Arterial Grafting for Coronary Artery Bypass Surgery

349 Pages·2006·10.52 MB·English

by  Guo-Wei He

Guo-WeiHe(Ed.)ArterialGraftingforCoronaryArteryBypassSurgery
SecondEdition
Guo-Wei He (Ed.)
Arterial Grafting
for Coronary Artery
Bypass Surgery
Second Edition
ForewordbyDentonA.Cooley,Houston,USA
Contributionsby
FloydD.Loop,Cleveland,USA GianniD.Angelini,Bristol,UK
BruceW.Lytle,Cleveland,USA AntonioM.Calafiore,Torino,Italy
JosephF.Sabik,Cleveland,USA ChristopheAcar,Paris,France
HendrickB.Barner,St.Louis,USA BrianF.Buxton,Melbourne,Australia
MichaelJ.Mack,Dallas,USA JamesTatoulis,Melbourne,Australia
HartzellV.Schaff,Rochester,USA HisayoshiSuma,Tokyo,Japan
JohnPym,Philadelphia,USA MasashiKomeda,Kyoto,Japan
AlfredJ.Tector,Milwaukee,USA AnthonyP.C.Yim,HongKong
DavidP.Taggart,Oxford,UK andOtherWorldExperts
With148Figuresin205Partsand77Tables
Guo-WeiHe(Ed.)ArterialGraftsforCoronaryBypassSurgery
FirstpublishedbySpringer-VerlagLtd.,Singapore,1999
ISBN3-540-30083-X Springer-VerlagBerlinHeidelbergNewYork
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THEEDITOR: ProfessorGuo-WeiHe,MD,PhD,DSc
ClinicalProfessorofSurgery
OregonHealthandScienceUniversity(2002–)andDirector,
CardiovascularResearch,AlbertStarrAcademicCenterforCardiacSurgery,
ProvidenceHeartandVascularInstitute(1994–),Portland,Oregon,USA
CardiacSurgeon-in-Chief
DepartmentofCardiacSurgeryandDirector,
WuhanHeartInstitute,TheCentralHospitalofWuhan,China(2003–)
ResearchProfessorofSurgeryandDirector
CardiovascularSurgicalResearch,
TheChineseUniversityofHongKong,HongKong(2000–)
Professor,ChairofCardiothoracicSurgery
TheUniversityofHongKong,HongKong(1995–2000)
Foreword
Dr.CooleyisPresidentandSurgeon-in-Chief,TexasHeartInstitute,andClinical
Professor,UniversityofTexasMedicalSchoolatHouston,Houston,Texas,USA
Ischemicheartdiseaseistheleadingcauseofdeathintheworldtoday,anditsinci-
denceislikelytoincreaseastheaverageageofthepopulationcontinuestorise,par-
ticularlyinindustrializednations.Inthe1950s,theprevalenceandseriousnessofis-
chemicheartdiseaseandtheadventofeffectivecardiopulmonarybypasstechnology
spurredsurgeonstodevelopcoronaryarterybypassgrafting(CABG)procedures.
Later,inthe1970s,percutaneouscoronaryinterventionsweredevisedasalessinva-
sive alternative to CABG, and the number of these performed annually now sur-
passesthatofCABGsurgery.Nonetheless,CABGremainsamongthemostcommon
cardiac surgical procedures, with more than 500,000 performed each year in the
DentonA.Cooley UnitedStatesalone.
For thesereasons, advances in CABG techniques have tremendous potential to
savelivesandimprovetheirquality.Thisisparticularlytrueforimprovementsinthe
durabilityofarterialconduits,theuseofwhichisthecentralandmosttechnically
demandingportionoftheCABGprocedure.Thisbookismeanttobeacomprehen-
siveresourceforcardiacsurgeonsconcerningarterialgraftingandgraftmaterialsin
CABG.
Manyrenownedcardiacsurgeonsandcardiovascularresearchershavecontribut-
ed to this volume, which has been compiled by Guo-Wei He, MD, PhD, DSc.
Dr.HehaspublishedahugebodyofliteratureaboutarterialgraftinginCABG,and
hisextensiveexperiencein,anddeepunderstandingof,thissubjecthasearnedhim
globalrecognition.HecurrentlyservesasDirectorofCardiovascularResearchPro-
gramsattheChineseUniversityofHongKongandtheProvidenceHeartInstitutein
Portland,Oregon,andheisClinicalProfessorofSurgeryattheOregonHealth&Sci-
ence University. Additionally, Dr. He directs the Wuhan Heart Institute in China,
whereheisalsoChiefofCardiacSurgery.
