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Woo YJ, Gardner TJ. Myocardial Revascularization with Cardiopulmonary Bypass.
In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:581607.

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Chapter 21

Myocardial Revascularization with Cardiopulmonary Bypass

Y. Joseph Woo/ Timothy J. Gardner

HISTORY
OPERATIVE INDICATIONS
PATIENT EVALUATION
????Specific Comorbidities
ANESTHESIA
BLOOD CONSERVATION
INCISIONS
CONDUITS
????Internal Thoracic Artery
????????CHARACTERISTICS
????????HARVEST TECHNIQUE
????????BILATERAL ITA
????Radial Artery
????????CHARACTERISTICS
????????HARVEST TECHNIQUE
????Gastroepiploic Artery
????????CHARACTERISTICS
????????HARVEST TECHNIQUE
????Inferior Epigastric Artery
????Alternative Arterial Conduits
????Greater Saphenous Vein
????????CHARACTERISTICS
????????HARVEST TECHNIQUE
????Lesser Saphenous Vein
????Cephalic Vein
????Nonautogenous Conduits
CARDIOPULMONARY BYPASS
DISTAL ANASTOMOSES
????Sequence of Anastomoses
????Distal Target Selection
????Arteriotomy
????Anastomotic Technique
????Sequential Grafting
????Distal Anastomotic Devices
CORONARY ENDARTERECTOMY
PROXIMAL ANASTOMOSES
????Prior to Distal Anastomosis
????Single Cross-clamp
????Partial Occlusion Clamp
????Anastomotic Technique
????Composite Grafts
????Proximal Anastomotic Devices
WEANING FROM CARDIOPULMONARY BYPASS
CHEST CLOSURE
POSTOPERATIVE MANAGEMENT
OUTCOMES
????Perioperative Mortality
????Perioperative Morbidity
????Other Perioperative Parameters
????Long-Term Graft Patency
????Long-Term Survival
SUMMARY
REFERENCES

?? HISTORY
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Surgery for human atherosclerotic coronary arterial disease began in 1935, when Beck attached a pedicled graft of pectoralis muscle to the heart in an attempt to provide a new blood supply.1 In 1941, Beck reported constricting the coronary sinus, mechanically abrading the pericardium and epicardium, instilling asbestos and trichloracidic acid into the pericardium, and placing mediastinal fat onto the epicardial surface. In 1951, Vineberg described the implantation of the internal thoracic artery directly into the myocardium.2 Although long-term patency of the graft was demonstrated later, the amount of blood flow and region of distribution were insignificant with this approach. In the mid-1950s, Murray reported experimental studies of internal thoracic arterycoronary artery anastomoses.3 In 1953, Gibbon successfully used cardiopulmonary bypass clinically for intracardiac surgery.4 In the late 1950s, Bailey described direct coronary endarterectomies.5 In 1961, Senning described a patch angioplasty of a stenotic coronary artery.6 In 1962, Sohns and Shirey reported the development of coronary angiography, which would subsequently permit guided interventions for distinct coronary stenoses.7

Credit for performing the first coronary artery bypass procedure in humans is given to several different surgeons. In 1958, Longmire described a patient in which a coronary endarterectomy was attempted, but the coronary artery disintegrated. In a desperate attempt to reconstruct the coronary, the internal thoracic artery was harvested and anastomosed to the coronary artery.8 In 1962, Sabiston reported the first aortocoronary bypass, but this patient died in the early postoperative period of a cerebrovascular accident.9 Garrett and DeBakey are credited by some with performing the first successful aortocoronary bypass in 1964, although this was not reported until 1973.10 In 1964, Kolesov in Leningrad performed the first planned anastomosis between the left internal thoracic artery and the left anterior descending artery.11 In 1968, Favolaro reported the first large series of coronary artery bypass graft patients.12 From the late 1960s and early 1970s, aortocoronary venous bypass grafting, together with internal thoracic artery to coronary artery bypass grafting, grew rapidly in popularity to become one of the most commonly performed major operations today. Likewise, alternative strategies for myocardial revascularization have propagated and exist across a wide spectrum of approaches ranging from variations on the standard operation with elimination of cardiopulmonary bypass, to extensive catheter-based angioplasty and stenting, and finally to laser and genetic endogenous revascularization.13


?? OPERATIVE INDICATIONS
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The specific indications for coronary revascularization are covered in Chapter 19, and methods of percutaneous coronary interventions are described in Chapter 20. Globally, the indications for operative myocardial revascularization have been well delineated and can be viewed as specific anatomic criteria such as left main coronary artery disease, multivessel coronary disease, and double-vessel coronary disease with proximal left anterior descending artery involvement, and with or without physiological sequelae such as myocardial ischemia, myocardial infarction, and left ventricular dysfunction.1421 Furthermore, an additional subset includes patients undergoing other cardiovascular surgery with coronary artery disease that would otherwise not indicate operative revascularization. In general, only coronary arteries with significant (greater than 70%) stenoses are bypassed, because graft patency is otherwise severely limited by competitive native coronary flow.


?? PATIENT EVALUATION
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A patient referred for myocardial revascularization should undergo a complete history and physical examination with particular attention focused upon identifying coexisting cardiovascular diseases, comorbid processes, and specific issues that may impact the technical aspects of surgery. Standard laboratory data evaluating chemistry, hematologic, and coagulation profiles should be reviewed. Blood bank studies are performed. Diagnostic studies, which consist primarily of coronary angiography, perfusion ischemia-viability studies, electrocardiograms, and echocardiography, are reviewed. Coronary arterial targets are identified and vascular conduits are chosen and assessed by appropriate studies. The timing of surgery is determined and the patient is pharmacologically and hemodynamically optimized. Once all data are obtained, risk stratification can be performed and the patient can provide fully informed consent.22 The patient can then undergo standard preoperative preparation, which will vary by institution, surgeon, and anesthesiologist.

Specific Comorbidities

Although potential comorbid conditions for coronary artery bypass grafting abound, several specific disease processes should be excluded by history and physical examination and, if present, should be appropriately addressed in an attempt to facilitate safer myocardial revascularization. These conditions include advanced age, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, hepatic insufficiency, gastrointestinal hemorrhage, a hematologic or pharmacologically induced bleeding disorder, malignancy, HIV infection, prior surgery, radiation/chemotherapy, and likely postoperative debilitation that would require rehabilitation.23,24

In 1989, the Society of Thoracic Surgeons initiated a national database to evaluate coronary artery bypass graft and valvular surgery. To date, approximately 1.7 million patients have been registered, and the STS Database is now the largest cardiothoracic surgery outcome and quality improvement program in the world. A particularly useful feature is the ability to obtain immediate risk stratification for a given patient by simple online entry of clinical data. This database can be accessed at https://www.sts.org. Analysis of trends in preoperative risk factors reveals progressively increased severity of risk over the past decade.25


?? ANESTHESIA
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The anesthetic management for cardiac surgical patients is detailed in Chapter 9. There exists an ongoing controversy regarding the extent of monitoring required or deemed appropriate for myocardial revascularization procedures performed with cardiopulmonary bypass. Centers vary in their use of pulmonary artery monitoring catheters, oximetric continuous cardiac output monitors, and transesophageal echocardiography. Perioperative antibiotic administration should be designed to prevent primarily gram-positive but also gram-negative infections.26


?? BLOOD CONSERVATION
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Although homologous blood products are multiply screened and considered extremely safe in the current era, the remote risk of infection still exists. Blood product administration does increase the risk of multiorgan dysfunction, particularly that of the lungs, and transfusion is costly. Thus, strategies for the conservation of blood abound. These will often include autologous as well as donor-directed blood donation.27 However, these strategies tend to be less utilized among cardiac surgical patients, particularly autologous donation, where compromised oxygen carrying capacity may exacerbate myocardial ischemia or hemodynamic instability. Preoperative multivitamins, iron, and erythropoietin have been used among patients in an effort to increase red cell mass.28,29 Intraoperative prebypass hemodilution and blood storage as well as platelet harvest devices have been utilized. Complicated formulas for heparin and protamine dosing have also been used in an attempt to reduce blood loss.30 Pharmacologic measures with antifibrinolytics such as epsilon-aminocaproic acid and aprotinin are utilized.31,32 Although of some theoretical concern, aprotinin does not appear to increase the risk of early thrombosis in patients who have primary coronary artery bypass grafts.33 Also of some potential value are DDAVP and vitamin K.34 During surgery, the use of a cell saver and a cardiotomy suction device helps to conserve blood, and autotransfusion systems can be utilized postoperatively. Total creatine kinase and lactate dehydrogenase enzyme levels may be elevated because of the hemolysis associated with the use of such systems, and care must be taken in the interpretation of these values.35 There is also ongoing active research in artificial blood substitute development. These tend to be categorized into two types: liquid compounds with increased oxygen solubility and mammalian hemoglobin derivatives. All of the above issues become particularly relevant when choosing to operate on patients who, for religious or other reasons, refuse the administration of blood products.


?? INCISIONS
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The standard operative approach for coronary revascularization is the median sternotomy, which provides the greatest access to the heart and great vessels. Alternative incisions include partial sternotomy as well as a right or left thoracotomy approach, which can be used to address coronary targets on specific sides. Incisions other than the median sternotomy often require femoral arterial and/or venous access for cardiopulmonary bypass.


?? CONDUITS
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The choice of conduit for coronary artery bypass grafting is influenced by patient age, medical history, target vessels, conduit availability, and surgeon preference. Of particular note, a pedicled arterial graft to a high-outflow system has been clearly shown to significantly improve early and late postoperative survival, and thus should be utilized whenever possible.36,37 Specific conduits, their evaluation, and their preparation are described in the following sections.

Internal Thoracic Artery

CHARACTERISTICS

The internal thoracic artery possesses distinct molecular and cellular characteristics that contribute to its unique resistance to atherosclerosis and extremely high long-term patency rates. Structurally, there is no vaso vasorum. There is a dense, nonfenestrated, intact internal elastic lamina that inhibits cellular migration and subsequent initiation of hyperplasia. The ITA possesses a thin medial layer with few smooth muscle cells, which provides little vasoreactivity. Even among these few smooth muscle cells, there exist distinct populations with varying biochemical functions and ultrastructural features.38,39 Saphenous vein smooth muscle cells exhibit markedly enhanced proliferation in response to platelet-derived growth factor as compared with internal thoracic artery smooth muscle cells.40 Pulsatile mechanical stretch is also a potent mitogen for saphenous vein but not for internal thoracic artery smooth muscle cells.41 The vasoactivity of the internal thoracic artery has also been well characterized. The internal thoracic artery produces significantly more prostacyclin, a vasodilator and platelet inhibitor, than does the saphenous vein.42 The potent vasodilator nitric oxide is produced in markedly higher quantities by internal thoracic artery endothelium compared to that of saphenous vein.41,43 In studies of the human internal thoracic artery, nitric oxide also antagonizes the potent vasocontrictive effects of endogenous endothelin-1.44 The internal thoracic artery vasodilates in response to milrinone and does not vasoconstrict in response to norepinephrine.45 Nitroglycerin causes vasodilation in the internal thoracic artery but not in saphenous vein.46 Conduit resistance to harvest injury may also vary. Scanning electron microscopy of representative sections of internal thoracic artery and saphenous vein conduits at the time of anastomosis revealed large thrombogenic intimal defects with exposed collagen fibrils in veins and essentially no endothelial injury in arteries.47 Lipid and glycosaminoglycan composition of internal thoracic artery compared to saphenous vein suggests greater atherogenecity in saphenous vein.48 Finally, the pedicled internal thoracic artery can exhibit flow adaptation over time and is often observed to be larger when visualized on late postoperative angiograms.

HARVEST TECHNIQUE

Because the internal thoracic artery is almost always of adequate caliber and provides adequate flow, it is rarely evaluated preoperatively. Occasionally, an internal thoracic artery is imaged at the time of cardiac catheterization. The incidence of subclavian artery or internal thoracic artery ostial stenosis is estimated to be well under 5% in patients undergoing revascularization. The preparation of the internal thoracic artery begins immediately after median sternotomy (Fig. 21-1). A RULTract device or asymmetric sternal retractor is placed to elevate the hemisternum. Care should be taken not to exert excessive traction on the hemisternum as this may cause brachial plexus injury, although this is more commonly a result of overly wide distraction with the sternal retractor.49 The table is turned away from the surgeon and raised to an appropriate level. The tidal volume on the mechanical ventilator is decreased and the pleural space is opened widely. A moistened laparotomy pad can be placed onto the surface of the lung to keep the lung away from the field of dissection. Alternatively, some surgeons prefer not to enter the pleural space and simply push the parietal pleura away from the endothoracic fascia, utilizing the pleura itself to retract the lung away from the operative field.



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FIGURE 21-1 Left internal thoracic artery harvest. An asymmetric retractor is used to elevate the left hemisternum. The parietal pleura and endothoracic fascia medial and lateral to the internal thoracic artery and accompanying veins are incised with the electrocautery and then, using a combination of blunt and electrocautery dissection, the internal thoracic artery pedicle is separated from the chest wall. Metal clips are used to secure the larger branches. The pedicle can be harvested from the level of the subclavian vein down to the bifurcation of the superior epigastric and musculophrenic arteries. After systemic heparinization, the pedicle is divided distally and flow is assessed.

