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Eur J Cardiothorac Surg 2002;21:794-799
© 2002 Elsevier Science NL

The results of radial artery Y-graft for complete arterial revascularization

Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Ankara, Turkey

Received 21 November 2001; received in revised form 4 February 2002; accepted 6 February 2002.

* Corresponding author. Tel.: +90-312-3045203; fax: +90-312-3229494
e-mail: atyilmaz{at}gata.edu.tr

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 
Objective: Harvesting of multiple arterial grafts is commonly associated with prolonged operating times and increased trauma in complete arterial coronary artery bypass grafting (CABG). Using sequential grafting techniques, CABG is possible with only two arterial grafts in multi-vessel coronary artery disease (CAD). However, sequential grafting may not be convenient for all circumstances and sometimes surgical technique may be challenging. We present our experience in the use of radial artery (RA) Y-graft on a routine basis. Methods: Between January 1996 and November 2001, 127 patients (aged 63±8 years) with the diagnosis of multi-vessel disease underwent complete arterial revascularization using left internal mammarian artery (LIMA) and RA. Left ventricular ejection fraction ranged from 23 to 65% (mean 51±11%). Triple-vessel disease was present in 73.2% of patients. We used the division technique of RA during harvesting and formation of one or more composite Y-grafts of the RA itself to allow end-side rather than sequential anastomoses without any significant decrease the usable conduit length. The results of this technique were compared with the data of patients (n=109) who underwent completely arterial CABG with the use of the multiple arterial grafts in the same period. Results: LIMA was anastomosed to the left anterior descending coronary artery (LAD) system in all patients. Two to four (mean 2.8±0.6) anastomoses were performed with RA Y-graft per patient. Proximal end of the radial graft was anastomosed to LIMA (60.6%) or aorta (39.4%). Mean operating time was 185 (45 min; bypass time, 68±23 min; and cross-clamp time, 49±17 min). Perioperative intraaortic balloon pump was necessary in five patients (3.9%). There was no operative mortality or morbidity. During the follow-up period of 2–30 months, none of the patients had any complication. Postoperative coronary angiography in 54 patients (42.5%) documented excellent early patency rates (LIMA 100%, and RA 98.1%). Conclusions: We believe that keeping our technique in their armamentarium will be useful for cardiac surgeons as an alternative method during complete arterial revascularization. This approach allows for complete arterial revascularization in multi-vessel CAD using only single IMA and RA grafts with excellent early results.

Key Words: Complete arterial revascularization • Radial artery • Y-graft technique

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 
Complete arterial coronary artery bypass grafting (CABG) is a surgical option to improve long-term results in the treatment of coronary artery disease (CAD). The goal of coronary artery bypass operations is complete revascularization and there is an increasing interest toward complete arterial revascularization to achieve this goal because of high late failure of saphenous vein graft [1,2].

The availability of arterial conduit which is long enough to perform complete arterial revascularization is the limitation of the procedure and it is mandatory to adjust length of the available graft to serve the need. To overcome this problem, sequential or/and composite grafting techniques are used and one conduit is used for more than one distal anastomoses or multiple arterial grafts are preferred [3]. Bilateral internal mammarian arteries (IMAs), the gastroepiploic artery (GEA), inferior epigastric artery and the radial artery (RA) have been used as conduits in selected patients. However, sequential grafting using arterial grafts may not be convenient for all circumstances and sometimes surgical technique may be challenging. Besides, classical Y-graft technique of RA has the disadvantage of shortening the graft. Harvesting multiple arterial conduits is more time consuming and may result in elevated operative trauma and perioperative complications (sternal dehiscence, sternal infection, pulmonary complications, required laparatomy, prolonged ICU time and hospitalization time, etc.) [4].

We describe a modification of radial Y-graft technique in which sidearm are each based on the previous sidearm for more than one end-side distal anastomoses without any significant shortening in graft length before initiating cardiopulmonary bypass, and report the results of coronary artery bypass operations using this technique.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 
Between January 1998 and December 2001, 127 patients with multi-vessel disease underwent complete-total arterial revascularization with left internal mammarian artery (LIMA) and RA using a new RA Y-graft technique in our department. Patients who had concomitant procedures (valve replacement, carotid endarterectomy, left ventricular aneurysmectomy, etc) were not included in this study.

