• Journal of Chest Surgery
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• v.42 no.3
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• pp.324-330
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• 2009

Background: The long term patency of the free saphenous vein graft, which is the most commonly used conduit, anastomosed to the ascending aorta has been reported to be lower than that of arterial grafts. We evaluated early clinical outcome and the angiographic patency of the saphenous vein composite graft based on the left internal thoracic artery, and compared these results with those of using arterial composite grafts. Material and Method: From September 2006 to October 2008, 419 patients underwent off-pump coronary revascularization. Among those, 295 patients (70.4%) were revascularized using composite grafts (group I: saphenous vein composite graft, n=71, group II: arterial composite graft, n=224). The clinical results were compared between the 2 groups. Early postoperative coronary angiograms were performed in all the patients. ($1.6{\pm}1.6$ days) Result: The number of the distal anastomosis per patient was $3.5{\pm}1.0$ and $3.1{\pm}0.8$ in group I and II, respectively (p=.002). The operative mortality (n=2, 0.7%) and postoperative complications such as atrial fibrillation (n=73, 24.7%), perioperative myocardial infarct (n=6, 2.0%), acute renal failure (n=6, 2.0%), reoperation for bleeding (n=5, 1.7%), cerebrovascular accident (n=3, 1.0%), and mediastinitis (n=1, 0.3%) were not related with the use of saphenous vein graft. Early coronary angiograms revealed a 96.9% (126/130) for the saphenous vein grafts and a 98.8% (479/485) for the composite graft in group II (p=.231). Conclusion: Our data suggested that a saphenous vein graft might be used as analtemative conduit to the arterial graft for constructing a composite graft, as based on our early clinical and angiographic results. Further study is required to establish the long-term efficacy of using a saphenous vein as a composite graft.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.309-315
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• 2003

Background: To avoid the adverse effects of cardiopulmonary bypass and to overcome late vein graft failure we routinely peformed off-pump total arterial coronary revascularization. Material and Method: From July 2000 to August 2001, 104 consecutive patients underwent first elective off-pump total arterial coronary revascularization. Both internal mammary, radial and gastroepiploic arteries were used. Sequential and composite grafts were used to achieve complete revascularization. Perioperative adverse events and postoperative angiograms were analyzed. Result: A total of 252 arterial conduits were used with an average of 2.47 grafts per patient. A total of 326 distal anastomosis were performed with a mean of 3.13 distal anastomosis per patient. Cross over to on-pump occurred in seven patients (6.7%). Of these 4 were due to unstable hemodynamics during lateral or posterior wall stabilization as a result of cardiomegaly and 3 were due to uncontrolled bleeding during dissection of diffusely dimunitive deeply placed intramyocardial coronary arteries. There were no opeartive deaths. Two cases of perioperative myocardial infarction and transient neurologic complications occurred, respectively. Of the 312 distal anastomoses, 308 (98.7%) were compatible with Fitz-Gibboll A or B patency grading. Conclusion: Off-pump total arterial coronary revascularization was technically feasible in most elective cases with satisfactory early results. However, on-pump coronary bypass surgery should be considered in difficult circumstances, such as cardiomegaly or unfavorable anatomy of the target coronary artery.

• Journal of Chest Surgery
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• v.35 no.12
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• pp.898-901
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• 2002

It is now widely accepted that the complete arterial coronary revascularization has better short and long term results compared to coronary bypass surgery using arterial graft mixed with vein graft mainly due to its superior patency rate. However, sometimes the internal thoracic artery and other conventionally used grafts might be unavailable or it may require caution in using bilateral internal thoracic artery especially in diabetic patient because of the possible risk of the mediastinitis or other associated morbidities. Moreover, there could also be a shortage for arterial graft in case of coronary reoperation. We report our first three cases using thoracodorsal artery(TDA) as an alternative graft in complete arterial coronary revascularization.