Thefirsteditionofthisbookwaswrittenin1999toprovideadetailedreviewof
existingknowledgeaboutthenatureandselectionofgraftmaterialsforCABGand
thetechniquesusedtoharvestthemandanastomosethemtothecoronaryarteries.
Rapidprogressinthisfieldduringthelast5yearshasstimulatedDr.Hetopublish
thisupdatededition.Notonlyhasnewmaterialbeenaddedtotheexistingchapters,
buttherearealsonewchaptersonvenousgrafts,reoperativeCABG,andtherecently
developedpracticeofinternalthoracicarteryandradialarteryT-grafting.
Readerswillfindthisbookvaluablebothasapracticalguideandasastimulusfor
further improvement of arterial grafting techniques and technology. I commend
Dr.Heandthemanyauthorsofthisvolumeforthediligenceandexpertisetheyhave
demonstratedinitscreationandrevision.
Houston,Texas,USA DentonA.Cooley
Preface
“Somebooksaretobetasted,otherstobeswallowed,
andsomefewtobechewedanddigested.“
FrancisBacon(1561–1626)
“Isn’titapleasuretostudyandpracticewhatyouhavelearned?“
Confucius(551–479b.c.)
Coronaryarterydiseaseremainsthemajorcauseofmortalityworldwide.Despite
aggressive application of percutaneous coronary interventions, the surgical ap-
proach,namelycoronaryarterybypassgrafting(CABG),remainsamajorapproach
forthetreatmentofcoronaryarterydisease.Usageofarterialgraftinghasbeenwell
acceptedasthemainapproachtoincreasingthelong-termpatencyofthegraftand
long-termsurvival.However,theuseofarterialgraftsisnotasimpleissue.Thisisre-
flectedbythediversityinpracticeamongmostexperiencedcardiacsurgeonsaround
the worldasto thechoice of conduit, thecombineduseof variousarterialgrafts,
pedicle versus free grafting, etc. The issue is further complicated by the usage of
thesegraftsduringconventionalcardiopulmonarybypassoronbeatinghearts,the
usageofminimallyinvasivesurgeryinCABG,and,moreover,bythefactthatmost
surgeonsarestillusingveingraftsincombinationwitharterialgrafts.Withallthese
Guo-WeiHe concerns,acomprehensivebookonCABGusingarterialgraftshasbecomeessential
forcardiacsurgeonsandrelatedprofessionalssuchascardiologists,cardiacanesthe-
siologists,nurses,andotheralliedprofessionalsfordailyreference.
Thefirsteditionofthisbookwaspublishedin1999bySpringer-Verlag.Sincethen,
muchexperiencehasbeenobtainedregardingarterialgraftinginCABG.Theprinci-
palroleoftheleftinternalmammaryartery(IMA)asthefirstchoiceofarterialgraft
standswithoutargumentandtheuseofalternativearterialgraftshasbecomemore
matureinthehandsofmostcardiacsurgeons.However,variousmethodsofusingthe
leftIMAincombinationwithalternativegraftsarebeingusedsincetheroleofthelat-
terisdefineddifferentlyamongevenmostexperiencedcardiacsurgeons.Forexample,
useoftheradialarteryisroutinepracticebysomesurgeonsbutisignoredbyothers.
Asimilarattitudeisheldbysurgeonsastotheuseofthegastroepiploicarteryandin-
feriorepigastricartery.ThisissueexistsintheuseofthesecondIMA,namelytheright
IMA.Inaddition,theuseofcomplexarterialgraftsremainssubjecttodiverseopin-
ions.Furthermore,muchattentionhasbeenpaidtothelogicaluseoftheminimally
invasivetechnique.Forexample,therolesofminimallyinvasivedirectcoronaryartery
bypass(MIDCAB)andport-accesstechnologyhavebeenredefined.
This second edition is an effort to provide the reader with the most advanced
knowledgeregardingtheissuessuchasthosementionedabovefromworld-renowned
experts.Tobestreflectthecurrentstatusofarterialgraftingworldwide,newcontribu-
torshavebeeninvitedtowriteintheirareasofexpertise.Iwouldparticularlymention
thecontributionbythesenewauthorsandtheircolleaguesinthesecondedition:Dr.