There were 105 men and 22 (17.3%) women, with a mean age of 63±8 (range 47 to 73). The operative data for these completely arterially revascularized patients (Group I, n=127) with only LIMA and RA grafts were compared with the data for all patients (Group II, n=109) who underwent complete arterial CABG using LIMA, right IMA, RA or right GEA in the same period. When compared to the other group (Group II), the study group (Group I) included more patients with older age (63±8 versus 54±6 years, P<0.05), lower left ventricular ejection fraction (51±11 versus 58±7%, P<0.05), diabetes mellitus (38 versus 9.2%, P<0.05), chronic pulmonary obstructive disease (14.2 versus 5.5%, P<0.05) limiting use of bilateral IMA grafts. The other demographic characteristics of both groups were similar.

All operations were performed through median sternotomy, using cardiopulmonary bypass (CPB) and cardioplegic arrest. In Group II, pedicled bilateral IMAs were harvested routinely and RA was used as a third graft. Right GEA was used in 17 patients. LIMA, RIMA and right GEA were anastomosed to coronary artery individually. Longitudinal sequential anastomoses were performed with RA grafts as necessary (n: 43 patients). In group I, the CABG was performed with only two arterial conduits (in situ LIMA and RA Y-graft). Construction of the RA Y-graft and LIMA–RA composite graft were made before CPB. LIMA was anastomosed to the left anterior descending (LAD) coronary artery system in all patients. Other occluded coronary arteries were bypassed using RA Y-graft technique [5].

2.1. Surgical technique
RA of the non-dominant arm (n: 116, 91.4%) was chosen as the second graft in all patients with acceptable collateral perfusion as assessed by Allen's test, RA of the dominant arm was used in 11 (8.6%) patients. During LIMA graft harvesting, RA was dissected. Distal end of RA was cut and proximal end left in situ. The pericardium was opened and the distance between the proximal anastomosis and the first distal anastomosis was measured. In cases in which proximal end of the radial Y-graft was anastomosed to ascending aorta, the distance between the aorta and first distal anastomosis (usually diagonal or obtuse marginal branches) was measured with a silk suture or with the surgeon's left forefinger while the heart was full and beating.

When the RA Y-graft constructed as a composite graft with the LIMA, the distance between the left border of the main pulmonary artery and the first distal anastomosis was measured with the same method. In the remaining of the measured length from its origin of brachial artery, RA was divided and the distal segment was side-end anastomosed at 1–1.5 cm proximally to the in situ trunk (Fig. 1 ). If more than two distal anastomoses were planned, the distances between the other limbs of the radial Y-graft was measured both by cineangiographic views and by direct measurement on the beating heart. Right anterior oblique projection with 20–60° rotations and 20–30° caudal angulation, usually afford complete visualization of the left coronary system and provides optimal visualization for distal circumflex artery. The distance between the occluded coronary arteries that was planned to bypass was measured preoperatively at this projection and the real distance was calculated by proportion of external diameter of the catheter. During the operation, before establishing cardiopulmonary bypass, the heart was elevated by right hand of the surgeon and the real distances were measured with a pick-up or finger, and the angiographic measurements were checked. Leaving 1–2 cm additional distance to the measured ones, RA was divided and distal portion was side-end anastomosed to just proximal portion (Fig. 1). All side-to-end anastomoses of the RA Y-graft were performed using 7/0 prolene continuing sutures and constructing a Y form with 45–60° angle. The proximal anastomoses of each Y limb on the previous Y limb were performed as a Y anastomosis using running 7/0 polypropylene.

View larger version (48K): [in this window] [in a new window]   Fig. 1. Schematic view of the constriction of RA Y-graft in forearm.

In cases, in which composite graft of LIMA–RA was constructed, end-to-side anastomosis of the RA to the posterior aspect of the LIMA was done using running 8-0 polypropylene at the site where the LIMA enters the pericardial space adjacent to the left atrial appendage before cannulation. RA Y-graft and LIMA were filled with a solution of diluted papaverine after construction of the LIMA–RA composite graft and permitted to dilate under arterial pressure while preparations were made for CPB.