• Journal of Chest Surgery
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• v.40 no.8
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• pp.546-551
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• 2007

Background: The radial artery is gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there have been limited reports about its angiographic patency compared with that of internal thoracic artery or saphenous vein. We tried to evaluate angiographic patency of radial artery graft and to compare that of radial artery and other gratis with retrospective manner. Material and Method: From January 2001 to Jure 2006, totally 132 patients (male 92, female 40) who underwent coronary artery bypass graft using radial artery were re-admitted to our hospital for follow up angiographic examination. Mean age was 58.2+8.87 and mean follow up duration was 32 month ($2{\sim}110$ month). Off pump and on pump bypass surgery were performed 74 and 58 patients respectively. Along with radial artery, left internal thoracic arteries were used in 57 cases, concomitant left internal thoracic artery and saphenous veins were used in 47 cases and bilateral internal thoracic arteries were used in 20 cases. Result: Totally 412 distal anastomosis were performed and 376 anastomosis remained patent (91.2%). Left internal thoracic artery showed the most excellent patency in all of the conduits (98.5%). Radial artery graft patency was 90.8% (169/186). There was no statistical difference of the patency by conduit between on-pump and off-pump group. But radial artery showed more higher patency rate (98/110, 89%) in the severe stenotic lesion that preoperatively revealed more than 90% stenosis than in the lesser severe (<90%) stenotic lesion (60/76, 78%)(p < 0.005). Radial artery conduit represented the worst result when it was grafted in the right coronary system. But when it was positioned in the left heart especially diagonal or obtuse marginal area, patency was comparable with left internal thoracic artery. Conclusion: Radial artery graft showed good midterm patency when it was used in the severe stenotic lesion more than 90% and left coronary system. But great notice should be taken when it is grafted in the right coronary system or less severe stenotic lesion.

• Journal of Chest Surgery
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• v.39 no.1 s.258
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• pp.48-55
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• 2006

Background: The benefits of preoperative use of aspirin and plavix in coronary patients have been well documented. Due to their bleeding tendency, there have been many discussions about when to stop the antiplatelet agent before operation. We evaluated the effects of preoperative continuous use of aspirin and plavix in OPCAB patients. Material and Method: 123 patients underwent OPCAB from March, 2004 to Feb., 2005. We divided them into two groups; those who had continuous administration of aspirin and plavix during the preoperative period (n=45, 36.6$\%$) and those who discontinued them at least one day before the operation (n=78, 63.4$\%$). We then compared the platelet count, hemoglobin/hematocrit level, graft patency, postoperative bleeding and related complications, and operation time between the two groups. The patients were also divided into long-term users ($\geq$ 1 month) and short-term users (< 1 month), with the aforementioned factors equally compared. Result: There was no statistical difference between the two groups regarding postoperative bleeding, related complications, graft patency, operation time and mortality. Continuous users showed significantly low platelet levels on immediate post operation (p=0.02), postoperative day (POD) $\sharp$1 (p=0.002) and POD $\sharp$2 (p=0.021), respectively. But there was no difference on POD $\sharp$7. Long-term users showed statistically significant difference in pre- and postoperative platelet count, but none in postoperative bleeding and related complications. Conclusion: Continuous use of aspirin and plavix did not increase postoperative bleeding or related complications. Also graft patency and mortality had no statistical differences in continuous users. We think that there is no need to stop aspirin and plavix before OPCAB.

• Journal of Chest Surgery
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• v.36 no.9
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• pp.659-665
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• 2003