BruceLytleandJosephSabikfromtheClevelandClinic;Dr.HendrickBarnerfromSt.
Louis;Dr.HartzellSchafffromtheMayoClinic;Dr.AlfredTectorfromMilwaukee;Dr.
Matthew Slater from Portland; Dr. Piet Boonstra from The Netherlands; Professor
Gianni Angelini, Professor David Taggart, and Dr. Jamie Jeremy from the UK; and
ProfessorsMasashiKomeda,MasamiOchi,andTohruAsaifromJapan.Iwouldalso
acknowledgethecontributionofmycolleaguesProfessorAnthonyYim,Dr.SongWan,
andDr.QinYangattheChineseUniversityofHongKong.Inadditiontoallthecon-
tributorsforthefirstedition,theyhavemadethebookmorecomplete.
Thesuccessfuluseofarterialgrafts,i.e.,thearterialconduitwithadiameterof
around2mm,islargelyrelatedtothemethodofovercomingthevasospasmofthe
X Preface
graftintheperioperativeperiod.Withamoreadvancedunderstandingofthebasic
physiologyandpharmacologyofthearteriesandveinsusedforgrafting,thisedition
providesthenewestinformationontheendothelialfunctionandthemethodof
overcomingvasospasminthearterialgrafts.Theadvancementofourbasicknowl-
edgeofmyocardialprotectionisalsoreflectedinthisedition.
Thereareafewchaptersforwhichtheoriginalcontributorsarenotcontactable
duetoretirementorotherreasons.Inthesecaseswherenonewcontributorscould
beidentified,Ididtherelevantliteraturesearchesandupdatedthechaptermyself.
Thesechaptersare„HistologyandComparisonofArterialGraftsUsedforCoronary
Surgery,“„SplenicArteryGrafting,“and„UseofSubscapular-ThoracodorsalArtery
forCABG.“Thereisnonewliteratureaboutinferiormesentericarterygraftingand
Ithereforewroteanupdatenoteforthechapter.
ForthechapteronthecomparisonofunilateralandbilateralIMAgrafting,after
discussionwiththeoriginalauthor,Irewrotethechapterwithupdatedinformation
tobetterreflectthecurrentview.
Ontheotherhand,tobestreflecttheuseofveingraftsincombinationwitharteri-
algraftsinmostsurgeons’practice,thiseditionalsoincludesachapterontheroleof
veingraftsinCABGbymyself,achapterongenetherapyforveingraftdisease,and
achapteronthepreventionofveingraftfailure.Theuseofarterialgraftinginreope-
rativeCABGisincludedbypresentingthelargeexperiencefromtheClevelandClin-
ic.Intheminimallyinvasivetechniqueofarterialgrafting,Dr.MichaelMackhas
combinedhisthreechaptersinthefirsteditionintoanewconciseonewithupdated
information.TwochaptersonportaccessofCABGhavebeenreducedtooneinorder
toreflectthenewtrendinthisarea.
Asoneofthemostpressingandcontroversialissuesincoronarysurgerytoday,
theindicationsandresultsofcoronaryinterventionandCABGareattractingtheat-
tentionofallcardiacsurgeonsandcardiologists.Thesecondeditionthereforein-
cludesanewchapteronthecomparisonbetweencoronaryinterventionandCABG.
Thiseditionalsohasanaddedsectiononqualitycontrolofarterialgraftingby
presentingthemethodofmeasuringthebloodflowinthearterialgraft.Further-
more,tobetterreflecttheAmericanexperienceatlargeinarterialgrafting,inaddi-
tiontothenewchapterfromClevelandmentionedaboveontheuseofarterialgrafts
inreoperativeCABG,theexperienceonT-graftandinternalthoracicartery-radial
artery-T-graftfromothercentersisdescribedindetail.
Iwouldliketoextendmygreatgratitudetotheoriginalcontributorsofthefirst
editionwhoremainsointhesecond.Theseauthorshavemadegreateffortstopro-
videupdatestotheirexperienceandhavekeptthebookinstepwiththeadvance-
mentofscienceandmedicine.Theyhavemadethebookavaluableadditiontothe
referencelibraryofcardiacsurgeons,cardiologists,anesthesiologists,andallother
professionalsandscientistsworkingincardiovascularscienceandmedicine.