LIMA was anastomosed to left anterior descending artery in all patients. Other occluded coronary arteries were bypassed in an end-side fashion using RA Y-graft. All distal anastomoses were performed in an end-to-side fashion to the coronary arteries using 7-0 polypropylene suture under aortic cross-clamping. The most proximal limb of the RA Y-graft was anastomosed (to diagonal or obtuse marginal artery) first. The other limbs were anastomosed in order of proximal to distal and finally distal limb of the graft was anastomosed to posterodescending or posterolateral coronary arteries. If LIMA–RA composite graft had not been constructed, proximal anastomoses of the RA Y-graft were performed using a partial occlusion clamp on the ascending aorta and 7-0 polypropylene suture after release of aortic cross-clamp.

While deciding to construct a LIMA–RA composite graft or anastomosing the proximal end of the RA Y-graft to ascending aorta, the length of the RA (length of the patient's forearm), diameter and quality of LIMA, the width of the myocardial segments getting blood flow from LAD and the other coronary arteries, and quality of distal coronary arteries were taken into consideration. However, in all of the last seven cases proximal anastomoses were constructed to LIMA.

Intraluminal administration of 2% papaverine in heparinized arterial blood was used intraoperatively to prevent RA spasm. Intrapericardial ice slush was avoided. CPB was conducted at 32–33°C. Cardiac protection was achieved with antegrade blood cardioplegia at 20–25°C. Infusion of nitroglycerine (0.5–1 g/kg/min) was commenced on release of the aortic cross-clamp and continued routinely for 24 h. After CPB, mean arterial pressure was kept higher than 80 mmHg. Aspirin (300 mg) and nifedepine (30 mg, once daily, orally) were begun on the first postoperative day and maintained for 6 months. Aspirin was continued indefinitely.

Data were analyzed with the use of the StatView software package. All data are expressed as mean±SD. Operative data for the two groups were compared by unpaired t test. Regarding categorical data, the comparison between the groups was performed with ² tests.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 
No hemodynamic unstability or arrhythmia requiring pharmacological manipulation or urgent constitution of CPB occurred during elevation and visualization of posterior region of the heart. The distances that were calculated from cineangiographic views were same with the direct measured ones in 120 cases (95.5%). In 5.5% of the cases, they were 1–1.5 cm shorter than direct measurements.

Three to five (mean 3.8±0.6) anastomoses were performed per patient. LIMA was anastomosed to LAD artery system in all patients. Using RA Y-graft, 49 patients had three, 51 patients had two and 27 patients had four distal anastomosis (Table 1). Using this technique, total 357 end-to-side anastomoses were performed with RA Y-grafts limbs. The patterns of arrangements of RA Y-grafts are shown in Table 2. There was not any failure of the grafting strategy, only in three cases the distal limb did not reach the suitable area of the target coronary vessel. In these cases, localized open endarterectomy and little patch plasty (one with RA, two with LIMA) were performed before construction of distal anastomoses.

Prior to division of RA from brachial artery, blood flow of all limbs was controlled separately. In case of doubt about adequacy of flow, the anastomosis of the related limb was recontrolled. None of the anastomoses in this study was redone, but eight anastomosis that had lesser pulsatile flow than the others were evaluated with probe.

In group II, mean 3.6±0.6 distal anastomoses were performed per patient (P<0.05). When compared to the other arterial CABG group, there was not any difference related to mean cross-clamp times (49±17 versus 46±15, P>0.05), but the mean total operation and mean CPB time of the study group was significantly shorter (185± 45 versus 213±40 min, 68±23 versus 83±27 min, respectively). The incidence of an intra-aortic balloon pump support was 3.6% (n=4) in group II (P<0.05).

There was no operative mortality or morbidity. The implantation of an intra-aortic balloon pump was necessary in five (3.9%) patients. No signs of myocardial ischemia were encountered during early postoperative period. Postoperative bleeding with the need for revision was seen in two (1.5%) of the patients, and 90 (71%) of the patients required no blood transfusions during their hospital stay. These values were 6.4 and 92%, respectively, in group II (P>0.05). The amount of postoperative bleeding were elevated after bilateral harvesting of the IMA (1230±225 versus 765±110 ml, P<0.05). The overall incidence of sternal dehiscence or infection was zero. In group II, sternal dehiscence or infection was 2.7% (three patients) (Table 3).

