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Arterial Conduits in CABG. Ayman Abdul-Ghani June 2003 CTC - Liverpool. 35 - yr history of CABG. Better outcome with technical refinements, myocardial protection and search for better conduits. Vein grafts:. Early post-operative events: Thrombosis Hypercoagulable state Technical reasons

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arterial conduits in cabg

Arterial Conduits in CABG

Ayman Abdul-Ghani

June 2003

CTC - Liverpool

slide2
35 - yr history of CABG.
  • Better outcome with technical refinements, myocardial protection and search for better conduits.
vein grafts
Vein grafts:
  • Early post-operative events:
    • Thrombosis
    • Hypercoagulable state
    • Technical reasons
  • upto 2.5 yras post op: Intimal Hyperplasia
  • 3 years or more: Atherosclerotic
  • Post-op antiplatelets/lipid lowering agents.
why arterial patency is better
Why Arterial Patency is better:
  • Vasoconstrictor effects of leukotrienes less effective in IMA compared to SVG.
  • Antithrombotic properties of vein graft endothelium less well developed than in arterial grafts - less secretion of NO and PGI-2 by vein graft endothelium
  • Intimal proliferation
  • Graft-coronary discrepancy - eg.smaller proximal diameter, stasis + clot.
other alternative veins
Other Alternative veins:
  • Lesser Saphenous vein: acceptable in 70%,difficult to harvest,many valves,concomitant sinus dilatations that disrupts laminar flow, lots of branches, anecdotal results on long term patency.
  • Brachial vein,cephalic,basilic:arm veins are small and thin walled, difficult to use, abnormal due to previous iv,prone to aneurysmal dilatation,segmental stenosis-1 yr patency 57%-66%, 6 yr 10%
slide6
Umbilical Vein:Gluteraldehyde-prepared, off the shelf, difficult to contour around the heart, 1 yr patency 50%.
  • Cryopreserved allograft sahenous veins:off the shelf 1-4 yr patency 15-47%,last resort, life saving procedures, to be replaced.
arterial grafts
Arterial Grafts:
  • Intimal Hyperplasia and atherosclerosis RARE.
  • Long term failure is usually due to progressive athersosclerosis in CA.
slide8
ITA:
  • Gold Standard.
  • Superiority of ITA to LAD disclosed in 1986 - Loop and colleagues from the Cleveland Clinic.
  • Lytle and associates: Two ITA grafts are better than one.
slide9
ITA:
  • Resistant to atherosclerosis (well formed internal elastic lamina, perivascular lymphatic drainage,fewer muscle cells in the media, biochemical differences compared with SVG.
  • 3% are atherosclerotic at origin.
  • Use of papaverine !
slide10
ITA:
  • Longer operative time, post-op bleeding,sternal healing with bilateral use.
  • Uncommon problems: steal from proximal branches, atherosclerosis, fistulization to the lung, severe tortuosity and atherosclerosis.
  • Currently Best graft available.
radial artery
Radial artery:
  • First used for CABG by Carpentier & associates 1973.
  • Abandoned soon due to strong tendency to spasm.
  • Revived in 1990’s by Acar & colleagues with the use of Ca channel blockers.
radial artery12
Radial artery:
  • Thicker wall than ITA.
  • Ideal diameter.
  • Rarely affected by atherosclerosis.
  • When to use it ?
  • Contraindiction: positive Allen’s test.
  • Others: Raynaud’s,Buerger’s disease, subclavian bruit, planned AV fistula.
radial artery13
Radial artery:
  • Long term patency results.
  • Use of Calcium channel blockers.
  • Harvest/ enblock with fat and concomitant veins, temporary occlusion proximally, stump pressure measurement !
the allen test
The Allen Test:
  • 1929.
  • Thromboangiitis obliterans.
  • 6% UA originates from RA.
  • 3% incomplete deep palmar arch.
  • 53% incomplete superficial palmar arch.
  • 1% significant loss to SPA, 3% significant loss to DPA with sacrifice of RA.
the allen test15
The Allen Test:
  • 1929.
  • Thromboangiitis obliterans.
  • 6% UA originates from RA.
  • 3% incomplete deep palmar arch.
  • 53% incomplete superficial palmar arch.
  • 1% significant loss to SPA, 3% significant loss to DPA with sacrifice of RA.
right gastroepiploic artery
Right Gastroepiploic artery:
  • Early 1980’s.
  • Lumen-to-outer media distance is slightly less than ITA.
  • Less elastic tissue.
  • Fewer smooth muscle cells in media.
  • Initially strict indications: no other conduit available, now used more.
  • Propensity to spasm. In vitro studies, rings develop three times the force of ITA.
right gastroepiploic artery17
Right Gastroepiploic artery:
  • Too small for use as a bypass graft in only 1.4 % in USA.
  • Contraindications: previous gastric resection, morbid obesity, atherosclerosis of the descending aorta and celiac axis.
  • Harvest is time consuming, Emergency !
  • Long term patency !
  • Calcium Channel blockers start in theatre !
right gastroepiploic artery18
Right Gastroepiploic artery:
  • Atherosclerosis is rare.
  • Difficult to angio, spasm !
  • Use: avoid BIMA, near occlusion to RCA or PDA, anastomosis of SVG to GEA in calcified ascending aorta (no touch tech.).
  • Correct orientation.
inferior epigastric artery
Inferior epigastric Artery:
  • Harvest: different side of ITA.
  • Athersclerosis near orifice of IEA in small percentage.
  • Patency rate: 57-86% at 25 months.
  • Patch of pericardium or SV at proximal end improved patency.
  • Decreased patency with small coronaries, not to use in DG or small OM
  • Better patency reported with anastomses to ITA pedicle
splenic artery
Splenic artery:
  • Used in early years of CABG.
  • Patency 1-2 yr reported up to 90%.
  • Very difficult to harvest, tortuosity.
  • 42% evidence of atherosclerosis in vessel wall.
  • Significant incidence of pancreatitis.
left gastric artery
Left gastric artery:
  • Three cases reported by one surgeon.
lateral costal artery
Lateral costal artery:
  • Found in 27% of cadavers.
  • Traverses 6 intercostal spaces.
  • Originates from ITA,SCA or supreme ICA.
  • Histologically identical to ITA.
  • Can be used as free or pedicled graft.
subscapular artery
Subscapular artery:
  • Origin: axillary artery.
  • Bifurcates to thoracodorsal and circumflex scapular arteries.
  • Can be dissected in Lt. Thoracotomies for re-do CABG.
  • Used as free graft from descending aorta to CA.
  • 8% have atherosclerotic disease.
  • Few reported cases.
other grafts
Other grafts:
  • Dacron: no new intima formation, thrombogenic.
  • PTFE - Perma flow graft: 32% patency at 2 years, Aorta-SVC fistula. Diffuser-reducer cone at venous end, cautious optimism and pharmacologic agents.