Original ArticleArterial Conduits Update
Section snippets
Assessment of Graft Patency
Traditionally, assessment of graft patency has depended on re-angiogram for symptoms, using conventional selective coronary angiography. The quality of 32 and 64 multi-detector CT imaging has advanced rapidly, with current resolution being of about 500 μm (0.5 mm). While not as satisfactory as current selective angiography and flat panel screen techniques, which has a 130 μm resolution, the technique is non-invasive; it is rapid, the dose of radiation with modern equipment is slightly less than
Bilateral Internal Thoracic Artery (BITA) Grafts Survival
Meta-analysis of bilateral internal thoracic artery versus single internal thoracic artery (SITA) graft survival was published by Taggart et al.2 The two largest reported series are those of Buxton et al.,3 and Lytle et al.,4 which show a significant reduction in mortality of about 20% following BITA, compared with SITA grafting. The most recent evidence comes from a cohort of 1152 propensity-matched patient pairs from the Cleveland Clinic, followed from a mean survival of 16.5 years, with 50
Internal Thoracic Artery (ITA) Graft Patency
Unadjusted re-angiographic data over 20 years revealed that there was no increase in graft failure, which remained at 5% over the entire 20 years of follow-up.5 Similar results were found for right ITA grafting, although the failure rate was about 10–15% throughout the 20-year period (Fig. 3). The choice of techniques for using the RITA graft has varied. Preference is now given to skeletonisation with mobilisation proximally posterior to the subclavian vein to increase the length. In that way,
The Gastroepiploic Artery (GEA)
The gastroepiploic artery has not been used frequently at Epworth and in the USA, although it is used widely in Japan and to a lesser extent in Europe. The largest series is from Suma et al.7, which showed a 62% graft patency at 120 months using the Kaplan–Meier method, and this is almost certainly higher using the cumulative incidence assessment. The latest figures are from Takahashi, which show excellent graft rates in excess of 80% for the distal right coronary artery to the circumflex
The Radial Artery Graft Patency
Current perspective reveals that the angiographic patency using a Fitzgibbon Grade A is between 80 and 90%, an average follow-up of about 5 years. The largest reported series are those from Tatoulis et al.,8 8420 patients with 369 re-angiograms and 90% early graft patency. The best long-term figures are those of Possati et al.,9 with 91 grafts, all of which were reassessed with an 88% graft patency at a mean follow-up of 8 years. The worst figures are those by the Cardiology Group from the
Randomised Trials of Radial Artery Grafts
Four major studies are in progress; the Radial Artery Patency Study (RAPS),11 the Radial Artery Patency and Clinical Outcomes Study (RAPCO),12 Complete Arterial Revascularisation versus Conventional Coronary Artery Surgery (CARACCASS)13 from Europe, and the Radial Artery versus Saphenous Vein Graft Trial, from Veterans’ Administration in the USA.
A randomized comparison of RA and SV coronary grafts from the RA patency study group was published in the New England Journal of Medicine.14 Four
Recent Information
The benefits of the BITA compared with the SITA grafts continue into the second decade. Arterial graft failure increases three to four times with low-grade stenoses. Because of low number of graft failures using the LITA, this graft should not be discarded in situations in the presence of competitive flow. The ITA grafts remain superior when grafted to the left system compared to the right system. The SV graft is more tolerant to competitive flow than the ITA and when grafted to the right
Recommendations
Use of the bilateral ITA grafts should be considered at all ages. The late results of GEA grafts to the distal right or circumflex are excellent and perhaps more extensive use of the GEA should be explored. Carefully selected and preserved RA or SV grafts should be used as supplementary grafts. At 5 years there appears to be little difference to choose between these two conduits and a longer follow-up would be required to find whether there is a late benefit of RA compared with the SV graft.
The
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Cited by (11)
7.29 Vascular grafts
2017, Comprehensive Biomaterials IIComparison of radial artery patency according to proximal anastomosis site: Direct aorta to radial artery anastomosis is superior to radial artery composite grafting
2009, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :Direct aortic anastomosis seemed especially important for bypassing subcritically stenotic target vessels, provided the RA graft length was adequate. The quality of MDCT imaging has advanced rapidly, with a current resolution of approximately 500 μm.19 Although selective angiography remains the gold standard, the quality of MDCT imaging has improved sufficiently for it to be comparable to selective angiography in detecting significant vascular stenosis or occlusion for the purposes of the current study.
Contemporary Coronary Graft Patency: 5-Year Observational Data From a Randomized Trial of Conduits
2007, Annals of Thoracic SurgeryCitation Excerpt :The protocol of the RAPCO trial has been described elsewhere, as has our technique for minimal conduit handling and use of only gentle dilatation with papaverine diluted in heparinized blood [9, 12].
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