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Eur J Cardiothorac Surg 2008;33:341-348. doi:10.1016/j.ejcts.2007.12.025
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Right arrow Coronary disease

Angiographic results of the radial artery graft patency according to the degree of native coronary stenosis

Kilsoo Yiea, Chan-Young Nab,*, Sam Sae Ohb, Jae-Hyun Kimb, Sung-Ho Shinnc, Hong-Joo Seod

a Department of Thoracic and Cardiovascular Surgery, Kangwon National University, College of Medicine, Chuncheon, South Korea
b Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital & Sejong Heart Institute, 22-4 Sosadong Sosagu, Bucheon, South Korea
c Department of Thoracic and Cardiovascular Surgery, Hanyang University, College of Medicine, Seoul, South Korea
d Department of Thoracic and Cardiovascular Surgery, Chosun University, College of Medicine, Kwangju, South Korea

Received 26 August 2007; received in revised form 1 December 2007; accepted 11 December 2007.

* Corresponding author. Tel.: +82 33 258 2294; fax: +82 33 258 2182. (Email: koreaheartsurgeon{at}hotmail.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Objective: Radial arteries are gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there are limited reports about its angiographic patency compared with that of the internal thoracic artery or saphenous vein according to the degree of native coronary stenosis. Therefore, we tried to evaluate the mid-term angiographic results of the radial artery graft patency focusing on the native coronary stenotic status in a prospective manner. Methods: From March 2000 to September 2006, a total of 488 patients underwent coronary artery bypass grafting using radial artery graft at our institution. From this group, 123 patients (mean age of 59.02 ± 8.9 years (range 34–73 years)) were enrolled in the present study, and underwent a postoperative angiography after surgery (mean 32 months). The angiograms were assessed visually and quantitatively. Results: A total of 382 distal anastomoses were performed and 352 anastomosis remained patent (92.1%). Left internal thoracic artery showed the most excellent patency in all of the conduits (128/129, 99.2%). Overall the radial artery graft patency was 92% (160/174). In the univariate analysis, patency was significantly worse for targets of the right coronary system (left coronary system 129/135, 94.4% vs right coronary system 31/39, 79.4%. p < 0.05) and the radial artery graft showed a higher patency rate in the case of a severe stenotic lesion that preoperatively revealed more than 90% stenosis (defined as critical stenotic lesion) than in the case of a less severe lesion (50% < stenosis < 90%) (100/102, 98% vs 60/72, 83.3%. p < 0.05). The methods used for proximal anastomosis failed to affect radial artery patency (p = 0.123). Multivariate analysis revealed the target vessel stenotic degree (50% < stenosis < 90%) was closely related to radial artery graft failure (p = 0.002, Exp (B) = 0.067, CI = 0.012, –0.373). Conclusions: Regardless of the small study population, our data revealed that the radial artery conduit showed good midterm patency when it grafted to the critical stenotic lesion (over 90%). One might pay attention to the grafting strategy when the preoperative coronary angiogram reveals less than 90% of coronary stenosis, especially in the right coronary system but a larger and well-designed study should be warranted to confirm these findings.

Key Words: Radial artery • Post-operative angiogram • CABG • Arterial grafts


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Since Carpentier and colleagues introduced the radial artery (RA) as a source for coronary artery bypass grafting (CABG) in 1973 [1], early graft failure and frequent spasms led to its disuse. In 1989 Acar and colleagues [2] attributed this early graft failure to the spasm of the RAs and introduced pharmacological measures to minimize arterial spasms. In addition, they refined the harvest techniques reviving interest in the procedure. Since then, the RA graft has steadily gained popularity because of its diameter, length, safety, and ease of harvest as well as its encouraging early and mid-to-long-term results [3–8].

While the right internal thoracic artery (ITA) is also an increasingly important graft for CABG, its use is commonly avoided in elderly, obese, or diabetic patients due to higher rates of sternal infection, dehiscence, and mediastinitis, making an RA graft commonly preferable [9].

