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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 57-59

The fate of a composite arterial graft in a 58-year-old man having strong comorbidities and atherosclerotic burden


Division of Cardiac Surgery, Department of Cardio-Thoracic and Vascular, Trieste University Hospital, Trieste, Italy

Date of Web Publication22-Jan-2018

Correspondence Address:
Dr. Giuseppe Gatti
Division of Cardiac Surgery, Ospedale di Cattinara, via Pietro Valdoni, 7 - 34148 Trieste
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_21_17

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  Abstract 


For some difficult subsets of coronary patients having specific comorbidities, such as insulin-dependent diabetes and chronic renal failure, arterial myocardial revascularization could be a satisfactory option. The key question is which arteries should be used. A 58-year-old insulin-dependent diabetic patient with severe renal failure, despite previous kidney transplantation, underwent treatment of his severe and diffuse coronary disease using a composite arterial Y-graft and saphenous vein. Both internal thoracic arteries were harvested as skeletonized conduits. The patient's hospital course was totally uneventful. Fifty-six months later, the patient underwent hospital readmission due to a new (inferior) myocardial infarction. Coronary angiography showed both the progression of disease into the native vessels and occlusion of the venous graft. The Y-graft was patent and well functioning despite the presence of a preoperative left upper limb dialysis fistula. This case report emphasizes the concept that both internal thoracic arteries seem to be refractory to most aggressive forms of atherosclerosis, and that a more liberal use even for high-risk candidates could be a rational practice. However, many surgeons consider the use of both internal thoracic arteries for myocardial revascularization as a too risky strategy that has to be adopted only for young and low-risk patients.

Keywords: Arterial grafts, atherosclerosis, chronic renal failure, coronary bypass surgery, diabetes, insulin, kidney transplantation, outcome


How to cite this article:
Gatti G, Priolo L, Benussi B, Vitrella G, Sinagra G, Pappalardo A. The fate of a composite arterial graft in a 58-year-old man having strong comorbidities and atherosclerotic burden. Res Cardiovasc Med 2017;6:57-9

How to cite this URL:
Gatti G, Priolo L, Benussi B, Vitrella G, Sinagra G, Pappalardo A. The fate of a composite arterial graft in a 58-year-old man having strong comorbidities and atherosclerotic burden. Res Cardiovasc Med [serial online] 2017 [cited 2022 Jun 27];6:57-9. Available from: https://www.rcvmonline.com/text.asp?2017/6/4/57/223777


  Introduction Top


The use of the in situ left internal thoracic artery (ITA) to the left anterior descending coronary artery, and saphenous vein grafts for the remaining stenotic coronary vessels, is the standard for surgical myocardial revascularization. However, there are some difficult subsets of coronary patients with specific comorbidities, such as insulin-dependent diabetes and chronic renal failure, who do not benefit greatly from this model of revascularization, primarily because of early failure of the venous grafts.[1] For these challenging patients, arterial myocardial revascularization could be a more satisfactory option. Therefore, the key question is which arteries should be used.


  Case Report Top


During January 2012, a 58-year-old man with unstable angina and multiple risk factors for cardiovascular disease (tabagism, hypertension, and diabetes on insulin) and strong concomitant diseases, meaning severe renal impairment despite previous kidney transplantation (creatinine clearance, 41 mL/min), chronic lung disease, bilateral internal carotid artery and peripheral vascular disease, and a squamous cell carcinoma of the scalp spreading to lymph nodes that had been treated surgically and with radiotherapy, was admitted to the present authors' surgical unit for the treatment of a diffusely stenotic coronary tree (combined left main and three-vessel coronary artery disease; [Figure 1]a,[Figure 1]b,[Figure 1]c). In addition to angina, there were symptoms of congestive heart failure (New York Heart Association class III) and electrocardiographic signs of a recent inferolateral myocardial infarction without left ventricular dysfunction (ejection fraction, 0.61) or significant mitral regurgitation. The expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), was of 12.5%.[2] To perform a left-sided myocardial revascularization, the right ITA was taken down and used as a free graft from the in situ left ITA. Both ITAs were harvested as skeletonized conduits using low-intensity bipolar coagulation forceps.[3],[4] Finally, a saphenous vein graft with the proximal end from the ascending aorta was adopted to bypass the right posterior descending coronary artery. The lengths of cardiopulmonary bypass and aortic cross-clamping were 81 and 64 min, respectively. The patient's hospital course was totally uneventful. He was moved to the ward during postoperative day 2 and discharged home after 10 days from the operation. Neither blood transfusion nor renal replacement therapy was required. No sternal complications occurred.
Figure 1: (a-c) Preoperative and (d) follow-up coronary angiography. The Y-graft was used to bypass the left anterior descending coronary artery (right brunch and end-to-side anastomosis), the diagonal branch (right branch and side-to-side anastomosis), and the obtuse marginal branch (left branch and end-to-side anastomosis). The venous graft to the right posterior descending coronary artery could not be seen