AsImentionedabove,ouraimwiththesecondeditionistomakethisbookone
ofthefewtobechewedanddigested,asFrancisBaconsaid,andtomakeitapleasure
tostudyandbehelpfulinpractice,asindicatedbyConfucius.Itisuptothereaderto
judgewhetherthisgoalhasbeenfulfilled.
Finally,IamdeeplyindebtedtoDr.AlbertStarrforhiscontinualsupportanden-
couragementtomywork,nottomentionthatIhavebeentheDirectorofCardiovas-
cularResearchsince1994attheAlbertStarrAcademicCenterforCardiacSurgery,
theProvidenceHeartInstitute,Portland,Oregon.Iamalsoextremelygratefulto
Dr.DentonCooleyfortheusefulpersonalcommunicationsandfortheforewordhe
warmlywroteforthisedition.ThesecretarialassistanceofMissChing-YanNgis
greatlyappreciated.
Portland,Oregon,USA ProfessorGuo-WeiHe
WuhanandHongKongSAR,China
Contents
ForewordbyDentonA.Cooley................ VII 4 ClinicalClassificationofArterialGrafts
G.-W.He,C.-Q.Yang .................... 31
Preface .................................... IX
4.1 Introduction ............................ 31
4.2 ClinicalClassification .................... 31
I BiologicalCharacteristicsofArterialGrafts References .................................. 34
1 HistologyandComparisonofArterialGrafts
UsedforCoronarySurgery II UseofVasodilatorsforArterialGrafts
J.A.M.vanSon,F.M.M.Smedts,C.-Q.Yang, inCoronaryBypassSurgery
G.-W.He ................................ 3
5 PharmacologicalStudiesandGuidelines
1.1 InternalMammaryArtery ................. 3
fortheUseofVasodilatorsforArterialGrafts
1.2 RightGastroepiploicArtery ................ 7
G.-W.He,C.-Q.Yang .................... 39
1.3 InferiorEpigastricArtery .................. 8
5.1 PharmacologicalStudies .................. 39
1.4 RadialArtery ............................ 9
5.2 FactorsDeterminingtheEffectsofVasodilator
1.5 IntercostalArtery......................... 10
Substances.............................. 42
1.6 Comment................................ 11
5.3 GuidelinesfortheUseofVasodilators
References .................................. 14
forArterialGraftsinCABG ............... 44
2 EndothelialFunctionandInteraction References .................................. 44
BetweentheEndotheliumandSmoothMuscle
inArterialGrafts III MyocardialProtectionDuringCoronary
G.-W.He ................................ 17 BypassSurgeryUsingArterialGrafts
2.1 Endothelium-DerivedRelaxingFactors ...... 17
6 MyocardialManagementinArterial
2.2 Endothelium-DerivedContractingFactors.... 17
Revascularization
2.3 VasoconstrictorsandVasospasminArterial
B.S.Allen,G.D.Buckberg ............... 51
Grafts................................... 17
6.1 CardioplegicPrerequisites................. 51
2.4 Vasoconstrictor-StimulatedEDRFRelease
6.2 CardioplegicComposition ................ 52
inArterialGrafts ......................... 19
6.3 BloodCardioplegia ...................... 52
2.5 Endothelium-DependentRelaxation
6.4 OperativeStrategy ....................... 53
andHyperpolarizationinArterialGrafts ..... 20
6.5 CardioplegiaPressure .................... 57
2.6 TheBalanceBetweenEDRFsandEDCFs ..... 21
6.6 RetrogradeCardioplegia .................. 57
References .................................. 22
6.7 SpecificIssueswithallArterialConduits .... 59
3 ClinicalPhysiologyandRelatedBiological 6.8 Reperfusion............................. 59
6.9 TopicalHypothermia ..................... 60
Characteristics
G.-W.He ................................ 24 6.10 Conclusions............................. 61
References .................................. 61
3.1 DifferencesinBiologicalCharacteristics
BetweenVenousandArterialGrafts ......... 24
7 CardiacProtectionfromtheViewpoint
3.2 AreThereAnyDifferencesAmongArterial
ofCoronaryEndothelialFunction
Grafts? .................................. 24
Q.Yang,G.-W.He ....................... 63
3.3 BiologicalCharacteristics .................. 25
7.1 PossibleMechanismsUnderlyingtheDamage
References .................................. 29
ofCardioplegiaandOrganPreservation
onEndothelialFunction .................. 64
XII Contents
7.2 InfluenceofCardioplegicandOrgan 11 SurgicalTechniquesforInternalThoracic
PreservationSolutionsonIndividualEDRFs 65 ArteryGrafting
7.3 InfluenceofDifferentComponentsin S.Seevanayagam,B.Buxton........... 97