The aim of this study was to evaluate the early and midterm results of off-pump total arterial revascularization using the skeletonized right gastroepiploic artery (RGEA) as a third arterial conduit. Material and Method: We prospectively analyzed 103 patients who underwent off-pump total arterial revascularization using bilateral internal thoracic arteries (ITAS) and RGEA. The RGEA was used as in situ graft in 88 patients, composite graft in 10 patients, and free graft in 5 patients. Postoperative coronary angiographies were performed before discharge in 100 patients, and at postoperative one year in 88 patients. Result: The RGEA showed a significantly higher free flow (130$\pm$95 ml/min) than that of right ITA(113$\pm$57 ml/min) or left ITA (107$\pm$55 ml/min), which was measured before anastomosis (p < 0.05). The total number of distal anastomoses was 3.8$\pm$0.7. The number of distal anastomoses per bilateral ITAs was 2.8$\pm$0.7 and the number of distal anastomosis per RGEA was 1.0. There were two morialities including one operative mortality. The late mortality was not related to cardiac events. Early postoperative morbidities were atrial fibrillation in 15 patients, bleeding reoperation in 4 patients, mediastinitis in 1 patients, perioperative myocardial infarction in 2 patient, and transient ARF in 3 patients. Postoperative coronary angiographies showed the early patency rate of 98.6％ (272/276) for ITAs and 97.0％ (97/100) for RGEA, respectively (p=ns), and the one-year patency rate of 95.9％ (234/244) for ITAs and 88.6％ (78/88) for RGEA, respectively (p=0.07). Flow competition between the RGEA and NCA (native coronary artery) was seen in 5 of the 100 patients (5.0％) immediate postoperatively and 7 of the 88 patients (8.0％) 1 year after surgery. Since July, 2000, we measured transit time flow intraoperatively and could reduce flow competition significantly Conclusion: The skeletonized RGEA demonstrated excellent early and midterm patency rates and could be used as a third arterial graft following the bilateral ITAs.

• Journal of Chest Surgery
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• v.42 no.4
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• pp.456-463
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• 2009

Background: Although the reports on re-operative coronary revascularization (redo-CABG) have increased, there are only limited reports on redo-CABG using arterial grafts. The aim of this study was to analyze the safety and feasibility of using various arterial grafts for redo-CABG. Material and Method: A consecutive series of patients who underwent 33 redo-CABGs from March 2001 to July 2008 were retrospectively reviewed. We performed conventional CABG in 17 patients, on-pump beating CABG in 7, off-pump CABG in 7 and minimally invasive direct coronary artery bypass in 2. The grafted that were used included 34 internal thoracic arteries (ITA), 14 radial arteries, 14 right gastroepiploic arteries and others. Arterial composite grafts were constructed in 26 patients. Of these, a previously patent in-situ left ITA was re-used as the in-flow of a composite graft in 10 patients. Result: No hospital deaths or major wound problems occurred. The post-operative complications included 2 myocardial infarctions (6%), 1 intra-aortic balloon pump insertion (3%), 5 cases of atrial fibrillation (15.1 %) and 3 neurologic complications (9.1%). The meanfollow-up duration was 31.1$\pm$22.7 months and the 3 year survival rate was 86.4%. There were 4 late deaths (2 cardiac deaths) and no recurrent angina during the follow-up period. Conclusion: Redo-CABG with using various arterial grafts is currently a safe, feasible procedure, but further investigation and long term follow-up are needed.

• Journal of Chest Surgery
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• v.38 no.9 s.254
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• pp.601-608
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• 2005

Background: To maximize the histological advantage and minimize the physiological disadvantage, we have been using the skeletonized gastroepiploic artey (GEA) as a free graft for total arterial revascularization. The aims of the current study was to assess the efficacy of the skeletonized GEA as a composite or extended graft for total arterial revascularization. Material and Method: Between January 2000 and Feburary 2005, 133 patients (43 female, mean age=61.8 yrs) undergoing coronary artery bypass grafting (CABG) with a skeletonized GEA as free graft (22 extended, 107 composite and 4 others) were enrolled in this study. Coronary angiograms were performed in the immediate (median 44 days, n=86), early (median 366 days, n=56) and midterm (median 984 days, n=29) postoperative periods. Result: There were 3 ($2.2\%$) early and 4 ($3.3\%$) late cardiac-related deaths. The mean number of distal anastomoses per patient was 3.34 for total graft and 1.92 for GEA graft. The immediate, early, and midterm GEA patency were 157/159 ($98.7\%$), 106/142 ($94.6\%$), and 53/56 ($94.6\%$), respectively. During follow-up, four patients required percutaneous intracoronary intervention because of GEA and target coronary artery stenosis or competitive flow. Conclusion: These data demonstrate satisfactory clinical and angiographic results in the skeletonized GEA as free graft for total arterial revascularizatioh. Although we need a careful longer follow-up, the skeletonized GEA as a free graft will be a valuable option 'to be' for CABG.