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Dissection can be initiated at any point along the course of the internal thoracic artery. One technique is to incise the fascia with electrocautery at the most superior aspect of the artery near the level of the subclavian vein. Downward traction on the edge of the fascia together with a combination of cold dissection and electrocautery permits separation of the arterial-venous pedicle from the anterior chest wall. Depending upon size, arterial and venous branches to the chest wall are electrocauterized or secured with metal clips. Dissection is carried out in this manner along the entire course of the artery. Care must be taken not to grasp the artery. Gentle retraction against the artery is safe, but grasping the edge of the pedicle fascia, or even the internal thoracic vein, is preferable. Pulsations within the artery can often be observed visually or manually palpated. The absence of these pulsations does not necessarily correlate with poor internal thoracic artery flow at the time of division. When the majority of the internal thoracic artery is freely dissected, the patient is systemically heparinized. Dissection can then be completed and the distal internal thoracic artery can be divided. At this time, flow can also be evaluated. What may appear to be suboptimal flow in an internal thoracic artery at the time of division is often due to spasm from manipulation and usually improves in a period of time with the topical administration of papaverine solution. The pedicle is examined for hemostasis and is usually wrapped in a papaverine sponge or sprayed with a papaverine solution. Some surgeons directly infuse the distal internal thoracic artery with papaverine solution, but this may cause a frank dissection and studies suggest endothelial and medial injury may result from direct luminal exposure to concentrated papaverine.5052

Preparation of the internal thoracic artery for distal anastomosis can be performed at any convenient time. Options include preparation (1) immediately after harvest, (2) upon identification of likely distal target site, (3) during cardioplegia administration, or (4) after target arteriotomy. The primary advantage of earlier preparation is a small decrement in bypass and cross-clamp time. The advantage of later preparation is the ability to comfortably shorten the conduit and thus utilize a region of larger diameter. To prepare the internal thoracic artery for anastomosis, the adjacent veins and soft tissue are gently dissected away from the artery at the level of planned division. The artery is divided, flow is assessed, and the distal end is spatulated with a fine scissor (Fig. 21-2).



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FIGURE 21-2 Preparation of the distal internal thoracic artery for anastomosis. The internal thoracic artery is freed of its adjacent venous structures and areolar tissue and incised with fine scissors along the fascial aspect of the artery for a distance of approximately 5 to 10 mm to create a hood for distal anastomosis. The artery is carefully inspected for any evidence of injury.

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When an internal thoracic artery intended for use as a pedicled graft is injured during harvesting, it can often be used as a free graft, depending upon the location of the injury and the location of the intended anastomotic target. Care must be taken with dissection of internal thoracic artery grafts at the superior aspect as the phrenic nerve comes in close proximity to the ITA bilaterally. When a pedicled internal thoracic artery graft is found to be of insufficient length to provide a tension-free anastomosis, the conduit can be lengthened significantly by skeletonizing short segments of the artery, dividing the fascia, muscle, and accompanying veins. One to 1.5 cm of additional length can often be obtained with each region of skeletonization. Harvest of the internal thoracic artery by complete skeletonization is now less commonly practiced. Conflicting data exist regarding whether this technique results in decreased rates of long-term patency.53 Advantages include increased length, improved ability to identify spasm, facilitation of sequential anastomoses, and increased preservation of sternal blood supply. Clear disadvantages are increased harvest time, spasm, and likelihood of injury.

BILATERAL ITA

A moderate increase in long-term survival and decrease in ischemic events after coronary artery bypass grafting with the use of two versus one pedicled internal thoracic artery grafts have been demonstrated.5459 This benefit may not exist in all populations60 and may not be present in females.61 The use of bilateral internal thoracic arteries in nondiabetics has been shown to minimally increase the risk of sternal wound complications, particularly in obese patients.62,63 In diabetics, the risk is significantly increased with the use of bilateral internal thoracic arteries.6466 Harvest of the internal thoracic artery results in subtle transient changes in chest wall mechanics that resemble restrictive lung disease, possibly due to pain from asymmetric retraction.67 Bilateral internal thoracic artery utilization is not recommended in patients with chronic obstructive pulmonary disease. 68

When bilateral internal thoracic arteries are being harvested, a common practice is to dissect the majority of the left internal thoracic artery, leaving several terminal branches intact along the distal artery. The right internal thoracic artery is then dissected completely and after the administration of systemic heparin, the right internal thoracic artery is divided, followed by completion of the dissection of the left internal thoracic artery and division.

By far the most common scenario of the internal thoracic artery as a conduit is that of a pedicled LITA anastomosed to the left anterior descending artery. Other scenarios include a pedicled right internal thoracic artery to the right coronary artery or branch thereof, a pedicled RITA brought anterior to the aorta or posteriorly through the transverse sinus to anastomose to a circumflex marginal, a pedicled RITA brought anteriorly to supply the LAD with the pedicled LITA used to supply the circumflex marginal, and finally, the RITA used as a free graft.6870 It appears that the choice of the target vessel, in regards to outflow, has greater influence on long-term patency than the choice of which internal thoracic artery is used.71 Graft placement through the transverse sinus may subject the conduit to unrecognized tension and distortion and also obscure bleeding along the pedicle. Scenarios that place a pedicled RITA anteriorly across the mediastinum impose an extremely high risk of conduit injury during future reoperative surgery.

Radial Artery

CHARACTERISTICS

The use of a radial artery as a conduit for coronary artery bypass grafting was first described by Carpentier in 1973.72 Early patency rates were poor and interest in the use of this conduit faded. The radial artery possesses a pronounced medial layer and is highly vasoreactive.73,74 Cosmetic concerns have also been cited as a deterrent for radial artery usage. There has been a resurgence in the popularity of the use of the radial artery graft.75 This has been attributed to enhanced short- to mid-term radial artery patency rates, the observation of improved outcomes with use of two arterial grafts, and interest in total arterial revascularization.76,77 Bilateral radial artery grafting has been utilized as an effective means of facilitating all arterial revascularization.78 Improved patency rates may be due to a variety of factors, which include greater utilization of harvesting techniques that do not skeletonize the radial artery but rather harvest essentially an arteriovenous island of tissue, widespread application of calcium channel blockade or nitrates to counter spasm, and other pharmacologic manipulation such as the use lipid-lowering agents to retard graft atherosclerosis.79,80 Selection of left-sided target vessels with high-grade proximal stenoses and generous outflow improves radial graft patency rates.81,82 The evaluation of the suitability of the radial artery as a conduit for grafting consists usually of noninvasive duplex ultrasonography, and/or clinical examination with the Allen's test or a variant thereof utilizing a pulse oximeter.83 The radial artery from the nondominant arm is used unless proven unsatisfactory by the above tests, in which case the dominant arm radial artery can be used.

HARVEST TECHNIQUE

In the operating room, the arm is prepped circumferentially, the hand is wrapped sterilely, and the arm is placed on an arm board at 90? from the long axis of the table. In approximately 90% of the population, harvesting radial artery from the nondominant arm means harvesting from the left arm, which will not interfere with simultaneous left internal thoracic artery harvesting. When radial artery harvesting contralateral to the internal thoracic artery harvest is required, this can often be accomplished with the radial artery harvest surgeon working next to the patient's head and approaching the artery from the superior aspect of the arm. A longitudinal, slightly curved skin incision is made over the course of the radial artery with particular attention to avoiding the lateral antebrachial cutaneous nerve. Injury to this nerve results in forearm numbness. The location of initiation of radial artery dissection varies among surgeons. The artery is usually dissected with adjacent tissue similar to that of internal thoracic artery harvest.84 Particular attention is paid to avoiding injury to the superficial radial nerve, which is in close lateral proximity to the middle third of the radial artery (Fig. 21-3). Injury to this nerve results in dorsal thenar numbness. Paraesthesias and numbness occur transiently in 25% to 50% of patients undergoing radial artery harvest and persist in 5% to 10%.8587 After systemic heparinization, the radial artery is divided proximally and distally and removed with its adjoining venous and soft tissue island. It is usually stored in dilute heparin papaverine solution and can be flushed, depending upon surgeon preference. Hemostasis within the operative field is obtained and the arm is closed in multiple layers, and then abducted and secured to the table. The distal aspect of the excised radial artery is usually marked with a suture for proper identification. Very recently, endoscopic techniques of harvesting radial artery conduits have been reported.88 Early short-term data suggest no decrement in graft patency.



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FIGURE 21-3 Left radial artery harvest. The radial artery is harvested with adjacent venous structures. Care is taken to avoid injury to the nearby superficial radial nerve. Dissection is carried from 1 cm below the ulnar radial bifurcation to the level of the wrist crease.

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Gastroepiploic Artery

CHARACTERISTICS

The gastroepiploic artery was first described as a coronary artery bypass conduit in 1984 by Pym.89 This pedicled conduit has primarily been used in reoperative scenarios in the absence of other suitable conduits.90,91 It is now used more frequently as a secondary, tertiary, or quaternary arterial conduit in an attempt to provide all-arterial revascularization.9295 At present, the unclear benefits of third and fourth arterial grafts, the additional operative time required to harvest a gastroepiploic artery, and the involvement of an additional body cavity with potential abdominal complications limit the widespread use of this conduit. However, cellular and physiological studies of the gastroepiploic artery suggest near equivalent biological characteristics to the internal thoracic artery.96100

Guidelines for preoperative assessment of the right gastroepiploic artery are not well delineated. Suspicion of preoperative mesenteric vascular insufficiency may warrant angiographic evaluation. Noninvasive duplex measurement of intra-abdominal vasculature is not always reliable and the role of other noninvasive imaging modalities, such as magnetic resonance imaging, has simply not been studied. Previous abdominal surgery may complicate conduit harvest. Prior gastric surgery, interventional radiology therapies directed towards this vessel, or documented mesenteric vascular insufficiency contraindicate the use of this vessel as a conduit.

HARVEST TECHNIQUE

The harvest technique entails nasogastric decompression and extension of the median sternotomy incision for a few centimeters to perform a limited upper midline laparotomy. The stomach is retracted into the field and the gastroepiploic artery is palpated to evaluate patency. The artery is dissected with its associated veins away from the surrounding gastrocolic omentum (Fig. 21-4). The thin-walled nature of this artery and the tendency for mesenteric vessels to retract into fat and bleed persistently warrant the extensive use of surgical clips to control branches. Alternately, the use of a harmonic scalpel has been advocated. Distally, the dissection is carried for the extent of the artery, which is usually two-thirds along the greater curvature of the stomach. Proximally, the dissection is carried to the duodenum, close to the origin of the gastroepiploic artery from the gastroduodenal artery.101



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FIGURE 21-4 Right gastroepiploic artery harvest. Via upper midline laparotomy, the left lateral hepatic segment is retracted cephalad and the stomach is exposed. The right gastroepiploic artery is harvested from the stomach and greater omentum with the generous use of surgical clips. The artery is harvested from its most distal extent along the greater curvature of the stomach to the level of the pylorus. The artery can then be brought anterior or posterior to the stomach as well as anterior or posterior to the liver and subsequently through the diaphragm and into the pericardium.

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There are several options for the route of entry of the gastroepiploic artery from the abdomen into the pericardium.102 The pedicle can be placed anterior or posterior to the stomach and duodenum. It can be placed anterior or posterior to the left lateral segment of the liver, and can traverse the peritoneal pericardial junction in a variety of locations. A route posterior to the stomach and duodenum decreases risk of conduit injury on future laparotomy, but increases the possibility of tension on the pedicle resulting from gastric distention. Placement anterior to the stomach and duodenum provides the opposite trade-off. The coronary target and size of the left lateral segment of the liver usually determine the route, with respect to the liver. Entry into the pericardium should be close to the target, yet still allow several centimeters of conduit to be placed inside the pericardium and loosely draped to provide a tension-free anastomosis and allow cardiac mobility.

Although the gastroepiploic artery is most commonly used to supply the right coronary artery system, it can be used for the left anterior descending and distal circumflex system, depending upon length of conduit. Although primarily used as a pedicled graft, the gastroepiploic artery can be used as a free graft in the setting of inability to reach a target vessel and lack of conduit or desire to use an additional arterial conduit.

Inferior Epigastric Artery

An infrequently used free arterial conduit is the inferior epigastric artery.103,104 This artery exhibits favorable physiological vasoreactivity characteristics.105,106 It is rather variable in its diameter, length, and location relative to the rectus muscle, and in ease of harvesting. A paramedian incision beginning below the umbilicus is used to approach the conduit. A midline incision can be used to harvest both inferior epigastric arteries. The rectus sheath is entered and the rectus abdominus muscle is carefully dissected and retracted medially, avoiding avulsion of small vascular branches off the inferior epigastric vessels. The artery, together with its accompanying veins and a small amount of soft tissue, is dissected away from the rectus anteriorly and the peritoneum and pre-peritoneal fat posteriorly (Fig. 21-5). The artery is usually transected just distal to its takeoff from the external iliac artery and divided as far superiorly as technically feasible. It is then treated like a radial artery conduit, in terms of preparation.



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FIGURE 21-5 Epigastric artery harvest. The artery can be approached via a midline or paramedian skin incision with appropriate lateral or medial retraction of the rectus abdominus muscle, respectively. In a majority of cases, the inferior epigastric artery lies deep to the body of the rectus muscle. The dissection can be carried as cephalad as the costal margin and as caudad as the external iliac artery.