From the late 1990s, apart from the issue of technical or pharmacologic processing, it has been noted by many authors that the RA graft patency decreased when grafted to coronary arteries that exhibited mild to moderate obstruction [10,11]. These findings have been given special attention by many surgeons during surgery; however there have been limited reports about the angiographic patency of the RA compared with that of the right ITA or saphenous vein (SV), and a poor understanding of anastomosis at the lesser critical stenotic lesion of native coronary arteries (50% < stenosis < 90%) compared with the critical stenotic lesion (stenosis >90%). We tried to evaluate the mid-term angiographic patency of the RA graft, especially focusing on the native coronary stenotic status (over 90%, compared with under 90% stenosis) using prospectively collected angiographic data.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
2.1 Study design
From March 2000 to September 2006, a total of 488 patients at our institution underwent isolated myocardial revascularization using a normal RA conduit (59.8% of the coronary artery bypass procedures performed in this period). Of these patients, 202 patients who had agreed to undergo a postoperative angiography were initially enrolled in our study, the Institutional Review Board and Ethics Committee having approved our study protocol. Preoperative coronary angiograms (CAG) were evaluated for every operation by both the cardiac interventionist and the cardiac radiologist. Operative details including the quantity of anastomoses and target characteristics were prospectively recorded. The angiographic studies, originally scheduled on the 36th postoperative month, were performed 32.7 ± 5.7 months (median 33, ranging from 8 to 56 months) after surgery by the interventional cardiologists (Fig. 1 ).


Figure 1
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  		Fig. 1. The relationship between the number of patients and the follow-up angiogram in months.

 
2.2 Exclusion data
If one who had signs or symptoms of myocardial ischemia visited the outpatient clinic, an early angiogram was conducted (n = 33). Of these patients, 14 were excluded from the present study because of a too-early angiographic examination (within three months – all such angiograms were normal); the other 19 patients’ data were included. Seven patients were ruled out because of their late refusal of the invasive diagnostic test compared with none-invasive tools such as a computed tomographic angiogram. There were 16 cases of follow-up loss. Ten cases were excluded from the present study because they had undergone a postoperative angiogram in an outside hospital and we could not evaluate coronary perfusion status exactly. Five patients suffered in-hospital or early mortality within 30 days and nine patients that underwent emergency operation were all excluded. Seven patients who died before the angiogram, five intraoperative endarterectomy and three intraoperative conversions to on-pump cases were also excluded. Two Takayasu's arteritis and one Bechet's disease were confirmed postoperatively and we exempted them from this study as well.

2.3 Study population
Finally 123 patients, mean age 59.0 ± 8.9 years (range 34–73 years) of 86 male and 37 female, constituted this study population. The patient demographics, disease entity and comorbidity data were collected prospectively and are summarized in Table 1 . Postoperative angiograms were assessed visually and quantitatively by two cardiac radiologists and were graded for three groups; patent, partial stenosis, and occlusion. Where more than one CAG was performed on the same patient (n = 22), the most recent angiogram was analyzed to prevent double counting of findings.


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  		Table 1 Demographic findings and perioperative conditions of the study group
 
2.4 Definitions
Target vessels were classified as moderately (50–75%), severely (75–89%), or critically (>90%) stenosed as determined by the results of preoperative angiography. To calculate the degree of coronary stenosis, the normal segment of the artery proximal to the lesion was used as a reference and the difference with the minimum luminal diameter of the stenotic lesion was considered the percent of stenosis. In the evaluation of the postoperative angiogram, Patent was defined as the status of the grafted coronary artery filled with angiographic contrast from the conduit without any irregularity. Partial stenosis means that there were noted some luminal irregularity in the anastomotic surface or in the graft lumen. String sign was a diffusely narrowed conduit filled with contrast but not seen to opacify the native coronary artery. When a conduit did not fill with contrast at all, it was considered occluded and was included with string sign for the purposes of this analysis. Both of these latter findings were considered together and referred to as occlusion in the analysis. Partial stenosis and occlusion both imply inadequate coronary artery perfusion via the graft and defined non-patent. All statistical analysis was evaluated between patent group and non-patent group. Patency (%) was defined as the percentage of the number of anastomoses divided by the number of patent grafts.

