Eur J Cardiothorac Surg 2002;22:1036
© 2002 Elsevier Science NL
Reply to Hirose and Amano
Gilmar G. Santos*,
Noedir A.G. Stolf
Department of Cardiovascular Surgery, Hospital Beneficencia Portuguesa and Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
Received 28 August 2002;
accepted 4 September 2002.
* Corresponding author. Tel./fax: +55-11-2880-474
e-mail: gilmargsantos{at}uol.com.br
Key Words: Gastroepiploic artery • Radial artery • Coronary
We would like to answer the questions of Drs Hirose and Amano. As we detailed in the text, randomization was applied using the StateMate software after inclusion and exclusion protocols and patients agreement to enter the study. This was approved by the ethical committees of two institutes (Hospital Beneficência Portuguesa and Heart Institute of University of São Paulo). Patients were not pre-selected regarding any characteristic, for example diabetes, hypertension, tobacco use, and the incidence of diabetes was not so different from others [1]. We sought to expand the use of gastroepiploic artery (GEA) for lateral coronary branches avoiding proximal anastomoses in ascending aorta, and compared the results to radial artery (RA). Composite grafts have been used for many years in several countries, in routine basis, with good results and its concept has been widely discussed [2–4], and not only to avoid calcified aorta. After training, it is not so demanding. Before this study, we had performed approximately 800 composite grafts with RA (approximately 120 underwent angiography). Nowadays this number exceeds 2000. We used the concept of ‘perfect patency rate’, it was 68.9% for GEA, despite the patency rate of 82.7% (five occluded grafts), and high incidence of spasms (four grafts, 13.8%). The benefits of the use of bilateral mammary artery was not clear in other papers [1,5] and results of right mammary artery to lateral and inferior branches is not the same as for left mammary artery to left anterior descending (LAD) [6]. Otherwise, patency rate of RA was as much as 95.6%. The reasons we did not use bilateral mammary artery in this study were also explained in the text. We do favor the use of arterial grafts but in selected coronary branches. Preliminary data of GEA was of ‘in situs’ grafts, not composite graft. Off-pump coronary artery bypass grafting (CABG) is a matter of choice and depends on results, individual preferences and cost, which is different for each country. By the time this study had been finished, a survey in Toronto (AATS – 2000) showed that the majority of the surgeons all around the world applied off-pump CABG in only 20–30% of the cases. Of course, this number has now changed. We also wanted to avoid the effect of off-pump CABG learning curve on the results. The protocol was designed to achieve similarity between the groups and the same technique was applied. We expected to find better or similar results of GEA composite graft compared to GEA ‘in situs’ and RA grafts and we were also disappointed, but it was what we found not what we would like.
References
- Dewar L.R.S., Jamieson W.R.E., Janusz M.T. Unilateral versus bilateral internal mammary revascularization: survival and event-free performance. Circulation 1995;92(Suppl. 2):8-13.[Abstract/Free Full Text]
- Calafiore A.M., Giammarco G., Luciani N., Maddestra N., Nardo E., Angelini R. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg 1994;58:185-190.[Abstract]
- Royse A.G., Royse C.F., Raman J.S. Exclusive Y graft operation for multivessel coronary revascularization. Ann Thorac Surg 1999;68:1612-1618.[Abstract/Free Full Text]
- Sundt T.M., III, Barner H.B., Camilo C.J., Gay W.A., Jr. Total arterial revascularization with an internal thoracic artery and radial artery T graft. Ann Thorac Surg 1999;68:399-405.[Abstract/Free Full Text]
- Sergeant P., Blackstone E., Meyens B. Does extensive arterial revascularization decrease the early and long term risk of myocardial infarction after coronary bypass grafting. Ann Thorac Surg 1998;66:1-11.[Abstract/Free Full Text]
- Chow M.S.T., Sim E., Orszulak T.A., Schaff H.V. Patency of internal thoracic artery grafts: comparison of right versus left and importance of vessel grafted. Circulation 1994;90:II129-132.