	4. Conclusions

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 
Complete arterial revascularization is possible in triple-vessel disease by use of multiple arterial grafts or construction of sequential anastomoses. However, multiple arterial grafts harvesting may result in elevated operative trauma. By use of only two arterial grafts and avoidance of the harvesting of multiple arterial conduits, the operating time and postoperative complications are reduced compared with previous approaches of arterial revascularization [4].

One of the biggest problems encountered during complete arterial revascularization with one or two arterial grafts is difficulty to obtain sufficient graft length to perform multiple distal anastomosis. When a sequential anastomosis with an arterial graft is performed, a longitudinal (parallel to native coronary artery) anastomosis technique is preferable to a diamond-shaped (perpendicular to native coronary artery) technique because it provides wider ostium, causes less turbulent flow, prevents anastomotic stricture, avoids distortion of coronary artery or graft, and is easier technique to do [3,6–9]. However, the most important problem encountered during complete arterial revascularization using sequential anastomosis technique is insufficiency of graft length for the configuration of the graft, especially when more than two anastomoses are performed. To solve the problem of graft length insufficiency, a LIMA–RA artery composite graft can be constructed, but this may not be possible in every case for some reasons (e.g. poor quality of LIMA or two adjacent coronary branches) or there can still be same problem although it is anastomosed to LIMA.

In classical Y-graft technique, distal end of the graft is cut, and following distal anastomosis proximal end of the distal graft is anastomosed to the main trunk constructing Y or H form under cross-clamp or later [3,10]. In classical Y-graft technique, graft length is usually not long enough for more than two anastomoses. Compared with that technique, in our method the shortening of graft length is much less. In other words, to perform same number of distal anastomosis using classical Y-graft technique or sequential anastomosis technique one needs longer graft (Fig. 2 ). Construction of the classical Y-graft requires prolonged times of cardiac arrest and CPB time [3]. In addition, making a Y-graft in the pericardium is technically more difficult than doing one in the forearm. RA Y-graft constructed using this technique preserves its native taper property, and this provides more physiologic flow hemodynamics. Besides this, there are at least four advantages to constructing an RA Y-graft before it is severed from the brachial artery. Patency of the anastomoses can be tested using pulsatile blood. A minimal period of ischemia and maximal dilatation of the prepared graft is achieved by leaving it attached to the brachial artery until cross-clamp application or anastomoses to the LIMA. Any bleeding from an anastomosis or a little branch can be visualized and controlled easily. All proximal anastomoses of Y-graft segments are performed during preparation of the IMA, thus decreasing the time of operation [5]. Additionally due to the advantages of constructing RA Y-graft before disconnecting it from brachial artery, it is technically easier to perform side-to-end anastomoses while the graft is left in situ (comparing to performing the anastomoses in mediastinum or performing them following distal anastomosis like in classical Y-graft technique).

View larger version (34K): [in this window] [in a new window]   Fig. 2. Schematic view of the anastomoses performed at the posterior region of the heart using classical Y-graft, sequential graft and new Y-graft techniques. Longer graft is required to perform the same number of distal anastomoses in classical Y-graft and sequential graft techniques.

The major difficulty of this technique is correct measurements. The distances between the limbs of the RA Y-graft must be calculated properly because the graft is constructed before distal anastomoses are performed. The most important step is correctly gauging the distance between the proximal anastomosis of the RA Y-graft and the first distal anastomosis, and the distance between proximal anastomosis and the last distal anastomosis (the length of the Y-graft). There was no problem related to measurement and length of the limbs between the first and last limbs. We have encountered no problems related to measurement and lengths of the segments. Nevertheless, as a precaution, optimal length should be obtained by dissecting the RA from brachial artery to the wrist and by constructing LIMA–RA composite graft in cases in which the distal limb is anastomosed to the posterolateral or posterior descending branches.

As a result; we believe that this technique is better than the sequential grafting or to be reserved for those cases who are not suitable for sequential graft.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Conclusions References

 

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