Study population was divided into two groups according to proximal anastomosis method of RA. One is aortocoronary method and it means that RA was inter-positioned directly between aorta and coronary artery. Cabrol like methods that were previously reported by us [12] were included as aorto-coronary technique. The other method was composite Y-graft using left ITA and RA.

2.5 Surgical technique
Thorough investigations into the RA using ultrasonography and Allen's test were conducted preoperatively and if there had been any problem, RA was always discarded. To prevent immediate postoperative graft spasm, intravenous diltiazem (5–15 µg/kg/min) or nitroglycerin (20–40 µg/min) or milrinone (0.4–0.8 µg/kg/min) were commonly used perioperatively and intraoperatively for 24 h according to surgeon's preference.

After median sternotomy, the left ITA and left (non-dominant) RA harvest proceeded simultaneously. RA was harvested from its origin to the wrist crease by an experienced surgeon using the combination of sharp dissection and ultrasonic scalpel. Distal RA harvesting was performed to the level of the superior border of pronator quadratus muscle to prevent immediate postoperative spasm. All arterial grafts were prepared in a pedicled (not skeletonized) manner. Diluted papaverine was frequently sprayed on the arterial grafts during harvest to minimize vasospasm. After the harvesting, papaverine solution was introduced intraluminally via the distal end of the RA with a blunt-ended vascular needle and then, RA was kept in the same solution until it was used. Mechanical dilatation was not applied. In the cases of off-pump CABG, if a composite Y-graft was constructed, the proximal left ITA to RA anastomosis was completed soon after confirming that systemic heparinization was completed. The left ITA to LAD anastomosis was performed first. After that, other target vessel anastomoses were completed. Lastly, proximal aorto-saphenous and aorto-radial anastomoses were performed with continuous 6-0 polypropylene. In cases of on-pump CABG, however, the LITA to LAD anastomosis was performed last. There were 69 cases of off-pump CABG and 54 cases of on-pump CABG respectively. Graft flow was routinely evaluated using a transit time flowmeter (BF1001; Medi-Stim AS, Oslo, Norway) in the operating field and if any suboptimal blood flow was noted, re-anastomosis was undertaken to verify the findings (n = 6). We did not record the graft flow routinely because it varied as did patient's blood pressure. Postoperative oral calcium channel blockers (amlodipine or felodipine) were added to all patients, and continued for 6 months after discharge.

2.6 Graft strategy
With regard to graft strategy in this study group, the most common patterns of grafting were the left ITA to the left anterior descending (LAD) artery, the right ITA, if used, to the diagonal, circumflex or posterior descending artery (PDA). The RAs was frequently anastomosed to the circumflex (especially obtuse marginal artery) artery and diagonal branch. In the cases of relatively younger age, the radial artery usually grafted to the right coronary artery (RCA) and right ITA took charge of left circumflex territory revascularization. Which artery was chosen depended on the surgeon's views about the quality of the graft. But right coronary system revascularization was carried out mainly using SV. There were six cases of bilateral RA grafts and gastroepiploic artery (GEA) use. Concomitantly used conduits with RA are listed in Table 1.

2.7 Angiographic follow-up
Follow-up angiograms were performed with bi-plane cardiovascular cine angiography system (Integris BH 5000, Philips medical systems. Netherlands B.V) and 4F catheters were inserted through the radial or femoral artery. A complete study of the coronary arteries and of all the implanted grafts and a left ventriculogram were performed. Attention was paid to the exact coincidence of the different view between the preoperative evaluation and all the subsequent angiographic evaluations. RA graft status at both studies was classified into three subgroups: (1) patent, (2) partial stenosis, and (3) occlusion.

