Rapid Communication
The Composite Aortic Wall Graft Technique: An Option for a Short Coronary Artery Bypass Graft
João Bosco de OliveiraI, Roberto Rocha e SilvaII, Dennys Marcel Sanches MartinsIII, Ricardo De MolaIII, Marcos Vinicius Henriques de CarvalhoIV
I Hospital Beneficência Portuguesa, Cardiologia - São Paulo/SP, Brazil
II Cardiac Surgery, INCOR, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
III Hospital e Maternidade Paulo Sacramento - Jundiaí/ SP, Brazil
IV Faculdade de Medicina de Jundiaí - Jundiaí/ SP, Brazil, Tel: 55 11 4587.1095
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São Paulo/SP, Brazil" "etiqueta" => "I" "identificador" => "afI-cln64_8p815" ] 1 => array:3 [ "entidad" => "Cardiac Surgery, INCOR, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil" "etiqueta" => "II" "identificador" => "afII-cln64_8p815" ] 2 => array:3 [ "entidad" => "Hospital e Maternidade Paulo Sacramento - Jundiaí/ SP, Brazil" "etiqueta" => "III" "identificador" => "afIII-cln64_8p815" ] 3 => array:3 [ "entidad" => "Faculdade de Medicina de Jundiaí - Jundiaí/ SP, Brazil, Tel: 55 11 4587.1095" "etiqueta" => "IV" "identificador" => "afIV-cln64_8p815" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f2-cln64_8p815" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 789 "Ancho" => 993 "Tamanyo" => 161272 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Distal end of graft, ready for anastomosis with bridging vessel</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Coronary artery bypass graft (CABG) using the left internal thoracic artery (LITA) to the left anterior descending artery (LADA) is the gold standard for multi-vessel coronary disease procedures. The second graft is usually implanted with its proximal segment to the aorta. However, approximately 20% of the saphenous veins present some degree of stenosis during the first year after surgery.<a class="elsevierStyleCrossRef" href="#bib1">1</a> Recent studies have demonstrated that wall shear stress is maximized at the proximal anastomosis, probably due to turbulence.<a class="elsevierStyleCrossRefs" href="#bib2">2,3</a> This elevated wall shear stress may be related to the occurrence of intimal hyperplasia that leads to late graft failure.<a class="elsevierStyleCrossRef" href="#bib4">4</a>–<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para20" class="elsevierStylePara elsevierViewall">In order to avoid graft failure, we propose a new technique for performing the proximal anastomosis procedure such that the high wall shear stress will be localized at an “in situ” aortic wall graft that may exhibit improved pressure tolerance. Our approach may help avoid proximal intimal hyperplasia.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">MATERIAL AND METHODS</span><p id="para30" class="elsevierStylePara elsevierViewall">This research was approved by the Ethics Committee of the Jundiaí School of Medicine. An 80 kg pig was subjected to general anesthesia with mechanical ventilation. Access to the heart was through sternotomy and pericardial opening. Four stitches were placed in the anterior ascending aorta to create a 2 cm by 4 cm patch (<a class="elsevierStyleCrossRef" href="#f1-cln64_8p815">Figure 1A</a>). This patch was isolated using a tangential clamp that was positioned parallel to the axis of the aorta (<a class="elsevierStyleCrossRef" href="#f1-cln64_8p815">Figure 1B</a>). After releasing the patch, which was held to the aorta through its cranial end pedicle (<a class="elsevierStyleCrossRef" href="#f1-cln64_8p815">Figures 1C and 1D</a>), the rims of the patch were sutured to each other, creating a conduit of length 4 cm and with an internal diameter of 4 mm (<a class="elsevierStyleCrossRef" href="#f1-cln64_8p815">Figure 1E</a>). The rest of the aortotomy was closed by applying a direct suture between it’s rims. In addition, a PTFE tube that simulated a saphenous conduit was sutured to the distal end of the conduit (<a class="elsevierStyleCrossRef" href="#f1-cln64_8p815">Figure 1F</a>).</p><elsevierMultimedia ident="f1-cln64_8p815"></elsevierMultimedia><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Results</span><p id="para40" class="elsevierStylePara elsevierViewall">This technique resulted in the creation of a proximal aortic wall graft 4 cm long with an internal diameter of 4 mm. This graft possessed a distal end with an opening similar to the usual aortic site for proximal anastomosis (<a class="elsevierStyleCrossRef" href="#f2-cln64_8p815">Figure 2</a>). The graft exhibited sufficient mobility and was appropriate for either the right or left coronary arteries. The graft allowed for the implantation of the composite graft without further aortic clamping.