• Journal of Chest Surgery
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• v.38 no.8 s.253
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• pp.551-556
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• 2005

Background: Complete arterial off-pump coronary artery bypass grafting (OPCAB) by sequential anastomoses with one or two arterial grafts provides favorable outcomes. However, problems of insufficient graft length, hypopefusion, kinking of graft, and unfavorable course of graft may be encountered. To solve these problems, we have used different technique with multiple arterial Y composite graft to allow end-to-side rather than sequential anastomoses and evaluated the results of this method. Material and Method: Between February 2003 and October 2004, If patients underwent total arterial OPCAB using multiple arterial V composite grafts with left internal mammary artery (LIMA), radial artery (RA), and right internal mammary artery (RIMA). We divided RA into multiple segments by number of distal target site after measuring of individual proper length and constructed arterial composite graft. One of segments was sutured end-to-side to LIMA and other segment was sutured end-to-side to the previously constructed radial graft. Postoperative graft patency was evaluated in 6f patients by multi-slice computed tomegraphy. Result: An average of $2.5\pm0.6$ arteries and $3.7pm0.7$ distal anastomoses per patient were done. There was no perioperative myocardial infarction, clinical hypoperfusion syndromes, and operative mortality. Postoperative mean CK-MB level was $17.4pm29.7\;IU/L.$Overall graft patency was $99.1\%\;(214/216)(LIMA:\;100\%,\;RA:\;98.4\%,\;RIMA:\;100\%).$ Conclusion: This technique allows total arterial OPCAB without technical problems and provides excellent early clinical results and graft patency. We believe that this technique is more convenient in the obtuse marginal area compared to sequential technique, and helpful in patients who require complex arterial grafting.

• Journal of Chest Surgery
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• v.39 no.5 s.262
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• pp.359-365
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• 2006

Background: Arterial grafts have been used to achieve better long-term results for coronary revascularization. Bilateral internal thoracic artery (ITA) grafts have a better results, but it may be not used in some situations such as diabetes and chronic obstructive pulmonary disease (COPD). We evaluated the clinical and angiographic results of composite left internal thoracic artery-radial artery (LITA-RA) Y graft. Material and Method: Between April 2002 and September 2004, 119 patients were enrolled in composite Y graft for coronary bypass surgery. The mean age was $62.6{\pm}8.8$ years old and female was 34.5%. Preoperative cardiac risk factors were as follows: hypertension 43.7%, diabetes 33.6%, smoker 41.2%, and hyperlipidemia 22.7%, There were emergency operation (14), cardiogenic shock (6), left ventricle ejection fraction (LVEF) less than 40% (17), and 17 cases of left main disease. Coronary angiography was done in 35 patients before the hospital discharge. Result: The number of distal anastomoses was $3.1{\pm}0.91$ and three patients (2.52%) died during hospital stay. The off-pump coronary artery bypass (OPCAB) was applied to 79 patients (66.4%). The LITA was anastomosed to left anterior descending system except three cases which was to lateral wall. The radial Y grafts were anastomosed to diagonal branches (4), ramus intermedius (21), obtuse marginal branches (109), posterolateral branches (12), and posterior descending coronary artery (8). Postoperative coronary angiography in 35 patients showed excellent patency rates (LITA 100%, and RA 88.5%; 3 RA grafts which anastomosed to coronary arteries <70% stenosed showed string sign with competitive flow). Conclusion: The LITA-RA Y composite graft provided good early clinical and angiographic results in multivessel coronary revascularization. But it should be cautiously used in selected patients.