CardioplegicandOrganPreservation 11.1 Introduction .......................... 97
SolutionsonEndothelialFunction ......... 65 11.2 Anatomy ............................. 97
7.4 EffectofDifferentAdditivestoCardioplegic 11.3 Harvesting ........................... 97
orOrganPreservationSolutionsonEndo- 11.4 Histology............................. 100
thelialFunction ......................... 66 11.5 GoalsofArterialGrafting............... 100
References .................................. 68 11.6 GraftingStrategy ...................... 101
11.7 GraftingTechniques ................... 101
11.8 BeatingHeartBypassSurgery ........... 103
IV PercutaneousCoronaryInterventionsVersus
11.9 LessInvasiveSurgicalTechniques ........ 103
CoronaryArteryBypassSurgery
11.10 Conclusions .......................... 104
8 NeedleorKnife?AComparisonBetween References ................................. 104
PercutaneousCoronaryInterventions(Includ-
ingPlainBalloonAngioplastyandCoronary 12 Long-TermResultsofInternalThoracic
Stenting)andCoronaryArteryBypassSurgery ArteryGrafting
D.J.Drenth,P.W.Boonstra ............. 73 J.F.SabikIII,F.D.Loop................. 105
8.1 Introduction............................ 73 12.1 Introduction .......................... 105
8.2 PercutaneousCoronaryInterventions ...... 73 12.2 History .............................. 105
8.3 CoronaryArteryBypassGrafting .......... 73 12.3 Patency .............................. 105
8.4 PCIVersusCABG........................ 74 12.4 Survival.............................. 107
8.5 DrugElutingStents ...................... 75 12.5 FreedomfromRecurrentIschemicEvents 109
8.6 RevascularizationStrategy ................ 76 12.6 Conclusions .......................... 110
References .................................. 76 References ................................. 110
13 BilateralVersusUnilateralInternalThoracic
V ClinicalChoiceofArterialGrafts
ArteryinCoronaryBypassGrafting
9 ConsiderationsintheChoiceofArterial E.Berreklouw,G.-W.He .............. 113
Grafts 13.1 Introduction .......................... 113
G.-W.He ............................... 81 13.2 History .............................. 113
9.1 GeneralConditionofthePatient ........... 82 13.3 IndicationsforUseofBilateralITAs ...... 113
9.2 BiologicalCharacteristics ................. 82 13.4 RelativeContraindications .............. 114
9.3 AnatomyoftheCoronaryArtery........... 84 13.5 EarlyMortality........................ 114
9.4 VesselMatchBetweentheGraftandthe 13.6 MyocardialInfarction .................. 115
CoronaryArtery ........................ 84 13.7 LateResults........................... 119
9.5 TechnicalConsiderations ................. 84 13.8 PostoperativeFlowMeasurements........ 123
9.6 Conclusion ............................. 84 13.9 LateECG-StressTesting ................ 123
References .................................. 84 13.10 LateBloodFlowStudies ................ 123
13.11 LatePatencyRates ..................... 124
13.12 Conclusions .......................... 125
VI InternalThoracicArteryGrafting
References ................................. 125
10 HistoryofInternalThoracicArteryGrafting
andAlternativeArterialGrafts 14 Left-SidedMyocardialRevascularization
M.Durairaj,B.Buxton................. 89 withBilateralSkeletonizedInternal
10.1 EarlyDirectArterialRevascularization ThoracicArtery
Techniques ............................. 90 R.Mohr,A.Kramer .................. 130
10.2 CoronaryArteriography.................. 91 14.1 Introduction .......................... 130
10.3 SaphenousVeinCoronaryArteryBypass.... 92 14.2 HarvestingandPreparationofthe
10.4 InternalThoracicArteryGrafting.......... 92 SkeletonizedITA ...................... 131
10.5 ExpandedUseoftheITAGraft ............ 92 14.3 StrategiesofLeft-SidedArterial
10.6 AlternativeArterialGrafts ................ 93 Revascularization...................... 132
10.7 ITAGraftsandMinimallyInvasiveCoronary 14.4 ClinicalResults........................ 137
ArteryBypassGrafting ................... 93 14.5 Comments............................ 137
10.8 TheFuture ............................. 93 References ................................. 138
References .................................. 94