</p><elsevierMultimedia ident="f2-cln64_8p815"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">In our experimental model, a PTFE tube was implanted towards the distal end of the aortic graft (simulating a saphenous graft) in order to create a composite graft with a homogenous diameter (<a class="elsevierStyleCrossRef" href="#f3-cln64_8p815">Figure 3</a>).</p><elsevierMultimedia ident="f3-cln64_8p815"></elsevierMultimedia></span></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">DISCUSSION</span><p id="para60" class="elsevierStylePara elsevierViewall">The aortic wall graft is an easy technique to perform because once the aortic patch is obtained, both conduit creation and the aortic closure only require linear sutures.</p><p id="para70" class="elsevierStylePara elsevierViewall">During standard anastomosis, the high wall shear stresses associated with the proximal anastomosis may lead to intimal hyperplasia and graft failure.<a class="elsevierStyleCrossRefs" href="#bib3">3,6</a> With this proposed technique, the high wall shear stress will be localized to the “in situ” aortic wall graft. This may offer better pressure tolerance and will thus be better equipped to avoid intimal hyperplasia.</p><p id="para80" class="elsevierStylePara elsevierViewall">Because the composite graft to be implanted in the end of the aortic graft will be of similar diameter, there will be little turbulence and consequently low wall shear stress. We expect that intimal hyperplasia would be unlikely to occur under these conditions.</p><p id="para90" class="elsevierStylePara elsevierViewall">Several studies have demonstrated the benefits of complete arterial revascularization.<a class="elsevierStyleCrossRef" href="#bib7">7</a>–<a class="elsevierStyleCrossRef" href="#bib11">11</a> This technique can add an additional 4 cm to a radial artery graft, which in turn allows it to reach the circumflex and the right coronary regions through sequential anastomosis. In addition, this should not increase the chances of morbidity because the aortic manipulation consists of a couple of linear sutures.</p><p id="para100" class="elsevierStylePara elsevierViewall">The potential benefits of this technique include a possible reduction in the graft failure rate due to intimal hyperplasia, which avoids the recurrence of symptoms and future operations.</p><p id="para110" class="elsevierStylePara elsevierViewall">In some cases, where the patient presents with some limitation in the graft (previous bilateral saphenectomy, redo CABG, or low quality saphenous graft), this technique may allow for a complete revascularization of the surgical area. Moreover, in circumstances when the graft size is underestimated, this technique can overcome the problem.</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">CONCLUSION</span><p id="para120" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this technique has never been described. Our results suggest that it allows for a proximal “in situ” aortic wall graft of excellent quality. Further work is required to determine its safety and reliability. As described above, this procedure appears to be a simple and straightforward approach that adds an extra 4 cm onto the composite graft.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "xpalclavsec1585134" "titulo" => "KEYWORDS:" ] 1 => array:2 [ "identificador" => "cesec10" "titulo" => "INTRODUCTION" ] 2 => array:3 [ "identificador" => "cesec20" "titulo" => "MATERIAL AND METHODS" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "cesec30" "titulo" => "Results" ] ] ] 3 => array:2 [ "identificador" => "cesec40" "titulo" => "DISCUSSION" ] 4 => array:2 [ "identificador" => "cesec50" "titulo" => "CONCLUSION" ] 5 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2009-05-22" "fechaAceptado" => "2009-05-28" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "KEYWORDS:" "identificador" => "xpalclavsec1585134" "palabras" => array:5 [ 0 => "Coronary artery bypass" 1 => "Anastomosis" 2 => "surgical" 3 => "Aorta" 4 => "Myocardial revascularization" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">SUMMARY</span><p id="spara40" class="elsevierStyleSimplePara elsevierViewall">During coronary artery bypass graft (CABG) surgery, the saphenous vein is sutured through its proximal segment to the aorta. Intimal hyperplasia is one of the possible causes of graft occlusion. Notably, blood turbulence can induce wall shear stress that may also play an important role in this process.