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Alternative Arterial Conduits

Various other arterial conduits have been anecdotally reported. These include the ulnar, left gastric, splenic, thoracodorsal, and lateral femoral circumflex arteries.107111

Greater Saphenous Vein

CHARACTERISTICS

Greater saphenous vein continues to be the primary conduit for coronary artery bypass grafting in conjunction with a pedicled left internal thoracic artery. Greater saphenous vein has many advantages as a conduit, including availability, accessibility, ease of harvest, reliability, resistance to spasm, and versatility. There are limitations to the greater saphenous vein, including patency rates, size mismatch in either direction, inadequate length, varicosity, sclerosis, and leg healing issues, particularly in patients with peripheral vascular disease. Venous conduit also exhibits poor compliance after arterialization and is prone to progressive atherosclerosis. Ultrasonographic localization and evaluation can be employed when the presence or adequacy of greater saphenous venous conduit is uncertain given specific findings in the history or physical examination.

HARVEST TECHNIQUE

Methods of harvesting the greater saphenous vein vary depending upon the length of segment required. In general, anterior coronary targets require 10 to 15 cm of conduit, lateral targets require 15 cm, and posterior targets require 20cm. The initiation of vein harvest begins with a skin incision to localize and identify the vein. Then, depending upon whether a completely open, bridged, or endoscopic technique is utilized, the initial skin incision is either extended or additional skin incisions are made (Fig. 21-6). Dissection can be started either in the upper thigh, above the knee, or at the ankle. Identification of the greater saphenous vein is easiest in the ankle, just above the medial malleolus. Patients with peripheral vascular disease and compromised distal arterial blood flow should undergo vein harvest initiated in the thigh. In the lower leg, the saphenous nerve lies in close proximity to the greater saphenous vein and should be preserved. Injury can result in localized numbness or hyperesthesia. When using a totally open technique, the tissue surrounding the vein is dissected away from the vein. All branches are directly ligated in situ and the vein is divided proximally and distally. When using bridged or endoscopic techniques, branches are divided in situ and ligated once the vein is explanted. Once harvested, the vein is cannulated, gently pressurized to identify and ligate additional previously unidentified branches, marked, and stored in heparin solution. Patency rates may be related to endothelial damage induced during harvest and preparation.112114 Procurement techniques with minimal vein contact or harvest of adjacent tissue have been advocated.115,116



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FIGURE 21-6 Left greater saphenous vein harvest. The figure demonstrates a technique of multiple skin bridges between which the left greater saphenous vein has been identified and dissected free of surrounding tissue. With proper retraction and the saphenous vein within the tunnels beneath the skin, bridges can be easily dissected free.

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Increasingly popular techniques of endoscopic vein harvest are currently being clinically employed. Initial studies suggest that vein graft patency is equal to that of open techniques and wound complication rates are significantly decreased.117122 Scanning electron microscopy reveals no difference in degree of endothelial injury.123

Lesser Saphenous Vein

This alternative venous conduit can be harvested in a supine position, either by flexing the hip and medially rotating the thigh and knee, thus providing a lateral approach, or by flexing the hip and lifting the leg straight up and providing an inferior approach. A skin incision is usually started midway between the Achilles tendon and the lateral malleolus (Fig. 21-7). Dissection is carried proximally along the leg. Attention should be paid to avoid injuring the sural nerve. The vein is otherwise managed similarly to the greater saphenous vein.



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FIGURE 21-7 Right lesser saphenous vein harvest. The figure demonstrates the location of the skin incision for harvest of the right lesser saphenous vein. The lesser saphenous vein can be found posterior to the lateral maleolus and followed cephalad into the popliteal fossa.

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Cephalic Vein

The patency rate of cephalic vein used for aortocoronary bypass is significantly lower than that of other venous and arterial conduits, and thus should be considered essentially a conduit of last resort.124,125 Vein from the arm and forearm can be used. The arm is prepared and positioned as during radial artery harvest. Incisions are placed along the superior aspect of the either the arm or forearm. The vein is identified and harvested similarly to the greater saphenous vein. Notably, the cephalic vein is relatively thin-walled in comparison to the greater saphenous vein and extra care should be taken during harvest. The cephalic vein is also predisposed to aneurysmal dilatation.

Nonautogenous Conduits

Alternative nonautogenous vascular conduits have been used for coronary artery bypass grafting. These include cryopreserved human saphenous vein allograft, autologous endothelialized vein allograft, processed bovine sacral artery, and various synthetic conduits, such as polytetrafluoroethylene (PTFE).126129 Such conduits exhibit extremely low short-term patency rates, and are generally not considered acceptable coronary conduits. Research in tissue engineering approaches such as endothelializing synthetic conduits is being actively pursued.


?? CARDIOPULMONARY BYPASS
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Myocardial revascularization without cardiopulmonary bypass is detailed in Chapter 22. In patients undergoing myocardial revascularization with cardiopulmonary bypass, systemic anticoagulation is initiated prior to cannulation, usually prior to division of the internal thoracic artery conduit. Direct epiaortic ultrasound can be utilized to augment the accuracy of manual palpation of the aorta in identification of suitable cannulation and cross-clamping sites.130,131 In highly diseased aortas, alternative cannulation sites include femoral and subclavian arteries. Ideally, a cross-clamp site should still be identified.132,133 Otherwise one can employ techniques such as cold fibrillatory, vented arrest or ascending aortic graft replacement with deep hypothermic circulatory arrest. These methods have essentially been supplanted by off-pump coronary artery bypass grafting using only pedicled arterial conduits, basing proximal inflow off pedicled conduits, brachiocephalic vessels, or (rarely) an uninvolved proximal native coronary artery, or, as will be described later, sutureless, clampless proximal connector devices.134

The distal ascending aorta is usually chosen as the site of cannulation. This is usually around the level of the superior pericardial reflection. Two partial-thickness concentric purse-string sutures using 3-0 Tevdek suture are placed in the aorta. Arterial blood pressure should be well controlled during aortic cannulation to avoid the risk of aortic dissection. The aortic adventitia within the purse strings just superior to the aortotomy is grasped with a forceps and using a #11 blade, an aortotomy is created. Bleeding is easily controlled with slight inferior traction of the forceps on the adventitia. An appropriately sized aortic cannula is then inserted into the ascending aorta. If this is not easily accomplished, an aortotomy dilator will facilitate cannulation. Once the aortic cannula is inserted and properly positioned, the purse strings are tightened and the cannula is secured to the skin at an appropriate level. The cannula is then de-aired and connected to the pump tubing.

Attention is then directed to venous cannulation. For standard coronary artery bypass grafting, a two-stage venous cannula inserted in the right atrial appendage is sufficient. A 2-0 Tevdek purse-string suture is placed around the right atrial appendage. A partial occlusion clamp is placed on the right atrial appendage at the level of the purse-string suture. An atriotomy is made with scissors at the tip of the appendage. This incision can then be extended superiorly and inferiorly to a size appropriate for the venous cannula. Small bridging fibers of muscle are divided with scissors to permit easy entry of the cannula. Both edges of the atrial appendage are grasped, the clamp is removed, and the venous cannula is inserted to an appropriate level with the tip in the inferior vena cava. A retrograde coronary sinus cardioplegia catheter is not routinely used, although use in patients with left main disease or severe proximal multivessel disease may be helpful. An aortic root cardioplegia and venting cannula can then be placed, usually at the site of a planned proximal anastomosis. A mattress 4-0 polypropylene pledgeted suture is placed in the ascending aorta and a needle-bearing catheter is placed in the ascending aorta and connected to the cardioplegia line and vent line. The heart is now properly cannulated for cardiopulmonary bypass. All conduits are reinspected and the distal portions can be appropriately prepared for anastomoses.

Prior to initiating bypass, it is helpful to attempt to localize the target vessels, which are often easier to identify when fully distended in their native state. After communication with the anesthesiologist and perfusionist, cardiopulmonary bypass is initiated.

Patients with known mild-to-moderate aortic insufficiency that is not to be surgically addressed may benefit from the placement of a left ventricular venting catheter via the right superior pulmonary vein. This is usually performed immediately after the initiation of cardiopulmonary bypass on a full heart to avoid air entrainment. Systemic cooling can now be initiated, the exact temperature of which is highly variable and surgeon dependent. A systemic temperature of 32 to 34?C is usually sufficient for a standard coronary artery bypass graft procedure. A myocardial temperature probe can now be placed into the interventricular septum, if desired.135 The ascending aorta is then cross-clamped at the appropriate time, usually upon initiation of ventricular fibrillation or significant bradycardia. Antegrade cardioplegia is then delivered via the aortic root cannula, taking care to confirm an adequate root pressure by palpation and a soft, nondistended left ventricle. Cessation of surface mechanical activity, an isoelectric EKG, and a septal temperature less than 10?C confirm an adequate arrest. There are significant differences on specific cardioplegic composition, quantities, regimens, and delivery techniques. Despite different perioperative outcome parameters attributable to cardioplegia strategy, overall survival is not influenced.136 Readministration of antegrade partial-dose cardioplegia at the completion of distal anastomoses is a common practice (Fig. 21-8).



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FIGURE 21-8 Cardiopulmonary bypass. The heart is shown here in a pericardial cradle with a venous cannula in the right atrial appendage, an aortic cannula in the distal ascending aorta, an aortic cross-clamp, and a cardioplegia cannula.

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?? DISTAL ANASTOMOSES
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Sequence of Anastomoses

A sequence of completing distal anastomoses usually entails grafting the most ischemic region first to permit antegrade delivery of cardioplegia via the new graft. Using this strategy, grafts can be placed from most ischemic to least ischemic territories, with, however, the pedicled left internal thoracic artery to left anterior descending artery anastomosis performed last to avoid tension and potential injury. Occasionally, in the setting of severe left main or proximal multivessel coronary artery stenosis, or concomitant valvular surgery, retrograde cardioplegia may be used to augment antegrade delivery. When relying upon retrograde cardioplegia, it is important to recognize that the right ventricle is not well protected and that the grafting sequence should be appropriately adjusted.137 If cardioplegia delivery is not a concern, completion of posterior anastomoses followed by right-sided anastomoses followed by anterior anastomoses forms a convenient grafting sequence.

Distal Target Selection

Angiographically identified distal target locations are usually confirmed by visual inspection and epicardial examination. Arteriotomy sites should be chosen proximal enough to provide the largest-sized target coronary and distal enough to avoid the region of disease. Regions of branching and bifurcation should be avoided if possible. Targets with intramyocardial location first require dissection of overlying tissue. This can usually be accomplished with sharp knife dissection or electrocautery on a low setting. Localization of intramyocardial vessels can often be accomplished by noting epicardial indentation, accompanying epicardial venous structures, or a faint discoloration or a whitish streak within the reddish brown myocardium. When extreme difficulty is encountered in identifying a left anterior descending artery, one controversial technique that has been described is that of locating the LAD near the apex of the heart, which is commonly very superficial in this location. A small transverse arteriotomy is then created in this very distal location and a metal probe can be passed retrograde into the LAD and manually palpated more proximally. This arteriotomy can be closed transversely with 8-0 polypropylene suture. Silastic tapes placed through the epicardium, around the proximal coronary artery, or other retracting and positioning techniques can be used to help with visualization and stabilization of the planned arteriotomy site.

Arteriotomy

The target coronary artery, once dissected free of overlying tissue, often displays a thin purplish stripe down the center. This usually correlates with the absence of anterior atheromatous disease and a suitable region of arteriotomy. Either a rounded tip blade or a pointed blade with the sharp side up is used to enter the coronary artery. This arteriotomy is then extended with fine scissors proximally and distally to generate an arteriotomy of approximately 5 mm in size (Fig. 21-9). Depending much upon the size of the native coronary artery and conduit, some surgeons will now probe the distal and/or proximal coronary artery from this arteriotomy prior to performing the anastomosis.



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FIGURE 21-9 Coronary arteriotomy. The epicardium overlying the coronary artery has been incised and dissected free of the anterior surface of the coronary artery. An initial arteriotomy is created with a knife, being careful not to injure the posterior intima. The arteriotomy is then extended in both directions with angled fine scissors.

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Anastomotic Technique

The previously prepared and beveled or notched conduit is brought to the field. Multiple anastomotic techniques exist and differ in various aspects: continuous versus interrupted versus combined, intiation at the heel versus the toe, and parachute versus anchored. The authors prefer a continuous, parachuting technique initiated at the heel for virtually all distal and proximal anastomoses. Starting slightly to the far side of the heel, a 7-0 polypropylene suture is passed outside-in on the conduit and then inside-out at the corresponding location near the heel of the arteriotomy. Four or five such suture throws are then placed with the conduit in the air, coming around the heel towards the near side. The conduit is then parachuted down onto the arteriotomy, and the suture is continued along the near side towards the toe, around the toe, and then back up the far side until the other end of the suture is met (Fig. 21-10). Precise endothelial approximation is critical. When conduits are notched, the two flanges can potentially be inadvertently included within the anastomosis and must be sutured out of the anastomosis. Bevelling the conduit instead of notching avoids this potential obstruction. Care should be taken to apply a proper amount of tension on the follow-through to avoid both leakage and a purse-string effect, both of which may also be avoided with an increased number of throws. Prior to tying down the suture, the heel and toe can be probed to confirm patency and a venous conduit is usually flushed free of air. The use of an intraluminal coronary occcluder during anastomotic construction may protect against back wall suturing at a minimal risk of endothelial injury. Anastomotic hemostasis can now be confirmed. With nonpedicled conduits, cardioplegia can be administered to the supplied territory. To prevent anastomotic tension and torsion, pedicled conduits can be suture fixated to the adjacent epicardium. This is particularly relevant when further manipulation of the heart for grafting or concomitant procedures is anticipated. A minority of surgeons advocate the use of interrupted anastomoses to avoid a purse-string effect on the anastomosis. Nitinol clips have been recently introduced to facilitate interrupted distal anastomoses by avoiding the need for tying of multiple sutures. When using a long segment of greater saphenous vein for multiple grafts, the heart should be placed in native position and filled with blood, and the conduit should be filled and cut to an appropriate length for later proximal anastomosis.



