Is the internal thoracic artery the conduit of choice to replace a stenotic vein graft?

Daniel Navia, Delos M. Cosgrove, Bruce W. Lytle, Paul C. Taylor, Patrick M. McCarthy, Robert W. Stewart, Eliot R. Rosenkranz, Floyd D. Loop

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Abstract

Reoperative coronary artery bypass grafting secondary to saphenous vein graft (SVG) stenosis is a mushrooming problem. The internal thoracic artery graft (ITA) provides superior Long-term patency, but its flow is limited and may be inadequate to meet large myncardial demands. To evaluate the efficacy of the ITA as a replacement conduit for a stenotic SVG, 387 consecutive patients undergoing reoperative bypass grafting from 1985 to 1990 with a stenotic SVG to a totally obstructed left anterior descending coronary artery (LAD) were analyzed. The patients were divided into four groups according to the management of the previously placed SVG. Group I (n = 155) underwent graft replacement with a new SVG. Group II (n = 90) received an ITA with the old SVG left intact. In group III (n = 37), an ITA was placed to the LAD with an SVG to the diagonal (old graft interrupted). Group IV (n = 104) had an ITA only to the LAD (old graft interrupted). There were 14 deaths (3.6%). Mortality rate was 7.9% for group IV and 2.1% for groups I through III (p = 0.01). Multivariate analyses identified advancing age (p = 0.01), ITA only (p = 0.01), and female sex (p = 0.04) as independent predictors of operative mortality. Evidence of hypoperfusion in the distribution of the LAD was present in 19 patients, all of whom were in group IV (18.9%). Predictors of hypoperfusion were moderate/severe left ventricular function (p = 0.02) and ITA to the LAD with interruption of the old graft (p = 0.0001). Hypoperfusion syndrome was treated with a new SVG to the LAD in 11 patients, and all but 1 survived; 8 were treated with an intraaortic balloon pump, for a 63% mortality (p = 0.01). We conclude that replacing a stenotic SVG to a totally occluded LAD with an ITA is associated with increased mortality and increased incidence of hypoperfusion syndrome. Hypoperfusion syndrome is best treated with supplemental vein grafting.

Original languageEnglish (US)
Pages (from-to)40-44
Number of pages5
JournalThe Annals of Thoracic Surgery
Volume57
Issue number1
DOIs
StatePublished - Jan 1994

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ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Navia, D., Cosgrove, D. M., Lytle, B. W., Taylor, P. C., McCarthy, P. M., Stewart, R. W., Rosenkranz, E. R., & Loop, F. D. (1994). Is the internal thoracic artery the conduit of choice to replace a stenotic vein graft? The Annals of Thoracic Surgery, 57(1), 40-44. https://doi.org/10.1016/0003-4975(94)90362-X