2.8 Statistical analyses
Results are reported as mean ± standard deviation and range. Percentages are given where appropriate. Comparisons between graft patency were performed with McNemar's test for paired proportional data (SPSS software; SPSS Inc., Chicago, IL). Continuous variables, such as age and ejection fraction, were compared using Student's t-test with correction for paired analyses where necessary. Multivariable analysis was performed using logistic regression test. A logistic regression model to demonstrate risk factors for radial artery occlusion was performed using the following predictor variables: target vessel stenotic degree, proximal anastomosis method, sequential grafting or not, target vessel site, on-pump CABG or not, preoperative conditions (age, sex, ejection fraction, diabetes, left main disease, urgent operation or not, history of peripheral artery disease). A p-value of less than 0.05 was considered significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusion
 Appendix A
 References
 
3.1 Clinical results
A total of 123 patients underwent postoperative angiogram at our institution between January 3, 2001 and December 30, 2006. Of the 202 patients that were initially enrolled in this study group, there were five in-hospital deaths or early mortality within 30 days. Seven patients died before the angiogram. They are all listed briefly in Table 2 . There was no late mortality within the study population of 123 patients during the follow-up period. Early RA graft stenosis or occlusion that confirmed by emergency angiogram was documented in three patients. They all happened at the immediate postoperative period and were treated with intracoronary nitroglycerin infusion. Acute myocardiac infarction (AMI) was observed in four patients and they all fully recovered without any sequela. In two patients, ovarian cancer and gastric cancer were documented on the postoperative 28th and 41st month, respectively. During the follow-up period, nine of the 123 patients underwent medical or surgical intervention due to extra-cardiac vascular disease. Twenty-nine coronary stent insertions were performed in 25 (20.3%) patients postoperatively. Of these patients, 24 stent insertions were conducted in the anastomosed coronary arteries and among these interventions, 10 insertions were performed in the RA grafted coronary artery. Forearm numbness was documented in three patients and one of them has attended local neurology clinic until a recent date. Of the 19 early symptomatic patients that were included present study, two patients’ angiograms revealed early occluded SV graft.


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  		Table 2 Early and late mortality cases among 202 initial patients (not included the present study)
 
3.2 Graft analysis and angiographic results
The mean number of anastomoses per patient was 3.11 (382 anastomoses/123 patients). Overall graft patency was 92.1% (352/382). Each graft patency is listed in Table 3 and there were no significant differences between on-pump group and off-pump group. For 34 (27.6%) patients, the RA was proximally anastomosed to the ITA as a composite Y-graft configuration, and in 89 (72.3%) patients it was anastomosed to the ascending aorta. Cabrol-type proximal anastomoses that previously we reported were conducted in 18 (14.6%) cases [12]. According to each proximal anastomosis technique of RA, 55 and 119 distal anastomoses were preformed respectively (Table 4 ). The methods that were used for proximal anastomosis (aortocoronary or Y-graft anastomosis) failed to affect the RA patency in univariate analysis (112/119, 94.1% vs 48/55 87.2%, p = 0.123) and none of preoperative factors that are listed in Table 1 contributed as confounding factor. Our own technique of Cabrol type proximal anastomosis demonstrated 96.2% (25/26) of mid-term RA patency.


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  		Table 3 Overall angiographic patency of the each graft
 

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  		Table 4 Radial artery graft patency according to anastomosis area and to proximal anastomosis method
 
In case of RA, distal grafting area and angiographic patency rate are documented in Table 4 and univariate analysis showed that RA graft patency was significantly worse for targets of the right coronary system (left coronary system 129/135, 94.4% vs right coronary system 31/39, 79.4%. p = 0.02). However, multivariate analysis did not show the statistical significances between RA graft patency and coronary area (Table 5 , p = 0.076, CI = 0.871–16.316, Exp (B) = 3.770).


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  		Table 5 Multivariate analysis of risk factors for radial artery graft patency
 
RA patency according to the native coronary artery stenosis was documented and the RA patency increased steadily with increasing target stenosis (50% < stenosis < 75% 15/19 78.9%, 75% < stenosis < 90% 45/53 84.9%, stenosis >90% 100/102 98%, p = 0.000 x 2 = 12.432 by linear by linear association). Multivariate analysis was performed to evaluate and quantify the independent effects of target vessel stenotic degree, proximal anastomosis method, sequential grafting, target vessel site, on-pump CABG, preoperative conditions (age, sex, ejection fraction, diabetes, left main disease, urgent operation or not, history of peripheral artery disease). Target vessel stenotic degree under 90% remained a unique independent predictor of RA graft occlusion (Table 5). RA graft patency according to target vessel stenosis can be affected by other confounding factors. Table 6 demonstrated each RA patency relationship between every possible confounding factor and target vessel stenosis. Apart from one factor of proximal anastomotic method, RA patency was significantly affected by the degree of target vessel stenosis in each group. As shown in Table 7 , demographic and perioperative conditions evenly distributed both stenosis groups except ejection fraction. Ejection fraction was higher in the 50% < stenosis < 90% group than 90% < stenosis group (57.7 ± 12.9% vs 55.8 ± 15.5%, respectively, p = 0.02).