</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">OBJECTIVE</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">We propose a new technique for performing proximal anastomosis to avoid CABG failure.</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">METHOD</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">An 80 kg pig was subjected to open heart surgery. Four stitches were placed in the anterior ascending aorta, which formed a 2 cm by 4 cm patch. This patch was isolated through the application of a tangential clamp that was oriented parallel to the axis of the aorta. After releasing the patch, which was held to the aorta through its cranial end pedicle, the rims were sutured to each other creating a conduit with a length of 4 cm and an internal diameter of 4 mm. The rest of the aortotomy was closed by placing a direct suture between its rims.</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">RESULT</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">This novel technique created an “in situ” aortic wall graft that was 4 cm long and characterized as being of uniform 4 mm caliber.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "ceabs10" "titulo" => "SUMMARY" ] 1 => array:2 [ "identificador" => "ceabs20" "titulo" => "OBJECTIVE" ] 2 => array:2 [ "identificador" => "ceabs30" "titulo" => "METHOD" ] 3 => array:2 [ "identificador" => "ceabs40" "titulo" => "RESULT" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "f1-cln64_8p815" "etiqueta" => "Figure 1(A–F)" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1666 "Ancho" => 2022 "Tamanyo" => 462386 ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of surgical steps</p>" ] ] 1 => array:7 [ "identificador" => "f2-cln64_8p815" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 789 "Ancho" => 993 "Tamanyo" => 161272 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Distal end of graft, ready for anastomosis with bridging vessel</p>" ] ] 2 => array:7 [ "identificador" => "f3-cln64_8p815" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 711 "Ancho" => 993 "Tamanyo" => 115903 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">PTFE tube implanted in the distal end of the aortic graft (simulating a saphenous graft) resulting in a composite graft with a homogenous diameter</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term serial angiographic studies after coronary artery bypass surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ DF Guthaner \n \t\t\t\t\t\t\t\t """ 1 => """ EW Robert \n \t\t\t\t\t\t\t\t """ 2 => """ EL Alderman \n \t\t\t\t\t\t\t\t """ 3 => """ L Wexler \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.cir.60.2.250" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1979" "volumen" => "60" "paginaInicial" => "250" "paginaFinal" => "259" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/312703" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Analysis of blood flow in an out-of-plane CABG model" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ M Sankaranarayanan \n \t\t\t\t\t\t\t\t """ 1 => """ DN Ghista \n \t\t\t\t\t\t\t\t """ 2 => """ LP Chua \n \t\t\t\t\t\t\t\t """ 3 => """ YS Tan \n \t\t\t\t\t\t\t\t """ 4 => """ GS Kassab \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/ajpheart.01347.2005" "Revista" => array:6 [ "tituloSerie" => "Am J Physiol Heart Circ Physiol" "fecha" => "2006" "volumen" => "291" "paginaInicial" => "H283" "paginaFinal" => "H295" "link" => array:1 [ 0 => array:2 [ "url" => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 18 | 20 | 38 |
| 2024 September | 24 | 16 | 40 |
| 2024 August | 21 | 13 | 34 |
| 2024 July | 14 | 14 | 28 |
| 2024 June | 23 | 12 | 35 |
| 2024 May | 47 | 13 | 60 |
| 2024 April | 32 | 8 | 40 |
| 2024 March | 19 | 16 | 35 |
| 2024 February | 9 | 15 | 24 |
| 2024 January | 17 | 8 | 25 |
| 2023 December | 11 | 18 | 29 |
| 2023 November | 18 | 21 | 39 |
| 2023 October | 11 | 24 | 35 |
| 2023 September | 20 | 12 | 32 |
| 2023 August | 6 | 2 | 8 |
| 2023 July | 11 | 9 | 20 |
| 2023 June | 12 | 5 | 17 |
| 2023 May | 44 | 1 | 45 |
| 2023 April | 31 | 4 | 35 |
| 2023 March | 27 | 1 | 28 |
| 2023 February | 8 | 10 | 18 |
| 2023 January | 4 | 1 | 5 |
| 2022 December | 4 | 1 | 5 |
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