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FIGURE 21-10 Distal anastomosis. (A) A fine polypropylene suture is passed through the conduit and coronary artery in a running fashion towards and around the anastomotic heel. (B) After several throws, the conduit is gently parachuted down to the coronary artery. (C) A suture is continued towards and around the anastomotic toe until the other end of the suture is reached.

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Sequential Grafting

Sequential grafting permits the performance of additional distal anastomoses while sparing conduit and additional proximal anastomoses. A purported advantage is the effective augmentation of outflow and, in venous grafts, an increase in patency rates compared to single distal anastomoses.138140 Sequential grafting with the internal thoracic artery is occasionally performed, usually to a stenotic diagonal coronary artery, although specific anatomic concerns exist.141143 Potential additional advantages with ITA sequential grafting include an arterial revascularization of the second target, and significant coronary flow reserve in the ITA.144 Routine use of the LITA for multiple sequential anastomoses of the circumflex system and the RITA for the LAD has also been described.145 The gastroepiploic artery has also been used to sequentially graft multiple inferoposterior targets.146 A clear disadvantage of sequential grafting is the reliance of two or more distal targets upon a single conduit and proximal anastomosis. A potentially larger region of myocardium may be jeopardized. In general, most surgeons avoid using the left internal thoracic artery for sequential grafting or as a donor for composite Y-grafting of other conduits because of valid concerns of compromising critical LITA to LAD flow.

When planning sequential anastomoses, the most distal anastomosis should be to the largest target vessel with the greatest outflow potential.147,148 If the reverse situation is created, the most distal anastomosis is at high risk for failure given the likelihood of preferential flow to the more proximal distal anastomosis. Although sequential anastomoses can be performed in any order, completing the distal anastomosis first and moving proximally subsequently is often easier from the spacing and positioning perspective. One exception to this may be the use of a pedicled left internal thoracic artery graft to the left anterior descending artery with a sequenced anastomosis to a diagonal branch more proximally. In this setting, performing the diagonal anastomosis first may be spatially more feasible. Sequential anastomoses are performed in side-to-side fashion. These are usually performed with a longitudinal native coronary arteriotomy and a longitudinal conduit venotomy or arteriotomy. An excessively long arteriotomy and venotomy are avoided to prevent flattening of the conduit. The two incisions can then be aligned in parallel, perpendicular to one another to create a diamond-shaped anastomosis, or at any angle in between depending upon the spatial geometry. When aligned in parallel, the anastomosis can be performed in running fashion heel-to-heel, similar to that described previously for standard distal anastomosis. When aligned at 90?, one can start the anastomosis in the heel of the conduit and match this region to the corresponding midportion of either the near or far side of the coronary artery, but subsequently perform the running anastomosis around the arteriotomy in a fashion similar to that described above for a standard distal anastomosis (Fig. 21-11). When aligned at any other angle, the suture placement is modified accordingly. Hemostasis is then confirmed and cardioplegia can be delivered as indicated. In the rare circumstance in which a coronary stenosis occurs at the bifurcation of two graftable vessels, conduit is limited, and a sequential graft is anatomically difficult to align, an alternative is a bifid anastomosis over the coronary bifurcation.



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FIGURE 21-11 Sequential distal anastomosis. After determination of the appropriate geometric alignment of the conduit and coronary artery, a coronary arteriotomy and conduit venotomy or arteriotomy are created and, in a manner similar to that described for distal anastomosis, a polypropylene suture is used in continuous fashion beginning near the heel.

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Distal Anastomotic Devices

Several sutureless devices that facilitate distal anastomosis are under active clinical investigation.149 In general, these are based upon variations of stent technology utilized in an intra- or extraluminal manner.


?? CORONARY ENDARTERECTOMY
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Coronary endarterectomy is a relatively infrequently utilized procedure for creating a distal target from an otherwise unsuitable site. Endarterectomy is considered only for diffusely diseased coronary arteries or occluded coronary arteries that supply a large distribution.150,151 In general, the larger the size of the distal vessel, the greater the chance of success with endarterectomy.152 Thus, this technique is utilized more commonly in the right coronary artery than any other distribution. The primary disadvantages of this technique are technical difficulty, increased thrombogenicity in the region of endarterectomy, and the risk of vessel occlusion from an intimal flap. The patency of grafts to endarterectomized vessels is clearly lower than that of grafts to nonendarterectomized vessels.153 Contemporary endarterectomy series demonstrate improvements in long-term patency.154,155

The closed technique for endarterectomy, usually of the right coronary system, entails a slightly longer than standard arteriotomy, followed by elevating the plaque and encircling it with an instrument such as a spatula or an endarterectomy knife. With traction on the plaque and countertraction on the artery, the plaque is extracted (Fig. 21-12). An open endarterectomy, usually of the left anterior descending coronary artery, begins with an arteriotomy along the entire length of the plaque. The plaque is dissected free of the native coronary vessel along its entire length and then removed (Fig. 21-13). This technique is particularly useful in the left anterior descending artery because it permits extraction of plaque branches from septal perforators. The native artery is not closed primarily, but rather covered by a long side-to-side anastomosis with a bypass conduit, usually saphenous vein.156 There are limited reports of long internal thoracic artery anastomoses to endarterectomized left anterior descending arteries.



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FIGURE 21-12 Closed coronary endarterectomy. (A) A coronary arteriotomy is created and an appropriate dissection plane is initiated between the plaque and the arterial wall. (B) This plane is continued circumferentially around the plaque and extended proximally. The plaque is then extracted from the proximal coronary artery. (C) The dissection plane is carried as far distally as possible from the arteriotomy and the plaque is extracted.

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FIGURE 21-13 Open coronary endarterectomy. (A) A long coronary arteriotomy is created. (B) A dissection plane is initiated between the plaque and arterial wall and extended proximally and distally. (C) The proximal extent of the plaque is extracted, if possible, or flushly divided with a sharp knife. (D) The proximal portion of the endarterectomized coronary artery is shown. (E) The endarterectomy dissection plane is continued down to the distal extent of the arteriotomy and the extensive plaque is extracted.

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?? PROXIMAL ANASTOMOSES
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Great variation exists in the technique of performing proximal anastomoses. These differences relate to timing with respect to distal anastomoses, timing with respect to aortic cross-clamp removal, sequence, location, and technical considerations.

Prior to Distal Anastomosis

A minority of surgeons prefer to perform venous and free arterial conduit proximal anastomoses prior to performing the distal anastomoses. There are several primary advantages cited by advocates of this technique. The first advantage is that the performance of the proximal anastomoses can be done with the use of a partial occlusion clamp prior to the initiation of cardiopulmonary bypass, thus decreasing the overall bypass period. The second advantage is that upon completion of the distal anastomoses and removal of the aortic cross-clamp, all regions of the myocardium are immediately revascularized. The third advantage, which is at the same time a disadvantage, is that conduits need to be measured peripherally on a full, beating heart prior to initiation of cardiopulmonary bypass and cut to an appropriate length. This technique, which is somewhat difficult and may occasionally result in undersizing or oversizing of the conduit, does utilize conduit very efficiently. There are many disadvantages to performing proximal anastomoses first. The use of a partial occlusion clamp on the aorta during normal myocardial function increases the risk of traumatizing the aorta and potentially causing a dissection. As mentioned, the grafts need to be measured very carefully to avoid creating too long or too short of a conduit. The technique of measuring conduit first assumes the adequacy of a distal target site for anastomosis. Occasionally, identification of and careful inspection of a planned distal anastomosis site reveals an unsuspected plaque necessitating a more distal anastomosis. This would increase the risk of a precut graft being too short. Many surgeons test the adequacy of a distal anastomosis from a flow and hemostasis standpoint by the manual administration of cardioplegia or heparinized saline via a cannulated graft. This option is eliminated when proximal anastomoses are completed first. Cardioplegia can still be given through the graft, via aortic root administration; however, this requires the heart being returned to native position and the presence of a competent aortic valve. Thus, a leaking distal anastomosis, which requires repair, would potentially necessitate multiple awkward repositionings of the heart.

Single Cross-clamp

This technique entails performance of distal anastomoses followed by proximal anastomoses just prior to the removal of the aortic cross-clamp. This technique is commonly used when coronary artery bypass grafting is performed in conjunction with valvular procedures, but some surgeons advocate this technique in performing coronary bypass grafting by itself. The advantages, when compared to other techniques, include the ability to perform distal anastomoses first, and the ability to place proximal anastomoses onto areas of the aorta that may be otherwise more difficult to access with a partial occlusion clamp, such as the proximal or lateral ascending aorta. The primary purported advantage is the avoidance of additional aortic manipulation and risk of neurologic injury.157 Disadvantages include longer cross-clamp time and a need to de-air the heart. One can see, in the setting of, for example, an aortic valve replacement with concomitant coronary artery bypass grafting, that the heart needs to be de-aired anyway, and the retrograde coronary sinus cardioplegia catheter can be used to minimize the effects of the additional cross-clamp time required for proximal anastomoses. One also avoids the potential need to place a partial occlusion clamp across an aortotomy suture line.

Partial Occlusion Clamp

This technique is probably still the most common method of completing proximal anastomoses. When performing coronary artery bypass grafting alone, this technique permits the advantages of performing the distal anastomoses first, without increasing the ischemic cross-clamp time. Only the vein graft, and not the heart itself, requires de-airing. The aorta does need to be manipulated during placement of the partial occlusion clamp; however, the risk of initiating dissection is lower, while the patient is still on full bypass and the heart has yet to recover vigorous activity. The locations of proximal anastomoses are somewhat limited to the anterior aspect of the ascending aorta.

Anastomotic Technique

An appropriate site for aortotomy is identified. The fatty tissue overlying the aorta is removed, an arteriotomy is created with a #11 blade, and a 4.8 punch is used to create a circular aortotomy. When the venous conduit is somewhat smaller in diameter or when using arterial conduits, a 4.0 punch may be preferable. The proximal aspect of the conduit is cut to an appropriate bevel and an additional notch is usually made in the heel. For a venous conduit, a running 5-0 or 6-0 polypropylene suture can be used. For an arterial conduit, a 6-0 or 7-0 polypropylene suture can be used. The long axis of the graft should be aligned at an appropriate angle from the long axis of the ascending aorta in such a way as to provide a gentle curvature with the conduit either around the right atrium for a right-sided graft or over the pulmonary artery for a left-sided graft. Occasionally, left-sided grafts can be taken off the right side of the ascending aorta and routed posteriorly behind the aorta and through the transverse sinus. A running suture is then started outside-in on the conduit, two bites counterclockwise from the heel. The needle is then passed inside-out on the aorta at an appropriate location along the circumference of the arteriotomy such as to generate the appropriate angle of approach of the conduit relative to the long axis of the aorta. As mentioned above, four or five passes are then made in similar fashion moving clockwise along the conduit, coming around the heel. The conduit is then parachuted down onto the aorta and the suture is then continued around over the toe of the anastomosis until completed (Fig. 21-14). Alternatively, once the toe of the anastomosis has been reached, the other needle can be used outside-in on the aorta and used to complete the other half of the anastomosis and meet the other suture essentially at the toe. The site of anastomosis can be marked with a surgical clip or wire of some sort to facilitate future cardiac catheterization, if necessary. To de-air a vein graft, a soft bulldog is placed distally along the graft before the aortic cross-clamp or partial occlusion clamp is removed. A 27-gauge needle is used to pierce the vein graft in its most elevated portion, from which air will usually extrude. The bulldog can then be removed. Hemostasis can be evaluated proximally and distally, as indicated. Generally, arterial conduits are not de-aired in this fashion for fear of conduit needle injury. Conduits such as the free RIMA and radial artery that are harvested with surrounding venous and soft tissue structures should be carefully inspected along the entire length for hemostasis.



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FIGURE 21-14 Proximal anastomosis. (A) The technique of single cross-clamp is demonstrated. An aortotomy is created with a knife and punch. Appropriate conduit length and orientation are established and a fine polypropylene suture is used in a running fashion towards and around the anastomotic heel. (B) The conduit is then carefully parachuted down onto the aorta. (C) The suture is continued towards and around the anastomotic toe.

