ANGIOGRAPHIC ASSESSMENT OF LIMA GRAFT AFTER MID-CAB PROCEDURE - KINKS ARE BENIGN
H.D. Wolfenden*, N.S. Jepson, R.M. Allan, M.R. Pitney.
Department Cardiology and Cardiothoracic Surgery, Prince of Wales Hospital and Eastern Heart Clinic, Sydney, New South Wales.
Minimally invasive direct coronary artery bypass (MIDCAB) surgery has gained increasing attention. However, there are concerns of early graft failure. We report the angiographic findings in 35 consecutive patients, 26 male, mean age 61 (43-82) yrs. Surgery was undertaken from the lateral anterior small thoracotomy approach and entailed LIMA to LAD grafting in all cases.
Of the 35 patients, 1 required immediate catheterisation (deemed a poor result in theatre) revealing subtotal LAD occlusion requiring re-grafting on CPB. Angiography was performed from the left radial artery on a routine basis on day one post-operatively in the remaining 34 cases and demonstrated graft patency in all patients. Only 1 patient had any angiographic stenosis at the anastomosis and was treated conservatively as there was no evidence of ischaemia. Angiography revealed evidence of kinking in the extra-pericardial course of the LIMA graft in 10 of 35 cases (29%). When present, kinks were multiple (2-4) in 50% of cases and were most evident in the LAO-cranial projection. Although kinks represented high grade angiographic lesions (>70% luminal reduction) in 3 of 10 cases, there was no angiographic impairment of flow (TIMI III in all cases). At follow-up (4-23 months), 33 of 34 patients were free of angina and one had residual pain but improved functional class (known ungraftable RCA disease).
In conclusion, the MIDCAB procedure can provide excellent early patency to selected LAD vessels. Although kinks in the IMA graft are common and can be associated with significant stenosis angiographically, they do not appear to have an adverse impact on early clinical outcome.
