006.11.025
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Graft design strategies with optimum antegrade bypass flow in total arterial off-pump coronary artery bypass

Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan

Received 21 August 2006; received in revised form 20 October 2006; accepted 14 November 2006.

^_* Corresponding author. Tel.: +81 6 6833 5012; fax: +81 6 6872 7486. (Email: hnakajim{at}hsp.ncvc.go.jp).

Objective: In arterial conduits, graft flow is one of the major determinants of long-term patency. We sought to delineate the effect of strategy for graft arrangement and design to three-vessel disease by evaluation of the dominant flow direction in each segment of a bypass graft. Materials and methods: We reviewed coronary angiograms of 1571 bypass grafts in 395 patients who underwent total arterial off-pump coronary revascularization without aortic manipulation for three-vessel disease since December 2000. The graft flow graded as A (antegrade), B (competitive), C (reverse), and O (no flow = occlusion). The current arrangement and design has been introduced since March 2003, and consists of the in-situ left internal thoracic artery (ITA) to the anterior descending artery and the composite I-graft of the right ITA and radial artery to the left circumflex (LCX) and right coronary artery (RCA) territories. Either clockwise or counterclockwise orientation, the I-graft was chosen to achieve a sufficient antegrade flow. Group I consisted of 181 patients with a single in-situ ITA as a composite Y-graft. Group II consisted of 214 patients with bilateral in-situ ITAs, which subdivided into Subgroup II-A consisted of 80 patients with bilateral in-situ ITAs until February 2003, and Subgroup II-B consisted of 134 patients with bilateral in-situ ITAs since March 2003. Results: The number of distal anastomoses was 3.52 ± 0.63 in Group I, and 4.36 ± 0.83 in Group II, respectively (p < 0.0001). The overall graft patency rate was 98.6% (1549/1571), and there was no significance different between the groups. The rate of grade A in Group II was 863/933 (92.5%) and was significantly higher (p = 0.049) than that of Group I 572/638 (89.7%). The rate of functioning bypass in Subgroup II-B was (95.8%) 568/593, and was significantly higher (p = 0.03) than that in Subgroup II-A (92.4%) 314/340. In Subgroup II-B, 233/268 (86.9%) of the conduits had completely grade A bypass flow, and this ratio was significantly higher (p = 0.04) than that in Subgroup II-A (79.4%) 127/160. Conclusion: Usage of bilateral ITAs and selecting the orientation of the I-graft to LCX and RCA branches provide maximal distal anastomotic sites with satisfactory graft patency rate, and simultaneously minimized the incidence of reverse and competitive flow.

Key Words: Off-pump • CABG • Arterial graft • Angiography