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Composite Grafts

Various configurations of Y- and T-grafts can be devised to accommodate multiple issues such as limited conduit length and limited aortotomy sites, as well as to minimize aortic proximal anastomoses on single cross-clamp and intentionally base proximal sites on locations other than the ascending aorta (Fig. 21-15). An additional stimulus for creating composite grafts is the concern about long-term arterial conduit patency with direct aortic anastomosis in which there is marked mismatch between aortic wall thickness and conduit size. In such a setting, it may be advantageous to base an arterial conduit proximal on a vein graft, a pedicled arterial graft, or the right subclavian or innominate artery.158160 An example is that of basing a radial artery graft off the proximal left internal thoracic artery pedicle.161 This configuration takes advantage of ITA flow reserve.162 Disadvantages include technical difficulties and reliance upon a single inflow source for two or more distal targets. The critical LITA to LAD graft may be in jeopardy should there be a technical problem with the composite graft. Delicate all-arterial Y-grafts are usually planned in advance and constructed prior to the initiation of cardiopulmonary bypass. Y-grafting can also be performed more distally along a conduit and used in lieu of sequential grafting. Compared to sequential grafting, this technique requires an additional anastomosis, but may facilitate distal grafting of targets that, because of anatomic alignment, may not be ideally suited for sequential grafting. This technique may also facilitate complete myocardial revascularization with only internal thoracic arteries.163 Other creative variations such as an inverted "T " comprised of a single radial artery anastomosed to all distal coronary targets in an end-to-side or side-to-side manner and subsequent LITA end-to-side anastomosis into the radial artery have been constructed.164 As with sequential grafting, a disadvantage of composite grafting is reliance of multiple myocardial regions on a single proximal graft. Particular care must also be taken during construction of composite grafts to avoid tension, rotational torsion, or narrowing of either segment.



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FIGURE 21-15 Y-graft. (A) In the example shown, a completed coronary artery bypass graft is used as a proximal donor site for another conduit. A venotomy or arteriotomy is created in the donor conduit. (B) The recipient conduit is then anastomosed in an end-to-side fashion using a fine polypropylene suture in running fashion, beginning near the heel. (C) The recipient conduit is then gently parachuted down onto the donor conduit. (D) A representative example of a completed Y-graft in a relatively less common configuration of an aortocoronary saphenous vein graft to the LAD with a composite vein graft to an obtuse marginal.

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Proximal Anastomotic Devices

Currently, sutureless proximal anastomotic devices are in various stages of clinical evaluation and commercial availability. These devices are used for creating an aortotomy and subsequently attaching a vein graft to the aorta with a circular wire appliance (Fig. 21-16).165 These devices obviate the need for application of a partial occlusion clamp. Reportedly, these devices will soon be able to anastomose free arterial conduits as well.



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FIGURE 21-16 Sutureless proximal connector. (A) A venous conduit is shown anastomosed in end-to-side fashion to the aorta with a multipronged wire connecting device. (B) The anastomosis is shown in cross-section with two layers of opposing wire connection devices and the venous conduit within the aortic wall.

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?? WEANING FROM CARDIOPULMONARY BYPASS
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Upon completion of all anastomoses, the patient is extensively prepared for separation from cardiopulmonary bypass (Table 21-1). Critical aspects include the establishment of a stable intrinsic or paced cardiac rhythm, metabolic optimization, appropriate pharmacologic support, and the initiation of effective mechanical ventilation. While closely monitoring the hemodynamic profile, the patient is weaned from cardiopulmonary bypass (Table 21-2). In rare instances, mechanical circulatory support in the form of an intra-aortic balloon counterpulsation or ventricular assist device may be required; these are detailed in Chapter 17.


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TABLE 21-1 Preparation of the patient for separation from cardiopulmonary bypass

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TABLE 21-2 Primary considerations when unable to separate patient from cardiopulmonary bypass

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Once separated from cardiopulmonary bypass, all cannulae are removed with the exception of the aortic cannula. The state of anticoagulation is reversed with a calculated dose of protamine. Systemic hypotension may develop with rapid infusion of protamine, primarily from a vasodilatory effect. This can be treated by slowing the protamine infusion, providing pharmacologic support, and administering volume rapidly via the aortic cannula. With normalization of the activated clotting time, the aortic cannula is removed. All surgical sites are appropriately reinforced and adequate hemostasis is confirmed.


?? CHEST CLOSURE
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Thoracostomy drainage tubes are carefully placed, usually in any opened pleural space, the inferior mediastinum, and the superior mediastinum. Direct contact with conduits is generally avoided.166 A minority of surgeons will attempt to reapproximate the pericardium in an effort to decrease the risk of cardiovascular injury during reoperation. Thymic and mediastinal tissues in the superior mediastinum can usually be easily reapproximated without undue tension on the heart, great vessels, or grafts.167 The sternum is usually reapproximated with interrupted stainless steel wire, although heavy suture, bands, and plates have also been utilized. The fascial, subdermal, and skin layers are reapproximated.

In rare instances, prolonged cardiopulmonary bypass and cross-clamp may result in significant myocardial edema and subsequent hemodynamic intolerance of chest closure. In addition to appropriate pharmacologic and mechanical support, prolonged open sternotomy may be required. Delayed sternal closure should only be attempted after significant diuresis.168


?? POSTOPERATIVE MANAGEMENT
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In a carefully coordinated and monitored manner, the patient is transferred to the surgical intensive care unit. The enormous complexities of postoperative care are detailed in Chapter 15.


?? OUTCOMES
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Outcomes can be broadly categorized into perioperative results and long-term results. The perioperative results that are most commonly measured include mortality, major morbidity such as myocardial infarction and cerebrovascular accident, other major organ system failures, reoperation for hemorrhage, and mediastinitis. Other parameters such as length of stay and costs are now being evaluated more commonly. Long-term outcomes most commonly measured include graft patency, recurrence of symptoms such as angina, myocardial infarction, need for reoperation, and overall survival.

Perioperative Mortality

Hospital mortality or 30-day mortality after primary coronary artery bypass grafting has been evaluated extensively and has been reported in the range of 1% to 5% overall for a heterogeneous population. The rate has remained at approximately 3% overall for the past decade despite an increase in preoperative risk.25,169 The majority of these deaths are related to primary cardiac failure with or without associated myocardial infarction. Risk factors for perioperative mortality can be viewed in two categories. The first category consists of preoperative factors, such as age, comorbidities, degree of myocardial ischemia and function, and anatomy. The other category of risk factors relates to operative factors such as year of operation, surgeon, cardiopulmonary bypass time, myocardial ischemic time, extent of revascularization, failure to use the internal thoracic artery to the left anterior descending artery, and the need for pharmacologic and mechanical cardiac support.170

Perioperative Morbidity

Perioperative myocardial infarction, as defined by elevation of creatine kinase MB fraction and/or troponin I with the development of new electrocardiographic Q-waves, occurs at a rate of approximately 2% to 5% during primary coronary artery bypass grafting procedures. Causes of perioperative myocardial infarction include inadequate myocardial protection, incomplete revascularization, technical issues with bypass grafts, embolism, and hemodynamic instability, among others.

Perioperative neurologic injury can manifest in a wide range of clinical sequelae. These will include anything from subtle neuropsychological changes detected only with intensive testing, to severe gross neurologic deficits of either a transient or permanent nature.171 These gross deficits occur at rates highly dependent upon patient age. Approximately 0.5% of young patients and 5% of patients older than age 70 will experience gross neurologic deficits after primary coronary artery bypass grafting. The preoperative risk factors of age, hypertension, prior neurologic event, and diabetes repeatedly correlate most highly with the development of stroke after coronary revascularization.172175

The rate of injury to other major organ systems is highly dependent upon multiple variables, particularly preoperative organ status. For example, patients with underlying chronic renal insufficiency are at significantly higher risk of developing postcoronary artery bypass acute tubular necrosis, which will often require temporary or permanent hemodialysis.176

Other Perioperative Parameters

Current medical, economic, and environmental factors emphasize the evaluation of additional parameters of outcome, such as time to extubation, time in the intensive care unit, length of stay, and various other costs.177182

Long-Term Graft Patency

The combination of the unique biology of the pedicled internal thoracic artery and the extensive diagonal and septal outflow of the left anterior descending artery provides an extremely durable coronary artery bypass graft. The LITA anastomosed end-to-side to the LAD has a 10-year patency of over 90%, and there are reports of continued patency 15, 20, 25, and 30 years postoperatively.183 The patency of the pedicled left internal thoracic artery when anastomosed to a target vessel other than the LAD is approximately 90% at 5 years and 80% at 10 years. The pedicled right internal thoracic artery, when anastomosed to the right coronary distribution, results in a 5-year patency rate of approximately 90% and a 10-year patency of approximately 80%. In rare instances, when the pedicled right internal thoracic artery is anastomosed to the left anterior descending artery, the patency rates appear to approach that of the pedicled LITA to LAD anastomosis, thus further supporting the notion that a large vascular runoff bed contributes significantly to long-term patency rates. Free internal thoracic artery grafts yield excellent patency rates of approximately 90% at 5 years.184,185

The patency rates of a radial artery graft off the aorta are approximately 80% at 5 years,82,186 although significantly higher patency rates have been reported.187,188 Placement of the radial artery graft onto a left-sided target vessel with a high-grade proximal stenosis and good runoff may result in higher patency rates. Basing the radial artery proximally off a vein graft hood or another arterial graft, such as a pedicled internal thoracic artery, also may increase the long-term patency rates.

Pedicled, in situ right gastroepiploic artery grafts have been reported to yield patency rates of approximately 85% to 90% at 5 years.92,189 Experience is limited and large-scale data are unavailable. Free gastroepiploic grafts based off the aorta yield patency rates similar to that of the radial artery. Patency data for inferior epigastric arterial grafts are very limited and suggest short-term patency rates similar to that of the radial artery.91,103

Greater saphenous vein and, to a similar extent, lesser saphenous vein fail in two general modalities. Early graft failure occurs during the first year in approximately 20% to 25% of all venous conduits.190 This is due to anastomotic problems, graft kinking, conduit harvesting trauma, aortic disease, poor runoff, or progression of native coronary disease. Late venous conduit failure is due to progression of graft atherosclerosis.191 Reported 5- and 10-year patency rates for saphenous vein grafts are 60% and 40%, respectively. Improvements in these patency rates may be possible with aspirin administration and aggressive antiatherosclerotic strategies such as the use of lipid-lowering agents.192194 Intraoperative gene therapy of saphenous vein conduit with novel antiproliferative agents is under clinical investigation and has yielded encouraging results.195

Long-Term Survival

Primary long-term outcomes can be expressed as freedom from the following events: angina, myocardial infarction, percutaneous coronary intervention, reoperation, and death. For heterogenous postoperative populations, overall rates of freedom from the above events are excellent.196200 A representative event-free survival curve is shown in Figure 21-17. Each of these events, particularly death, can be further stratified based upon preoperative, intraoperative, and postoperative variables. The most striking example would be survival estimates based on preoperative ejection fraction.201 A representative survival curve by preoperative ejection fraction is displayed in Figure 21-18. Another striking example is the completeness of revascularization and the use of the LITA to LAD.202204 Interestingly, very recent data challenge the importance of complete revascularization in long-term outcomes and, in fact, suggest that more than one graft to any non-LAD system may actually be detrimental.205 Increased utilization of arterial conduits may improve long-term survival.206 In terms of quality of life, coronary artery bypass grafting provides the greatest improvement to patients with preoperative functional impairment.207



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FIGURE 21-17 Kaplan-Meier event-free survival curves for death, angina, myocardial infarction, percutaneous transluminal coronary angioplasty, or repeat coronary artery bypass grafting. Data collected from Emory University Cardiac Surgical Databank, January 1977 to December 1995. N = 23,960.

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FIGURE 21-18 Kaplan-Meier survival curve for survival in primary coronary artery bypass grafting patients stratified by ejection fraction (EF). Data collected from Emory University Cardiac Surgical Databank, January 1977 to December 1995. N = 23,960, p .

