Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Total Arterial Revascularization Using Y-composite Graft for Isolated Left Main Coronary Artery Disease

단독 좌주간 관동맥 협착병변에서 Y-도관을 이용한 완전 동맥도관 관상동맥우회로 조성술

  • Ahn, Byong-Hee (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Yu, Ung (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Chun, Joon-Kyung (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Ryu, Sang-Wan (Dept. of Thoracic and Cardiovascular Surgery, Armed Forces Kwang-Ju Hospital) ;
  • Choi, Yong-Sun (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Kim, Byong-Pyo (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Hong, Sung-Bum (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Bum, Min-Sun (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Na, Kook-Ju (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School) ;
  • Jung, Myung-Ho (Dept. of Cardiology, Chonam National University Medical School) ;
  • Kim, Sang-Hyung (Dept. of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School)
  • 안병희 (전남대학교 의과대학 흉부외과학교실) ;
  • 유웅 (전남대학교 의과대학 흉부외과학교실) ;
  • 전준경 (전남대학교 의과대학 흉부외과학교실) ;
  • 류상완 (국군광주병원 흉부외과) ;
  • 최용선 (전남대학교 의과대학 흉부외과학교실) ;
  • 김병표 (전남대학교 의과대학 흉부외과학교실) ;
  • 홍성범 (전남대학교 의과대학 흉부외과학교실) ;
  • 범민선 (전남대학교 의과대학 흉부외과학교실) ;
  • 나국주 (전남대학교 의과대학 흉부외과학교실) ;
  • 정명호 (전남대학교 의과대학 심장내과학교실) ;
  • 김상형 (전남대학교 의과대학 흉부외과학교실)
  • Published : 2004.01.01
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Abstract

Background: For the treatment of isolated left main coronary artery disease, twelve arterial revascularizations with Y-composite grafts using left internal thoracic artery and radial artery or right gastroepiploic artery were peformed. This study was performed to investigate whether V-composite graft can satisfy the blood flow required to make myocardium act properly or not. Borderline stenotic lesions on the left main coronary artery, which are very prone to remodel the bypassed vessels due to competitive flows, were also considered. Material and Method: Among 247 patients who underwent coronary artery bypass grafting from March 2000 to April 2003, 12 patients (4.7%) who had received total arterial revascularizations for the isolated left main coronary artery disease were studied retrospectively. Result: left anterior descending arteries were bypassed with left internal thoracic artery by off-pump technique in all patients, however, 2 cases of left obtuse marginal branches were bypassed under on-pump beating heart. Except for one patient, who did not have an obtuse marginal branch more than 1 mm in diameter, 11 patients had gone through complete arterial revascularizations by use of the Y shape arterial graft. Among five patients who had less than 75% stenosis, one patient showed string sign on left internal thoracic artery grafted to left anterior descending artery. However, two grafts to obtuse marginal blanches were completely obstructed and one showed slender sign. There were no graft-dominant flow in patients with stenotic lesion less than 75%. On the contrary to the result of patients with stenotic lesions less than 75%, all the patients with stenotic lesions more than 90% showed graft-dominant blood flow. Conclusion: In conclusion, it is assumed that, when stenotic lesions are over 90%, coronary artery bypass grafting with an Y shape arterial graft could possibly give enough help to the obstructed coronary arteries in blood supplying to myocardium, which needs massive quantity of blood to act well. However, when patients have borderline stenoses, through scrupulous examinations, more prudent and flexible decisions are required in choosing the treatment methods, such as, direct anastomosis of vein or artery to aorta, or adding supplementary treatment methods like percutaneous coronary intervention, rather than choosing a fixed treatment methods.

배경: 허혈성 좌주간 관동맥 협착병변은 돌연사의 위험성이 높아 조속한 재관류를 요한다. 본 교실에서는 단독 좌주간 관동맥 협착병변으로 좌측 내흉동맥에 요골동맥이나 우위대망동맥을 Y모양으로 연결하여 관상동맥우회로 조성술을 시행했던 경우를 분석함으로써 내흉동맥만으로 심근의 혈액요구량을 충분하게 감당할 수 있는지의 여부와 경계부 협착을 보이는 좌주간 관동맥 협착병변에서 경쟁혈류에 의한 우회혈관의 재구성이 초래되는가를 알아보았다. 대상 및 방법: 2000년 3월부터 2003년 4월까지 관상동맥우회로 조성술을 시행받은 247명의 환자 중 단독 좌주간 관동맥 협착병변으로 진단되어 동맥이식편만을 이용한 관상동맥우회로 조성술을 시행받은 12명(4.8%)의 환자를 대상으로 하여 의무기록과 본 교실의 database를 기초로 역행성 연구를 시행하였다. 결과: 좌전하행지 문합은 전예에서 인공심폐기를 사용하지 않고 시행하였으나 둔각변연분지 문합 중 2예에서는 인공심폐기 가동 후 심박동하에서 문합하였다. 직경이 1 mm 이상되는 좌회선분지가 없어 문합을 시행하지 못한 1예를 제외한 11예에서 Y-도관을 이용한 완전재관류를 시행하였으며 환자 1인당 문합 수는 평균 2.0개이었다. 좌주간동맥의 협착이 75% 이하이었던 경우에서는 좌전하행지 문합 중 1예에서 좌내흉동맥에 string sign을 보였으며 좌회선분지 문합 7예 중 완전히 막힌 경우 2예, slender sign 1예가 있었으며 문합 원위부 관상동맥 혈류 형태가 도관의존성인 경우는 없었다. 그러나 이와는 반대로 90% 이상의 협착 병변에서는 문합된 관상동맥 모두에서 도관의존성의 원위부 혈류 형태를 보였다. 결론: 90% 이상의 협착을 보인 좌주간동맥 협착병변에서는 동맥이식편을 V-도관으로 만들어 TAR를 시행하더라도 심근의 혈류요구량을 충분하게 감당할 수 있을 것으로 판단된다. 그러나 경계부 협착을 가진 환자의 경우에는 고정된 치료방침을 택하기보다는 면밀한 진단을 통하여 정맥도관이나 동맥도관의 대동맥에 직접 문합 또는 경피적 관동맥중재술과의 보완 치료 등 좀 더 유연하고 신중한 치료방침의 결정이 필요할 것으로 생각된다.