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  		Table 6 Angiographic radial graft patency of each group according to native coronary artery status
 

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  		Table 7 Demographic and perioperative factors compared among all patients and all RA grafts with respect to target vessel stenosis
 
Diabetes, hyperlipidemia, peripheral vascular disease did not affect mid-term angiographic patency.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusion
 Appendix A
 References
 
Although total arterial revascularization using bilateral ITA or GEA have shown superior long-term patency compared with coronary bypass surgery using vein graft, it was not our main graft selection strategy in older patients over 65 years. Because the anatomic structure of the pedicle artery is thought to be more intact compared with that of skeletonized artery [13], we always harvest the ITA and RA with pedicle artery. But this technique may increase the risk of sternal wound infection, so we selectively use the total arterial revascularization using bilateral ITA in younger non-diabetic patients (under 65 years) that seem to have over 20 years of life expectancy. These graft strategies might affect our angiographic results, but we could not evaluate the exact effect of graft interaction because of small study population.

This is a clinical observational study for RA graft patency, especially focusing on the degree of coronary stenosis. The authors tried to evaluate the effects of native coronary stenotic degree, coronary territory, methods of proximal anastomosis on RA patency and so on. Our data shows acceptable RA graft patency in the left coronary system but unsatisfactory results in the right coronary territory. In our data, the right coronary territory was a risk factor for RA patency in univariate analysis but was not in multivariate analysis. These findings correspond with other reports and have been understood mainly due to caliber mismatch between graft and coronary artery [14–17]. Recently, Souza and colleagues [18] demonstrated that the no-touch technique for SV harvesting provides a significantly better patency rate than veins treated by the conventional technique (odds ratio = 3.7 and p = 0.007). Furthermore, its patency was similar to that of the LITA. Two other recent randomized studies supported this hypothesis and provided no evidence of RA's superiority [19,20]. We always have paid attention to the harvesting technique, conservation of the graft and technical aspects of anastomosis of the RAs to improve its patency. However, present study data and above reports about relatively good results of SV graft patency in CABG make us hesitate to use the RA in the right coronary system. Rather, proper target selection appears to be the principal determinant of RA patency rather than grafting strategy chosen [16].

RA patency can be affected by a number of other factors such as graft harvesting technique, pedicled or not, the presence of atheroma at the site of anastomosis at the time of surgery and the presence of symptoms as an indication for angiography. Unfortunately, the distribution of these factors might be not uniform and so no single factor can be examined in isolation. In the present study, the distribution of first two factors was uniform in our study because authors harvested all RA grafts with pedicled manner and used only faultless ones. Regarding the presence of symptoms as an indication for angiography, we included 19 patients who had revealed early symptoms or sign. It would be expected that the patency rate in the symptomatic group would be lower than for those without symptoms and, therefore, also lower overall patency. But there were two cases of graft occlusion in our study group and these all happened not in RA graft but in SV graft.

We found a statistical significance between RA patency and the degree of native coronary artery stenosis. In fact, this was not a newer finding and many authors have reported similar results. But our data might suggest a kind of new possibility that RA patency may be reduced even though the RA was grafted to the severe stenotic coronary lesion (75% < stenosis < 90%). It might act on one reference of judgment to many surgeons that perform CABG using RA conduits but larger and well-designed study should be warranted to confirm these findings. Because, although a positive tendency for the graft patency along with the degree of native coronary stenosis was observed in our study, the number of patients in the 50–75% native-stenosis group was only 19 (15 patent, 4 occluded), and this fact explains that the statistical power of the present study is relatively low and had preliminary status.