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?? SUMMARY
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Coronary artery disease is the most prevalent disease condition in industrialized civilization. Operative myocardial revascularization, the most commonly performed major operation overall in the United States, is still considered the gold standard for treatment of most patients with multivessel coronary disease. Cardiopulmonary bypass is currently utilized in approximately 80% of primary coronary artery bypass grafting procedures in the United States today. A pedicled left internal thoracic artery anastomosed to the left anterior descending coronary artery with saphenous vein grafts to the right coronary and left circumflex distributions is the most common combination, although additional pedicled and free arterial grafts are being utilized more commonly. Perioperative major morbidity and mortality rates are very low and long-term outcomes are excellent. Emerging technologic advancements in anastomotic devices, beating heart surgery, and robotics will greatly influence multiple aspects of this operation.208212


?? REFERENCES
 Top
?
  1. Beck C: The development of a new blood supply to the heart by operation. Ann Surg 1935; 102:801.
  2. Vineberg AM, Miller G: Internal mammary coronary anastomosis in the surgical treatment of coronary artery insufficiency. Can Med Assoc J 1951; 64:204.
  3. Murray G, Porcheron R, Hilario J, Roschlau W: Anastomosis of a systemic artery to the coronary. Can Med Assoc J 1954; 71:594.
  4. Gibbon JH: Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med 1954; 37:171.[Medline]
  5. Bailey CP, May A, Lemmon WM: Survival after coronary endarterectomy in man. JAMA 1957; 164:641.
  6. Senning A: Strip grafting in coronary arteries: report of a case. J Thorac Cardiovasc Surg 1961; 41:542.
  7. Sones FM Jr, Shirey EK: Cine coronary arteriography. Mod Concepts Cardiovasc Dis 1962; 31:735.[Medline]
  8. Longmire WP, Cannon JA, Kattus AA: Direct vision coronary endarterectomy for angina pectoris. N Engl J Med 1958; 259:993.
  9. Sabiston DC Jr: Direct surgical management of congenital and acquired lesions of the coronary artery. Prog Cardiovasc Dis 1963; 6:229.
  10. Garrett EH, Dennis EW, DeBakey ME: Aortocoronary bypass with saphenous vein grafts: seven-year follow-up. JAMA 1973; 223:792.[Medline]
  11. Kolesov VI: Mammary artery-coronary artery anastomosis as a method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967; 54:535.[Medline]
  12. Favaloro RG: Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg 1968; 5:334.[Medline]
  13. Rosengart TK, Lee LY, Patel SR, et al: Angiogenesis gene therapy: phase I assessment of direct intramyocardial administration of an adenovirus vector expressing VEGF121 cDNA to individuals with clinically significant severe coronary artery disease. Circulation 1999; 100:468.[Medline]
  14. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators: Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996; 335:217.[Abstract/Free?Full?Text]
  15. Cashin WL, Sanmarco ME, Nessim SA, Blankenhorn DH: Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed. N Engl J Med 1984; 311:824.[Abstract]
  16. CASS Principal Investigators and their associates: Coronary Artery Surgery Study (CASS): a randomized trial of coronary artery bypass surgery; survival data. Circulation 1983; 68:939.[Medline]
  17. Cosgrove DM, Loop FD, Saunders CL, et al: Should coronary arteries with less than fifty percent stenosis be bypassed? J Thorac Cardiovasc Surg 1981; 82:520.[Medline]
  18. Eagle KA, Guyton RA, Davidoff R, et al: ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262.[Free?Full?Text]
  19. Varnauskas E: European Coronary Surgery Study Group: twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med 1988; 319:332.[Abstract]
  20. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group: Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med 1984; 311:1333.[Abstract]
  21. Niles NW, McGrath PD, Malenka D, et al: Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. J Am Coll Cardiol 2001; 37:1008.[Abstract/Free?Full?Text]
  22. Fortescue EB, Kahn K, Bates DW: Development and validation of a clinical prediction rule for major adverse outcomes in coronary bypass grafting. Am J Cardiol 2001; 88:1251.[Medline]
  23. Craver JM, Puskas JD, Weintraub WW, et al: 601 octogenarians undergoing cardiac surgery and comparison with younger age groups. Ann Thorac Surg 1999; 67:1104.[Abstract/Free?Full?Text]
  24. Thourani VH, Weintraub WS, Stein B, et al: Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg 1999; 67:1045.[Abstract/Free?Full?Text]
  25. Ferguson TB Jr, Hammill BG, Peterson ED, et al: A decade of changerisk profiles and outcomes for isolated coronary artery bypass grafting procedures, 19901999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons., Ann Thorac Surg, 2002; 73:480.[Abstract/Free?Full?Text]
  26. Kreter B, Woods M: Antibiotic prophylaxis for cardiothoracic operations: meta-analysis of thirty years of clinical trials. J Thorac Cardiovasc Surg 1992; 104:590.[Abstract]
  27. Sandrelli L, Pardini A, Lorusso R, et al: Impact of autologous blood predonation on a comprehensive blood conservation program. Ann Thorac Surg 1995; 59:730.[Abstract/Free?Full?Text]
  28. Yazicioglu L, Eryilmaz S, Sirlak M, et al: Recombinant human erythropoietin administration in cardiac surgery. J Thorac Cardiovasc Surg 2001; 122:741.[Abstract/Free?Full?Text]
  29. Hayashi J, Kumon K, Takanashi S, et al: Subcutaneous administration of recombinant human erythropoietin before cardiac surgery: a double-blind, multicenter trial in Japan. Transfusion 1994; 34:142.[Medline]
  30. Jobes DR, Aitken GL, Shaffer GW: Increased accuracy and precision of heparin and protamine dosing reduces blood loss and transfusion in patients undergoing primary cardiac operations. J Thorac Cardiovasc Surg 1995; 110:36.[Abstract/Free?Full?Text]
  31. Arom KV, Emery RW: Decreased postoperative drainage with addition of epsilon-aminocaproic acid before cardiopulmonary bypass. Ann Thorac Surg 1994; 57:1108.[Abstract]
  32. Ray MJ, Hales MM, Brown L, et al: Postoperatively administered aprotinin or epsilon aminocaproic acid after cardiopulmonary bypass has limited benefit. Ann Thorac Surg 2001; 72:521.[Abstract/Free?Full?Text]
  33. Kalangos A, Tayyareci G, Pretre R, et al: Influence of aprotinin on early graft thrombosis in patients undergoing myocardial revascularization. Eur J Cardiothorac Surg 1994; 8:651.[Abstract]
  34. Owen CH, Cummings RG, Sell TL, et al: Coronary artery bypass grafting in patients with dialysis-dependent renal failure. Ann Thorac Surg 1994; 58:1729.[Abstract]
  35. Nguyen DM, Gilfix BM, Dennis F, et al: Impact of transfusion of mediastinal shed blood on serum levels of cardiac enzymes. Ann Thorac Surg 1996; 62:109.[Abstract/Free?Full?Text]
  36. Loop FD, Lytle BW, Cosgrove DM, et al: Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986; 314:1.[Abstract]
  37. Cameron A, Davis KB, Green G, Schaff HV: Coronary bypass surgery with internal-thoracic-artery graftseffects on survival over a 15-year period. N Engl J Med 1996; 334:216.[Abstract/Free?Full?Text]
  38. Li S, Fan YS, Chow LH, van Den Diepstraten C, et al: Innate diversity of adult human arterial smooth muscle cells: cloning of distinct subtypes from the internal thoracic artery. Circ Res 2001; 89:517.[Abstract/Free?Full?Text]
  39. Ko YS, Yeh HI, Haw M, et al: Differential expression of connexin43 and desmin defines two subpopulations of medial smooth muscle cells in the human internal mammary artery. Arterioscler Thromb Vasc Biol 1999; 19:1669.[Abstract/Free?Full?Text]
  40. Yang Z, Oemar BS, Carrel T, et al: Differential proliferative properties of smooth muscle cells of human arterial and venous bypass vessels: role of PDGF receptors, mitogen-activated protein kinase, and cyclin-dependent kinase inhibitors. Circulation 1998; 97:181.[Medline]
  41. Yang Z, Luscher TF: Basic cellular mechanisms of coronary bypass graft disease. Eur Heart J 1993; 14(suppl I):193.
  42. Chaikhouni A, Crawford FA, Kochel PJ, et al: Human internal mammary artery produces more prostacyclin than saphenous vein. J Thorac Cardiovasc Surg 1986; 92:88.[Abstract]
  43. Broeders MA, Doevendans PA, Maessen JG, et al: The human internal thoracic artery releases more nitric oxide in response to vascular endothelial growth factor than the human saphenous vein. J Thorac Cardiovasc Surg 2001; 122:305.[Abstract/Free?Full?Text]
  44. Wiley KE, Davenport AP: Nitric oxide-mediated modulation of the endothelin-1 signalling pathway in the human cardiovascular system. Br J Pharm 2001; 132:213.[Medline]
  45. Gitter R, Anderson JM Jr., Jett GK: Influence of milrinone and norepinephrine on blood flow in canine internal mammary artery grafts. Ann Thorac Surg 1996; 61:1367.[Abstract/Free?Full?Text]
  46. Jett GK, Arcici JM Jr, Hatcher CR Jr, et al: Vasodilator drug effects on internal mammary artery and saphenous vein grafts. J Am Coll Cardiol 1988; 11:1317.[Abstract]
  47. Lehmann KH, von Segesser L, Muller-Glauser W, et al: Internal-mammary coronary artery grafts: is their superiority also due to a basically intact endothelium? Thorac Cardiovasc Surg 1989; 37:187.[Medline]
  48. Sisto T, Yla-Herttuala S, Luoma J, et al: Biochemical composition of human internal mammary artery and saphenous vein. J Vasc Surg 1990; 11:418.[Medline]
  49. Vahl CF, Carl I, M?ller-Vahl H: Brachial plexus injury after cardiac surgery. J Thorac Cardiovasc Surg 1991; 102:724.[Abstract]
  50. Cooper GJ, Gillot T, Parry EA, et al: Papaverine injures the endothelium of the internal mammary artery. Cardiovasc Surg 1995; 3:553.[Medline]
  51. Cooper GJ, Gillot T, Francis SE, Angelini GD: Distension produces medial but not endothelial damage in porcine internal mammary artery. Cardiovasc Surg 1995; 3:171.[Medline]
  52. Mills NL: Preparation of the internal mammary artery graft with intraluminal papaverine. J Card Surg 1991; 6:318.[Medline]
  53. Deja MA, Wos S, Golba KS, et al: Intraoperative and laboratory evaluation of skeletonized versus pedicled internal thoracic artery. Ann Thorac Surg 1999; 68:2164.[Abstract/Free?Full?Text]
  54. Hirotani T, Shirota S, Cho Y, Takeuchi S: Feasibility and suitability of the routine use of bilateral internal thoracic arteries. Ann Thorac Surg 2002; 73:511.[Abstract/Free?Full?Text]
  55. Galbut DL, Traad EA, Dorman MJ, et al: Seventeen-year experience with bilateral internal mammary artery grafts. Ann Thorac Surg 1990; 49:195.[Abstract]
  56. Dion R, Etienne PY, Verhelst R, et al: Bilateral mammary grafting: clinical, functional, and angiographic assessment in 400 consecutive patients. Eur J Cardiothorac Surg 1993; 7:287.[Abstract]
  57. Taggart DP, D'Amico R, Altman DG: Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001; 358:870.[Medline]
  58. Endo M, Nishida H, Tomizawa Y, Kasanuki H: Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting. Circulation 2001; 104:2164.[Abstract/Free?Full?Text]
  59. Berreklouw E, Rademakers PP, Koster JM, et al: Better ischemic event-free survival after two internal thoracic artery grafts: 13 years of follow-up. Ann Thorac Surg 2001; 72:1535.[Abstract/Free?Full?Text]
  60. Sergeant P, Blackstone E, Meyns B: Validation and interdependence with patient-variables of the influence of procedural variables on early and late survival after CABG. Eur J Cardiothorac Surg 1997; 12:1.[Abstract]
  61. Kurlansky PA, Traad EA, Glanut DL, et al: Efficacy of single versus bilateral internal mammary artery grafting in women: a long-term study. Ann Thorac Surg 2001; 71:1949.[Abstract/Free?Full?Text]
  62. He GW, Ryan WH, Acuff TE, et al: Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting. J Thorac Cardiovasc Surg 1994; 107:196.[Abstract/Free?Full?Text]
  63. Kouchoukos NT, Wareing TH, Murphy SF, et al: Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990; 49:210.[Abstract]
  64. Grossi EA, Esposito R, Harris LJ, et al: Sternal wound infections and use of internal mammary artery grafts [see comments]. J Thorac Cardiovasc Surg 1991; 102:342.[Abstract]
  65. Cosgrove DM, Lytle BW, Loop FD, et al: Does bilateral internal mammary artery grafting increase surgical risk? J Thorac Cardiovasc Surg 1988; 95:850.[Abstract]
  66. Accola KD, Jones EL, Craver JM, et al: Bilateral mammary artery grafting: avoidance of complications with extended use. Ann Thorac Surg 1993; 56:872.[Abstract]
  67. Cohen AJ, Moore P, Jones C: Effect of internal mammary harvest on postoperative pain and pulmonary function. Ann Thorac Surg 1993; 56:1107.[Abstract]
  68. Lev-Ran O, Pevni D, Matsa M, et al: Arterial myocardial revascularization with in situ crossover right internal thoracic artery to left anterior descending artery. Ann Thorac Surg 2001; 72:798.[Abstract/Free?Full?Text]