Keywords

References

  1. Circulation v.100 Survival in subgroups of patients with left main coronary artery disease CiAHA guidelines for coronary artery bypass graft surgery: Executive summary and recommendations Eagle,K.A.;Guyton,R.A.;Davidoff,R.D.(et al.) https://doi.org/10.1161/01.CIR.100.13.1464
  2. JAMA v.59 Clinical features of sudden obstruction of the coronary arteries Herrick,J.
  3. Circulation v.91 Comparison of surgical and medical group survival in patients with left main coronary disease: long term CASS experience Caracciolo,E.A.;Davis,K.B.;Sopko,G.(et al.) https://doi.org/10.1161/01.CIR.91.9.2325
  4. J Am Coll Cardiol v.38 Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance Park,S.J.;Hong,M.K.;Lee,C.W.(et al.) https://doi.org/10.1016/S0735-1097(01)01491-7
  5. Circulation v.106 Results and longterm predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery Takagi,T.;Stankovic,G.;Finci,L.(et al.) https://doi.org/10.1161/01.CIR.0000024983.34728.5D
  6. Ann Surg v.162 Coronary endarteretomy with patch-graft reconstruction: Clinical experience with 34 cases Effler,D.B.;Sones,F.M. Jr.;Favaloro,R.;Groves,L.K. https://doi.org/10.1097/00000658-196510000-00005
  7. Eur J Cardiothorac Surg v.11 Surgical angioplasty of the left main coronary artery Dion,R.;Elias,B.;Khoury,G.E.I.;Noirhomme,P.;Verhelst,R.;Hanet,C. https://doi.org/10.1016/S1010-7940(97)01181-0
  8. Ann Thorac Surg v.68 Arterial patch angioplasty for reconstruction of proximal coronary artery stenosis Liska,J.;Joensson,A.;Lockowandt,U.;Hertzfeld,I.;Gelinder,S.;Franco-Cereceda,A. https://doi.org/10.1016/S0003-4975(99)01124-8
  9. Eur J Cardiothorac Surg v.19 Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome Yeatman,M.;Caputo,M.;Ascione,R.;Ciulli,F.;Angelini,G.D. https://doi.org/10.1016/S1010-7940(01)00572-3
  10. 2002 Update in Coronary Artery Surgery(Abstract) OPCAB for the isolated left main disease: Korean society for research of coronary artery surgery kim,K.B.
  11. Eur J Cardiothorac Surg v.6 Revascularization with bilateral internal thoracic artery grafts in patients with left main coronary stenosis Barner,H.B.;Naunheim,K.S.;William,V.L.;Fiore,A.C. https://doi.org/10.1016/1010-7940(92)90077-B
  12. Eur J Cardiothorac Surg v.8 Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease: an incremental risk? Paolini,G.;Zuccari,M.;Di,Credico, G. https://doi.org/10.1016/1010-7940(94)90038-8
  13. J Thorac Cardiovasc Surg v.125 Safety and usefulness of composite grafts for total arterial myocardial revascularization; a prospective randomnized evaluation Munerreto,C.;Negri,A.;Manfredi,J.;Terrini,A.;Rodella,G.;ElQarra,S. https://doi.org/10.1067/mtc.2003.154
  14. Ann Thorac Surg v.68 Total arterial revascularization with an internal thoracic artery and radial artery T graft. Stunt,T.M. 3rd.;Barner,H.B.;Camillo,C.J.;Gay,W.A. Jr. https://doi.org/10.1016/S0003-4975(99)00563-9
  15. J Thorac Cardiovasc Surg v.112 Is internal thoracic artery grafting suitable for moderately stenotic coronary artery? Kawasuji,M.;Sakakibara,N.;Takemura,H.;Tedoriya,T.;Ushijima,T;Watanabe,Y. https://doi.org/10.1016/S0022-5223(96)70246-5
  16. J Thorac Cardiovasc Surg v.111 Effects of competitive blood flow on arterial graft patency and diameter Hashimoto,H.;Isshiki,T.;Ikari,Y.(et al.) https://doi.org/10.1016/S0022-5223(96)70449-X
  17. J Thorac Cardiovasc Surg v.102 Internal thoracic artery and competitive flow Suma,H.
  18. J Am Coll Cardiol v.38 Arterial remodeling and coronary artery disease: The concept of dilated versus obstructive coronary atherosclerosis Schoenhagen,P.;Ziada,K.;Vince,G.;Nissen,S. https://doi.org/10.1016/S0735-1097(01)01374-2
  19. J Thorac Cardiovasc Surg v.120 Midterm endothelial function and remodeling of radial artery grafts anastomosed to the aorta Gaudino,M.;Glieca,F.;Trani,C.;Lupi,A.;Mazzari,M.A.;Schiavoni,G. https://doi.org/10.1067/mtc.2000.108015
  20. Circulation v.100 no.suppl II Enhanced nitric oxid mediated vascular relaxation in radial artery compared with internal mammary artery or saphenous vein Shapira,O.M.;Xu,A.;Aldea,G.S.;Vita,J.A.;Shemin,R.J.;Keaney,J.F.