There have been many arguments for the proximal anastomosis type of RA graft in CABG. The most commonly used methods are direct anastomosis to the aorta as an aortocoronary conduit or non-direct connection to the other grafts (usually ITAs) as a composite Y-shaped graft. Maniar and colleagues [16] have demonstrated that the site of proximal anastomosis does not appear to influence RA conduit patency. In their study, postoperative angiographic RA patency (average postoperative 26.1 months) in aortocoronary versus composite Y-graft demonstrated no significant difference (72.0% vs 70.5%). But other authors [21,22] have reported excellent midterm (average period to reangiogram 16.2 and 36.8 months, respectively) RA conduit patency (96.8% and 91.9%, respectively) in aortocoronary configuration. The results of the present investigation showed that there was no statistical significance between RA patency and proximal anastomosis type (aortocoronary technique including Cabrol like technique vs left ITA Y-graft). Our surgical experience about CABG using Cabrol type proximal anastomosis revealed good mid-term results but long-term follow-up and larger study groups are warranted in these fields.

4.1 Study limitation
Besides those mentioned above, we have many other limitations for the present study. Firstly, 79 patients were excluded from this study due to many reasons. This makes it difficult to provide a simple guide to factors predicting arterial conduit patency because of a relatively small population. There might be additional factors not analyzed such as technical errors of grafting. But this study is continuing and we can get more exact and variable results some day.

All six surgeons participated in this study and there might be different view points about patient management among them. Although we did not hold a major different view of surgical strategies, postoperative care and follow-up strategies, some different technical skills amongst each other might affect the results.

In addition we could not demonstrate whether the impact of the native coronary stenosis was unique and specific for the RA. To do so, we should include the same analysis also for ITAs. Unfortunately, because our graft data for ITA patency was relatively small and we have only one occluded left ITA graft, we could not analyze this factor.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
Appendix A
 References
 
The RA conduit demonstrated good midterm patency when grafted in the critically stenotic lesion (over 90%) and in the left coronary system. The results were less satisfactory when preoperative CAG had revealed less than 90% of stenosis or right coronary stenosis. Larger studies are warranted to strengthen the preliminary status of the present study.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
References
 
Conference discussion

Dr B. Osswald (Essen, Germany): This study represents an interesting approach to a rather complex problem. The radial artery indeed has been shown to be not always the best or ideal graft.

The main point you focused on in your study was the potential adverse effect by a higher native vessel flow leading to a worse patency of grafts. Aside from the liberal inclusion of different surgical approaches in the rather small patient group are some other concerns about study design, comparability of the investigated patients, and statistical aspects.

The major concern, however, in view of the conclusion may be the very limited information you give on the various factors influencing coronary runoff such as cross-sectional diameter, vessel dominance, occurrence and complexity of the coronary lesions at the side or distal to the anastomosis, intraoperative graft flow measurements and so on.

So could you, please, comment on the rationale you give to the recommendation to perform best CABG grafting only in vessels with at least 90% stenosis when you do not take into account and adjust your analysis to at least some of the above-mentioned aspects concerning competitive flow and distal coronary morphology and leaving outside all the deaths you have observed in your early and midterm follow-up?

Dr Yie: Actually, in our center we didn’t perform the total arterial revascularization in over 65-year-old patients. Because, as you saw in our presentation, there are not so many merits of revascularization using radial artery to the patients who had from the 50% to under 90% of stenotic degree, especially right coronary system. So we always try to use other grafts, mainly saphenous vein for the patients who have lesser critical stenosis. If the patient showed over 90% stenosis, we use the arterial as a graft. But the grafted artery, especially radial artery, sometimes occluded during the follow-up period in the elderly patients.

And so we usually revascularized the right coronary system, for example, posterior descending artery, or right circumflex artery perfusion regardless of stenotic degree with the vein graft being the patients over 65 years of age is our strategy.


   Acknowledgments
 
We thank Dr HyunSuk Yang and Dr YangMin Kim for their assistance with the angiographic evaluation. We also thank Dr Jonghwan Kim for his educational devotion.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 

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