Radial artery for coronary artery bypass grafting: does proximal anastomosis to the aorta or left internal mammary artery achieve better patency?

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

Cardiogenic Shock After Arterial Y-Graft Coronary Bypass Surgery Secondary to Critical Stenoses of the Left Subclavian and Left Main Coronary Arteries

We present a case of a 62-year-old man who was in cardiogenic shock. He had a history of coronary artery bypass grafting 4 years previously, with left internal mammary radial artery Y-grafting to a left dominant coronary circulation. Critical stenoses of the left main coronary and left subclavian arteries were seen at angiography. An occluded abdominal aorta precluded the use of mechanical circulatory support. The patient underwent high-risk stenting of the left subclavian artery with a successful outcome. The case highlights the unresolved issue of screening for subclavian stenoses in patients being considered for revascularization with arterial Y-grafting.

Comparison of the Plasma Metabolome Profiles Between the Internal Thoracic Artery and Ascending Aorta in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Gas Chromatography Time-of-Flight Mass Spectrometry

BACKGROUND

The left internal thoracic artery (LITA) has been used as the first conduit of choice in coronary artery bypass grafting (CABG) because of excellent long-term patency and outcomes. However, no studies have examined substances other than nitric oxide that could be beneficial for the bypass conduit, native coronary artery or ischemic myocardium. This study was conducted to evaluate differences in metabolic profiles between the LITA and ascending aorta using gas chromatography-time of flight-mass spectrometry (GC-TOF-MS).

METHODS

Twenty patients who underwent CABG using the LITA were prospectively enrolled. Plasma samples were collected simultaneously from the LITA and ascending aorta. GC-TOF-MS based untargeted metabolomic analyses were performed and a 2-step volcano plot analysis was used to identify distinguishable markers from two plasma metabolome profiles. Semi-quantitative and quantitative analyses were performed using GC-TOF-MS and enzyme-linked immunosorbent assay, respectively, after selecting target metabolites based on the metabolite set enrichment analysis.

RESULTS

Initial volcano plot analysis demonstrated 5 possible markers among 851 peaks detected. The final analysis demonstrated that the L-cysteine peak was significantly higher in the LITA than in the ascending aorta (fold change = 1.86). The concentrations of intermediate metabolites such as L-cysteine, L-methionine and L-cystine in the 'cysteine and methionine metabolism pathway' were significantly higher in the LITA than in the ascending aorta (2.0-, 1.4- and 1.2-fold, respectively). Quantitative analysis showed that the concentration of hydrogen sulfide (H₂S) was significantly higher in the LITA.

CONCLUSION

The plasma metabolome profiles of the LITA and ascending aorta were different, particularly higher plasma concentrations of L-cysteine and H₂S in the LITA.

Technical Aspects of the Use of the Radial Artery in Coronary Artery Bypass Surgery

BACKGROUND

The radial artery has been used for coronary artery bypass surgery for more than 25 years. The recent confirmation of the clinical benefits associated with the use of the artery is likely to drive a new interest toward this conduit in the next few years.

METHODS

A group of surgeons with extensive experience in the systematic use of the radial artery summarize here the key technical aspects of the use of the conduit for coronary bypass operations.

RESULTS

Preoperative evaluation of the ulnar collateral circulation and attention to the characteristics of the target vessel are keys for the successful use of the radial artery. Open or endoscopic harvesting can be used, preferentially with the aid of the harmonic scalpel. The use of vasodilatory and antispastic protocols is probably important but poorly supported by the current evidence. The radial artery can be used for multiple grafting strategies with a variable degree of technical complexity.

CONCLUSIONS

With attention to few technical key points, the radial artery is a versatile conduit that can be easily introduced in the everyday practice of coronary artery bypass surgery.

The radial artery: a forgotten conduit

We reviewed the published literature on the clinical and angiographic outcome of radial artery (RA) grafts and on the comparison between the RA and the other conduits used in coronary operations. The RA is a better graft than the saphenous vein and comparable to the right internal thoracic artery (RITA); moreover, the RA seems a better choice than the RITA in patients at risk of sternal or pulmonary complications. We conclude that the RA should be preferred to the saphenous vein and considered at least equivalent to the RITA as the second conduit during every elective coronary artery bypass procedure.