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Fifty-six months later, the patient underwent hospital readmission due to a new (inferior) myocardial infarction. Coronary angiography showed both the progression of disease into native vessels and occlusion of the venous graft, and in the meantime, the Y-graft was patent and well functioning despite the presence of a preoperative left upper limb dialysis fistula [Figure 1]d.


  Discussion Top


The case presented here was a patient with strong comorbidities and atherosclerotic burden, who underwent successful treatment of his severe and diffuse coronary disease using both a composite arterial Y-graft and saphenous vein. After about 4½ years, the Y-graft was working well, while the venous one was occluded. In addition, there was a clear progression of atherosclerosis into the entire native coronary tree, except for the coronary vessels that had been revascularized by the Y-graft.

In the authors' opinion, this case emphasizes the concept that both ITAs seem to be refractory to most aggressive forms of atherosclerosis,[5] even in the presence of insulin-requiring status, renal failure, or long-standing immunomodulatory therapy.[1],[3],[5],[6] Besides, no sternal complications occurred after surgery and there were no symptoms of coronary steal despite the presence of a dialysis fistula ipsilateral to the composite in situ ITA graft (albeit it would always be preferable to avoid the use of an in situ ITA graft in the case of an ipsilateral arteriovenous fistula due to the risk of myocardial ischemia during hemodialysis).[7] Nevertheless, although there is increasing evidence of long-term survival benefits,[1],[3],[4],[5],[6] many surgeons consider the use of both ITAs for myocardial revascularization as a too risky strategy that has to be adopted only for young and low-risk patients.[8] Obviously, there are many factors that may affect the graft patency (primarily the coronary run-off), it is not a single (maybe) fortunate clinical case that may change the surgical practice, and the approach that is tailored to the baseline characteristics of each individual patient should always be preferred. However, a more liberal use of both ITAs, even for high-risk candidates, could not be a less rational practice. The present authors are currently performing left-sided myocardial revascularization using both ITAs in 100% of patients (n = 3440; mean EuroSCORE II, 3.8 ± 5.6%; 30-day mortality, 1.5%).[2],[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ohira S, Doi K, Numata S, Yamazaki S, Kawajiri H, Yaku H, et al. Impact of chronic kidney disease on long-term outcome of coronary artery bypass grafting in patients with diabetes mellitus. Circ J 2016;80:110-7.  Back to cited text no. 1
    
2.
Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734-44.  Back to cited text no. 2
    
3.
Gatti G, Soso P, Dell'Angela L, Maschietto L, Dreas L, Benussi B, et al. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: Early and long-term outcomes. Eur J Cardiothorac Surg 2015;48:115-20.  Back to cited text no. 3
    
4.
Gatti G, Maschietto L, Dell'Angela L, Benussi B, Forti G, Dreas L, et al. Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction. Heart Vessels 2016;31:1045-55.  Back to cited text no. 4
    
5.
Ueda T, Taniguchi S, Kawata T, Mizuguchi K, Nakajima M, Yoshioka A, et al. Does skeletonization compromise the integrity of internal thoracic artery grafts? Ann Thorac Surg 2003;75:1429-33.  Back to cited text no. 5
    
6.
Kinoshita T, Asai T, Murakami Y, Hiramatsu N, Suzuki T, Kambara A, et al. Efficacy of bilateral internal thoracic artery grafting in patients with chronic kidney disease. Ann Thorac Surg 2010;89:1106-11.  Back to cited text no. 6
    
7.
Cuthbert GA, Kirmani BH, Muir AD. Should dialysis-dependent patients with upper limb arterio-venous fistulae undergoing coronary artery bypass grafting avoid having ipsilateral in situ mammary artery grafts? Interact Cardiovasc Thorac Surg 2014;18:655-60.  Back to cited text no. 7
    
8.
Mastrobuoni S, Gawad N, Price J, Chan V, Ruel M, Mesana TG, et al. Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: The bilateral internal thoracic artery survey. J Thorac Cardiovasc Surg 2012;144:874-9.  Back to cited text no. 8
    


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