  69. Ura M, Sakata R, Nakayama Y, et al: Technical aspects and outcome of in situ right internal thoracic artery grafting to the major branches of the circumflex artery via the transverse sinus. Ann Thorac Surg 2001; 71:1485.[Abstract/Free?Full?Text]
  70. Tatoulis J, Buxton BF, Fuller JA: Results of 1,454 free right internal thoracic artery-to-coronary artery grafts. Ann Thorac Surg 1997; 64:1263.[Abstract/Free?Full?Text]
  71. Chow MS, Sim E, Orszulak TA, Schaaf HV: Patency of internal thoracic artery grafts: comparison of right versus left in importance of vessel grafted. Circulation 1994; 90(part 2):II129.
  72. Carpentier A, Guermonprez JL, Deloche A, et al: The aorta-to-coronary radial artery bypass graft. Ann Thorac Surg 1973; 16:111.[Medline]
  73. Chardigny C, Jebara VA, Acar C, et al: Vasoreactivity of the radial artery: comparison with the internal mammary and gastroepiploic arteries with implications for coronary artery surgery. N Engl J Med 1993; 88:II115.
  74. He GW, Yang CQ: Vasorelaxant effect of phosphodiesterase-inhibitor milrinone in the human radial artery used as coronary bypass graft. J Thorac Cardiovasc Surg 2000; 119:1039.[Abstract/Free?Full?Text]
  75. Acar C, Jebara VA, Portoghese M, et al: Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992; 54:652.[Abstract]
  76. Tatoulis J, Buxton BF, Fuller JA: Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998; 66:714.[Abstract/Free?Full?Text]
  77. Cohen G, Tamariz MG, Sever JY, et al: The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study. Ann Thorac Surg 2001; 71:180.[Abstract/Free?Full?Text]
  78. Tatoulis J, Buxton BF, Fuller JA: Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998; 66:714.
  79. Shapira OM, Alkon JD, Macron DS, et al: Nitroglycerin is preferable to diltiazem for prevention of coronary bypass conduit spasm. Ann Thorac Surg 2000; 70:883.[Abstract/Free?Full?Text]
  80. Dietl CA, Benoit CH: Radial artery graft for coronary revascularization: technical considerations. Ann Thorac Surg 1995; 60:102.[Abstract/Free?Full?Text]
  81. Maniar HS, Sundt TM, Barner HB, et al: Effect of target stenosis and location on radial artery graft patency. J Thorac Cardiovasc Surg 2002; 123:45.[Abstract/Free?Full?Text]
  82. Moran SV, Baeza R, Guarda E, et al: Predictors of radial artery patency for coronary bypass operations. Ann Thorac Surg 2001; 72:1552.[Abstract/Free?Full?Text]
  83. Ruengsakulrach P, Brooks M, Hare DL, et al: Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Cardiovasc Surg 2001; 121:526.[Abstract/Free?Full?Text]
  84. Reyes AT, Frame R, Brodman RF: Technique for harvesting a radial artery as a coronary bypass graft. Ann Thorac Surg 1995; 59:118.[Abstract/Free?Full?Text]
  85. Anyanwu AC, Saeed I, Bustami M, et al: Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery? Ann Thorac Surg 2001; 71:555.[Abstract/Free?Full?Text]
  86. Meharwal ZS, Trehan N: Functional status of the hand after radial artery harvesting: results in 3,977 cases. Ann Thorac Surg 2001; 72:1557.[Abstract/Free?Full?Text]
  87. Denton TA, Trento L, Cohen M, et al: Radial artery harvesting for coronary bypass operations: neurologic complications and their potential mechanisms. J Thorac Cardiovasc Surg 2001; 121:951.[Abstract/Free?Full?Text]
  88. Genovesi MH, Torrillo L, Fonger J, et al: Endoscopic radial artery harvest: a new approach. Heart Surg Forum 2001; 4:223.[Medline]
  89. Pym J, Brown PM, Charrette EJ, et al: Gastroepiploic-coronary anastomosis: a viable alternative bypass graft. J Thorac Cardiovasc Surg 1987; 94:256.[Abstract]
  90. Mills NL, Everson CT: Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989; 47:706.[Abstract]
  91. Manapat AE, McCarthy PM, Lytle BW, et al: Gastroepiploic and inferior epigastric arteries for coronary artery bypass: early results and evolving applications. N Engl J Med 1994; 90:II-144.
  92. Grandjean JG, Voors AA, Boonstra PW, et al: Exclusive use of arterial grafts in coronary artery bypass operations for three-vessel disease: use of both thoracic arteries and the gastroepiploic artery in 256 consecutive patients. J Thorac Cardiovasc Surg 1996; 112:935.[Abstract/Free?Full?Text]
  93. Nishida H, Tomizawa Y, Endo M, et al: Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery. Circulation 2001; 104(suppl 1):I76.
  94. Jegaden O, Eker A, Monthena P, et al: Risk and results of bypass grafting using bilateral internal mammary and right gastroepiploic arteries. Ann Thorac Surg 1995; 59:955.[Abstract/Free?Full?Text]
  95. Grandjean JG, Boonstra PW, den Heyer P, Ebels T: Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994; 107:1309.[Abstract/Free?Full?Text]
  96. Yang Z, Siebenmann R, Studer M, et al: Similar endothelium-dependent relaxation, but enhanced contractility, of the right gastroepiploic artery as compared with the internal mammary artery. J Thorac Cardiovasc Surg 1992; 104:459.[Abstract]
  97. Oku T, Yamane S, Suma H, et al: Comparison of prostacyclin production of human gastroepoploic artery and saphenous vein. Ann Thorac Surg 1990; 49:767.[Abstract]
  98. Kennedy JH: The gastroepiploic artery compared with the internal mammary artery in aortocoronary bypass. Annales de Chirurgie 1994; 48:814.[Medline]
  99. Koike R, Suma H, Kondo K, et al: Pharmacological response of internal mammary artery and gastroepiploic artery. Ann Thorac Surg 1990; 50:384.[Abstract]
  100. Mills NL, Hockmuth DR, Everson CT, et al: Right gastroepiploic artery used for coronary artery bypass grafting: evaluation of flow characteristics and size. J Thorac Cardiovasc Surg 1993; 106:579.[Abstract]
  101. Mills NL, Everson CT: Technical considerations for use of the gastroepiploic artery for coronary artery surgery. J Card Surg 1989; 4:1.[Medline]
  102. Tavilla G, van Son JAM, Verhagen AF, et al: Retrogastric versus antegastric routing and histology of the right gastroepiploic artery. Ann Thorac Surg 1992; 53:1057.[Abstract]
  103. Buche M, Schroeder E, Gurn? O, et al: Coronary artery bypass grafting with the inferior epigastric artery: midterm clinical and angiographic results. J Thorac Cardiovasc Surg 1995; 109:553.[Abstract/Free?Full?Text]
  104. Barner HB, Naunheim KS, Fiore AC, et al: Use of the inferior epigastric artery as a free graft for myocardial revascularization. Ann Thorac Surg 1991; 52:429.[Abstract]
  105. Cremer J, Mugge A, Schulze M, et al: The inferior epigastric artery for coronary bypass grafting: functional assessment and clinical results. Eur J Cardiothorac Surg 1993; 7:423.[Abstract]
  106. Tadjkarimi S, O'Neil GS, Schyns CJ, et al: Vasoconstrictor profile of the inferior epigastric artery. Ann Thorac Surg 1993; 56:1090.[Abstract]
  107. Buxton BF, Chan AT, Dixit AS, et al Ulnar artery as a coronary bypass graft. Ann Thorac Surg 1998; 65:1020.[Abstract/Free?Full?Text]
  108. van Aarnhem EE, Schreur JH, Firouzi M, Jansen EW: The left gastric artery as an in-situ conduit in coronary artery bypass grafting. Ann Thorac Surg 2001; 71:1013.[Abstract/Free?Full?Text]
  109. Edwards WS, Lewis CE, Blakeley WR, et al: Coronary artery bypass with internal mammary and splenic artery grafts. Ann Thorac Surg 1973; 15:35.[Medline]
  110. Yaginuma G, Sakurai M, Meguro T, Ota K: Thoracodorsal artery as a free arterial graft for myocardial revascularization. Ann Thorac Surg 2001; 72:915.[Abstract/Free?Full?Text]
  111. Schamun CM, Duran JC, Rodriguez JM, et al: Coronary revascularization with the descending branch of the lateral femoral circumflex artery as a composite arterial graft. J Thorac Cardiovasc Surg 1998; 116:870.[Free?Full?Text]
  112. Soyombo AA, Angelini GD, Bryan AJ, Newby AC: Surgical preparation induces injury and promotes smooth muscle cell proliferation in a culture of human saphenous vein. Cardiovasc Res 1993; 27:1961.[Medline]
  113. Bonchek LI: Prevention of endothelial damage during preparation of saphenous veins for bypass grafting. J Thorac Cardiovasc Surg 1980; 79:911.[Abstract]
  114. Angelini GD, Passani SL, Breckenridge IM, Newby AC: Nature and pressure dependence of damage induced by distension of human saphenous vein coronary artery bypass grafts. Cardiovasc Res 1987; 21:902.[Medline]
  115. Souza DS, Bomfim V, Skoglund H, et al: High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue. Ann Thorac Surg 2001; 71:797.[Abstract/Free?Full?Text]
  116. Tsui JC, Souza DS, Filbey D, et al: Preserved endothelial integrity and nitric oxide synthase in saphenous vein grafts harvested by a "no-touch" technique. Br J Surg 2001; 88:1209.[Medline]
  117. Bitondo JM, Daggett WM, Torchiana DF, et al: Endoscopic versus open saphenous vein harvest: a comparison of postoperative wound complications. Ann Thorac Surg 2002; 73:523.[Abstract/Free?Full?Text]
  118. Dusterhoft V, Bauer M, Buz S, et al: Wound-healing disturbances after vein harvesting for CABG: a randomized trial to compare the minimally invasive direct vision and traditional approaches. Ann Thorac Surg 2001; 72:2038.[Abstract/Free?Full?Text]
  119. Meyer DM, Rogers TE, Jessen ME, et al: Histologic evidence of the safety of endoscopic saphenous vein graft preparation. Ann Thorac Surg 2000; 70:487.[Abstract/Free?Full?Text]
  120. Paletta CE, Huang DB, Fiore AC, et al: Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg 2000; 70:492.[Abstract/Free?Full?Text]
  121. Kiaii B, Moon BC, Massel D, et al: A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery. J Thorac Cardiovasc Surg 2002; 123:204.[Abstract/Free?Full?Text]
  122. Crouch JD, O'Hair DP, Keuler JP, et al: Open versus endoscopic saphenous vein harvesting: wound complications and vein quality. Ann Thorac Surg 1999; 68:1513.[Abstract/Free?Full?Text]
  123. Lancey RA, Cuenoud H, Nunnari JJ: Scanning electron microscopic analysis of endoscopic versus open vein harvesting techniques. J Cardiovasc Surg 2001; 42:297.[Medline]
  124. Stoney WS, Alford WC Jr, Burrus GR, et al: The fate of arm veins used for aorta-coronary bypass grafts. J Thorac Cardiovasc Surg 1984; 88:522.[Abstract]
  125. Wijnberg DS, Boeve WJ, Ebels T, et al: Patency of arm vein grafts used in aorto-coronary bypass surgery. Cardiothorac Surg 1990; 4:510.
  126. Lamm P, Juchem G, Milz S, et al: Autologous endothelialized vein allograft: a solution in the search for small-caliber grafts in coronary artery bypass graft operations. Circulation 2001; 104(suppl 1):1108.[Abstract/Free?Full?Text]
  127. Laub GW, Muralidharan S, Clancy R, et al: Cryopreserved allograft veins as alternative coronary artery bypass conduits: early phase results [see comments]. Ann Thorac Surg 1992; 54:826.[Abstract]
  128. Kruse J, Borsow J, Buntrock P, et al: Aortocoronary vascular prosthesis made of siliconized homologous vein or bovine sacral artery. Thorac Cardiovasc Surg 1991; 39(suppl 3):233.
  129. Okoshi T, Soldani G, Goddard M, Galletti PM: Very small-diameter polyurethane vascular prostheses with rapid endothelialization for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1993; 105:791.[Abstract]
  130. Marshall WG Jr, Barzilai B, Kouchoukos NT: Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg 1989; 48:339.[Abstract]
  131. Ohteki H, Tsuyoshi I, Natsuaki M, et al: Intraoperative ultrasonic imaging of the ascending aorta in ischemic heart disease. Ann Thorac Surg 1990; 50:539.[Abstract]
  132. Mills NL, Everson CT: Atherosclerosis of the ascending aorta and coronary artery bypass. J Thorac Cardiovasc Surg 1991; 102:546.[Abstract]
  133. Wareing TH, Davila-Roman VG, Barzilai B, et al: Management of the severely atherosclerotic ascending aorta during cardiac operations: a strategy for detection and treatment. J Thorac Cardiovasc Surg 1992; 103:453.[Abstract]
  134. Rowland PE, Grooters RK: Coronary-coronary artery bypass: an alternative. Ann Thorac Surg 1987; 43:326.[Abstract]
  135. Dearani JA, Axford TC, Patel MA, et al: Role of myocardial temperature measurement in monitoring the adequacy of myocardial protection during cardiac surgery. Ann Thorac Surg 2001; 72:S2235.[Abstract/Free?Full?Text]
  136. Flack JE, Cook JR, May SJ, et al: Does cardioplegia type affect outcome and survival in patients with advanced left ventricular dysfunction? Circulation 2000; 102(suppl III):III84.
  137. Allen BS, Winkelmann JW, Hanafy H, et al: Retrograde cardioplegia does not adequately perfuse the right ventricle. J Thorac Cardiovasc Surg 1995; 109:1116.
  138. Vural KM, Sener E, Tasdemir O: Long-term patency of sequential and individual saphenous vein coronary bypass grafts. Eur J Cardiothorac Surg 2001; 19:140.[Abstract/Free?Full?Text]
  139. Yamaguchi A, Kitamura N, Miki T, et al: Comparative study in graft patency of individual and sequential grafting as coronary bypass. Circulation 1993; 41:577.
  140. Kieser TM, Fitzgibbons JM, Keon WJ: Sequential coronary bypass grafts: long-term follow-up. J Thorac Cardiovasc Surg 1986; 91:767.[Abstract]
  141. Bessone LN, Pupello DF, Hiro SP, et al: Sequential internal mammary artery grafting: a viable alternative in myocardial revascularization. Cardiovasc Surg 1995; 3:155.[Medline]
  142. Kesler KA, Sharp TG, Turrentine MW, Brown JW: Technical considerations and early results of sequential left internal mammary artery bypass grafting to the left anterior descending coronary artery system. J Card Surg 1990; 5:134.[Medline]
  143. Tashiro T, Todo K, Haruta Y, et al: Sequential internal mammary artery grafts: clinical and angiographic assessment. Cardiovasc Surg 1993; 1:720.[Medline]
  144. Hartman JM, Kelder JC, Ackerstaff RG, et al: Different behavior of sequential versus single left internal mammary artery to left anterior descending area grafts (1). Cardiovasc Surg 2001; 9:586.[Medline]
  145. Kootstra GJ, Pragliola C, Lanzillo G: Technique of sequential grafting the left internal mammary artery (LIMA) to the circumflex coronary system. J Cardiovasc Surg 1993; 34:523.[Medline]
  146. Ochi M, Bessho R, Saji Y, et al: Sequential grafting of the right gastroepiploic artery in coronary artery bypass surgery. Ann Thorac Surg 2001; 71:1205.[Abstract/Free?Full?Text]
  147. Christenson JT, Schmuziger M: Sequential venous bypass grafts: results 10 years later. Ann Thorac Surg 1997; 63:371.[Abstract/Free?Full?Text]
  148. Christenson JT, Simonet F, Schmuziger M: Sequential vein bypass grafting: tactics and long-term results. Cardiovasc Surg 1998; 6:389.[Medline]
  149. Eckstein FS, Bonilla LF, Meyer B, et al: Sutureless mechanical anastomosis of a saphenous vein graft to a coronary artery with a new connector device. Lancet 2001; 357:931.[Medline]
  150. Brenowitz JB, Kayser KL, Johnson WD: Results of coronary endarterectomy in reconstruction. J Thorac Cardiovasc Surg 1988; 95:1.[Abstract]
  151. Goldstein J, Cooper E, Saltups A, Boxall J: Angiographic assessment of graft patency after coronary endarterectomy. J Thorac Cardiovasc Surg 1991; 102:539.[Abstract]
  152. Ferraris VA, Harrah JD, Moritz DM, et al: Long-term angiographic results of coronary endarterectomy. Ann Thorac Surg 2000; 69:1737.[Abstract/Free?Full?Text]
  153. Qureshi SA, Halim MA, Pillai R, et al: Endarterectomy of the left coronary system: analysis of a ten year experience. J Thorac Cardiovasc Surg 1985; 89:852.[Abstract]
  154. Asimakopoulos G, Taylor KM, Ratnatunga CP: Outcome of coronary endarterectomy: a case-control study. Ann Thorac Surg 1999; 67:989.[Abstract/Free?Full?Text]
  155. Shapira OM, Akopian G, Hussain A, et al: Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy. Ann Thorac Surg 1999; 68:2273.[Abstract/Free?Full?Text]
  156. Goldman BS, Christakis GT: Endarterectomy of the left anterior descending coronary artery [review]. J Cardiac Surg 1994; 9:89.[Medline]
  157. Dar MI, Gillott T, Ciulli F, Cooper GJ: Single aortic cross-clamp technique reduces S-100 release after coronary artery surgery. Ann Thorac Surg 2001; 71:794.[Abstract/Free?Full?Text]
  158. Suma H: Innominate and subclavian arteries as an inflow of free arterial graft. Ann Thorac Surg 1996; 62:1865.[Abstract/Free?Full?Text]
  159. Tector AJ, Amundsen S, Schmal TM, et al: Total revascularization with T-grafts. Ann Thorac Surg 1994; 57:33.[Abstract]
  160. Calafiore AM, Di Giammarco G, Teodori G, et al: Radial artery and inferior epigastric artery in composite grafts: improved mid-term angiographic results. Ann Thorac Surg 1995; 60:517.[Abstract/Free?Full?Text]
  161. Barner HB, Sundt TM 3rd, Bailey M, Zang Y: Midterm results of complete arterial revascularization in more than 1,000 patients using an internal thoracic artery/radial artery T graft. Ann Surg 2001; 234:447.[Medline]
  162. Royse AG, Royse CF, Groves KL, et al: Blood flow in composite arterial grafts and effect of native coronary flow. Ann Thorac Surg 1999; 68:1619.[Abstract/Free?Full?Text]
  163. Tector AJ, McDonald ML, Kress DC, et al: Purely internal thoracic artery grafts: outcomes. Ann Thorac Surg 2001; 72:450.[Abstract/Free?Full?Text]
  164. Tashiro T, Nakamura K, Iwakuma A, et al: Inverted T graft: novel technique using composite radial and internal thoracic arteries. Ann Thorac Surg 1999; 67:629.[Abstract/Free?Full?Text]
  165. Eckstein FS, Bonilla LF, Englberger L, et al: Minimizing aortic manipulation during OPCAB using the Symmetry aortic connector system for proximal vein graft anastomoses. Ann Thorac Surg 2001; 72:S995.[Abstract/Free?Full?Text]
  166. Svedjeholm R, Hakanson E: Postoperative myocardial ischemia caused by chest tube compression of vein graft. Ann Thorac Surg 1997; 64:1806.[Abstract/Free?Full?Text]
  167. Rao V, Komeda M, Weisel RD, et al: Should the pericardium be closed routinely after heart operations? Ann Thorac Surg 1999; 67:484.[Abstract/Free?Full?Text]
  168. Furnary AP, Magovern JA, Simpson KA, Magovern GJ: Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992; 54:233.[Abstract]
  169. Estafanous FG, Loop FD, Higgins TL, et al: Increased risk and decreased morbidity of coronary artery bypass grafting between 1986 and 1994. Ann Thorac Surg 1998; 65:383.[Abstract/Free?Full?Text]
  170. Leavitt BJ, O'Connor GT, Olmstead EM, et al:. Use of the internal mammary artery graft and in-hospital mortality and other adverse outcomes associated with coronary artery bypass surgery. Circulation 2001; 103:507.[Medline]
  171. McKhann GM, Goldsborough MA, Borowicz LM Jr, et al: Cognitive outcome after coronary artery bypass: a one-year prospective study. Ann Thorac Surg 1997; 62:510.
  172. Puskas JD, Winston AD, Wright CE, et al: Stroke after coronary artery operation: incidence, correlates, outcome, and cost. Ann Thorac Surg 2000; 69:1053.[Abstract/Free?Full?Text]
  173. Gardner TJ, Horneffer PJ, Manolio TA, et al: Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985; 40:574.[Abstract]
  174. Rao V, Christakis GT, Weisel RD, et al: Risk factors for stroke following coronary bypass surgery. J Card Surg 1995; 10:468.[Medline]
  175. McKhann GM, Goldsborough MA, Borowicz LM Jr, et al: Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 1997; 62:516.
  176. Szczech LA, Best PJ, Crowley E, et al: Outcomes of patients with chronic renal insufficiency in the bypass angioplasty revascularization investigation. Circulation 2002; 105:2253.[Abstract/Free?Full?Text]
  177. Weintraub WS, Jones EL, Craver J, et al: Determinants of prolonged length of hospital stay after coronary bypass surgery. N Engl J Med 1989; 80:276.
  178. Weintraub WS, Craver JM, Jones EL, et al: Improving cost and outcome of coronary surgery. Circulation 1998; 98(19 suppl):II23.
  179. Cowper PA, DeLong ER, Peterson ED, et al: Variability in cost of coronary bypass surgery in New York State: potential for cost savings. Am Heart J 2002; 143:130.[Medline]
  180. Mauldin PD, Weintraub WS, Becker ER: Predicting hospital costs for first-time coronary artery bypass grafting from preoperative and postoperative variables. Am J Cardiol 1994; 74:772.[Medline]
  181. Engelman RM, Rousou JA, Flack JE 3d, et al: Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994; 58:1742.[Abstract]
  182. Mounsey JP, Griffith MJ, Heaviside DW, et al: Determinants of the length of stay in intensive care and in hospital after coronary artery surgery. Br Heart J 1995; 73:92.[Abstract/Free?Full?Text]
  183. Barner HB, Barnett M: Fifteen to 21 year angiographic assessment of internal thoracic artery as a bypass conduit. Ann Thorac Surg 1994; 57:1526.[Abstract]
  184. Tatoulis J, Buxton BF, Fuller JA, Royse AG: Total arterial coronary revascularization: techniques and results in 3,220 patients. Ann Thorac Surg 1999; 68:2093.[Abstract/Free?Full?Text]
  185. Loop FD, Lytle BW, Cosgrove DM, et al: Free (aorta-coronary) internal mammary artery graft: late results. J Thorac Cardiovasc Surg 1986; 92:827.[Abstract]
  186. Acar C, Ramsheyi A, Pagny JY, et al: The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998; 116:981.[Abstract/Free?Full?Text]
  187. Calafiore AM, Di Mauro M, D'Alessandro S, et al: Revascularization of the lateral wall: long-term angiographic and clinical results of radial artery versus right internal thoracic artery grafting. J Thorac Cardiovasc Surg 2002; 123:225.[Abstract/Free?Full?Text]
  188. Iaco AL, Teodori G, Di Giammarco G, et al: Radial artery for myocardial revascularization: long-term clinical and angiographic results. Ann Thorac Surg 2001; 72:464.[Abstract/Free?Full?Text]
  189. Suma H, Wanibuchi Y, Terada Y, et al: The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993; 105:615.[Abstract]
  190. Campeau L, Enjalbert M, Lesperance J, et al: Atherosclerosis and late closure of aortocoronary saphenous vein grafts: sequential angiographic studies at 2 weeks, 1 year, 5 to 7 years and 10 to 12 years after surgery. Circulation 1983; 68(suppl II):II-1.
  191. Campeau L, Enjalbert M, Lesperance J, et al: The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation: a study 10 years after aortocoronary bypass surgery. N Engl J Med 1984; 311:1329.[Abstract]
  192. Blankenhorn DH, Nessim SA, Johnson RL: Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts. JAMA 1987; 257:323.
  193. Goldman S, Copeland J, Moritz T, et al: Starting aspirin therapy after operation: affects on early graft patency. Circulation 1991; 84:520.[Medline]
  194. Domanski MJ, Borkowf CB, Campeau L, et al: Prognostic factors for atherosclerosis progression in saphenous vein grafts: the postcoronary artery bypass graft (Post-CABG) trial. Post-CABG Trial Investigators. J Am Coll Cardiol 2000; 36:1877.[Abstract/Free?Full?Text]
  195. Mann MJ, Dzau VJ: Therapeutic applications of transcription factor decoy oligonucleotides. J Clin Invest 2000; 106:1071.[Free?Full?Text]
  196. Myers WO, Blackstone EH, Davis K, et al: CASS Registry long term surgical survival. Coronary Artery Surgery Study. J Am Coll Cardiol 1999; 33:488.[Abstract/Free?Full?Text]
  197. Gardner SC, Grunwald GK, Rumsfeld JS, et al: Risk factors for intermediate-term survival after coronary artery bypass grafting. Ann Thorac Surg 2001; 72:2033.[Abstract/Free?Full?Text]
  198. Dzavik V, Ghali WA, Norris C, et al: Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Am Heart J 2001; 142:119.[Medline]
  199. Pell JP, MacIntyre K, Walsh D, et al: Time trends in survival and readmission following coronary artery bypass grafting in Scotland, 198196: retrospective observational study. BMJ 2002; 324:201.[Free?Full?Text]
  200. Graham MM, Ghali WA, Faris PD, et al: Survival after coronary revascularization in the elderly. Circulation 2002; 105:2378.[Abstract/Free?Full?Text]
  201. Trachiotis GD, Weintraub WS, Johnston TS, et al: Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg 1998; 66:1632.[Abstract/Free?Full?Text]
  202. Van den Brand MJBM, Rensing BJWM, Morel MM, et al: The effect of completeness of revascularization in event-free survival at one year in the ARTS trial. J Am Coll Cardiol 2002; 39:559.[Abstract/Free?Full?Text]
  203. Scott R, Blackstone EH, McCarthy PM, et al: Isolated bypass grating of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization. J Thorac Cardiovasc Surg 2000; 120:173.[Abstract/Free?Full?Text]
  204. Moon MR, Sundt TM 3rd, Pasque MK, et al: Influence of internal mammary artery grafting and completeness of revascularization on long-term outcome in octogenarians. Ann Thorac Surg 2001; 72:2003.[Abstract/Free?Full?Text]
  205. VanderSalm TJV, Kip KE, Jones RH, et al: What constitutes optimal surgical revascularization? Answers from the bypass angioplasty revascularization investigation (BARI). J Am Coll Cardiol 2002; 39:565.[Abstract/Free?Full?Text]
  206. Taggart DP, D'Amico R, Altman DG: Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001; 358:870.
  207. Rumsfeld JS, Magid DJ, O'Brien M, et al: Changes in health-related quality of life following coronary artery bypass graft surgery. Ann Thorac Surg 2001; 72:2026.[Abstract/Free?Full?Text]
  208. Mohr FW, Falk V, Diegeler A, et al: Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001; 121:842.[Abstract/Free?Full?Text]
  209. Loulmet D, Carpentier A, d'Attellis N, et al: Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999; 118:4.[Abstract/Free?Full?Text]
  210. Boyd WD, Rayman R, Desai ND, et al: Closed-chest coronary artery bypass grafting on the beating heart with the use of a computer-enhanced surgical robotic system. J Thorac Cardiovasc Surg 2000; 120:807.[Free?Full?Text]
  211. Damiano RJ Jr, Tabaie HA, Mack MJ, et al: Initial prospective multicenter clinical trial of robotically-assisted coronary artery bypass grafting. Ann Thorac Surg 2001; 72:1263.[Abstract/Free?Full?Text]
  212. Kappert U, Schneider J, Cichon R, et al: Development of robotic enhanced endoscopic surgery for the treatment of coronary artery disease. Circulation 2001; 104:I102.




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