Patrick Chenu

Coronary artery bypass grafting with the inferior epigastric artery. Midterm clinical and angiographic results.

Between December 1988 and September 1993, 157 patients (141 men, 16 women, average age 60.2 years, range 37 to 78 years) underwent a complete myocardial revascularization with 157 inferior epigastric artery grafts and 285 internal mammary artery grafts (281 in situ, 4 free grafts). A total of 543 distal arterial anastomoses (average 3.4, range two to five per patient) were constructed, 376 with the internal mammary artery and 167 with the inferior epigastric artery. The inferior epigastric artery grafts were anastomosed to two left anterior descending, 5 diagonal, 34 circumflex, and 126 right coronary arteries. The indications for the use of the inferior epigastric artery were the unavailability of conventional conduits in 56 patients and a favorable anatomy or a young age in 101 selected patients. The clinical follow-up averages 31.8 months (range 6 to 62 months). Four patients died early, and there were three perioperative nonfatal myocardial infarctions. Eight patients required early reoperation for thoracic bleeding (2) or drainage of an abdominal parietal collection (6). There were four late deaths (2 sudden deaths, 2 noncardiac causes) and one nonfatal myocardial infarction. Angina recurred in nine patients, of whom one required reoperation and three underwent successful percutaneous balloon angioplasty of a native coronary artery (2) or an old saphenous vein graft (1). An early recatheterization was obtained before discharge (average 11 days) in 135 patients: 132 of 135 inferior epigastric artery grafts were patent. Seventy-seven patients underwent a second angiographic restudy 6 to 43 months after the operation. Forty-four of the 48 inferior epigastric artery grafts restudied within the first postoperative year (average 8.5 months) were patent, but eight showed a diffuse narrowing. Twenty-eight of the 29 inferior epigastric artery grafts examined angiographically between 13 and 43 months (average 25 months) were open, and among those 29, 25 were widely patent, perfectly matching the receiving coronary artery. Most of the occluded or narrowed inferior epigastric artery grafts were grafted onto coronary arteries with mild stenosis at restudy. Five patients underwent a third angiographic reexamination up to 60 months after the operation (average 39 months). All five inferior epigastric artery grafts were widely patent. The early attrition rate of the inferior epigastric artery, as for any free arterial graft, is probably the result of both the loss of a true pedicle and the need for constructing an additional proximal anastomosis. The fact that the patency rate of the inferior epigastric artery graft seems to remain stable beyond 1 year could suggest a good durability in the future.

Long-term Outcome of Patients With Asymptomatic Restenosis After Percutaneous Transluminal Coronary Angioplasty

Restenosis with recurrence of symptoms after percutaneous transluminal coronary angioplasty (PTCA) is treated in most cases by a second successful PTCA. In the case of silent restenosis in a patient previously symptomatic, the problem is less clear. Previous reports with a mean follow-up of <18 months have suggested that the prognosis of these asymptomatic patients is favorable.

Revascularization of the circumflex artery with the pedicled right internal thoracic artery: Clinical functional and angiographic midterm results☆☆☆★★★♢♢♢♦

Retroaortic crossing of the pedicled right internal thoracic artery for revascularization of the circumflex artery used in combination with a pedicled left internal thoracic artery anastomosed to the left anterior descending artery and its branches is an attractive technique to achieve an extensive arterial revascularization of the left ventricle. However, there is a suspicion that pulling the right internal thoracic artery through the transverse sinus could compromise its blood flow capacity and patency. Between January 1990 and July 1994 this technique was applied in 256 patients (202 men, 54 women; average age 62 years, range 31 to 80 years). Sixty-one patients had two-vessel disease and 195 had three-vessel disease. Seventeen patients were undergoing a reoperation. Twenty-two had a left ventricular ejection fraction of 40% or less. Thirty had diabetes. Twenty-eight had morbid obesity. The right internal thoracic artery was directed to the circumflex artery (259 anastomoses) through the transverse sinus and the left internal thoracic artery was anastomosed to the left anterior descending artery and its branches (375 anastomoses) in all patients. The 195 patients with three-vessel disease received additional coronary artery bypass grafts to the right coronary artery (93 saphenous vein grafts, 89 free inferior epigastric artery grafts, 12 pedicled right gastroepiploic artery grafts). In total, the 256 patients received 833 distal anastomoses (average 3.2, maximum 5 per patient) and 634 distal anastomoses were internal thoracic artery anastomoses (average 2.4, maximum 4 per patient). Three patients died early and eight had a nonfatal myocardial infarction. Seven patients needed postoperative intraaortic balloon pump support. Six patients underwent early reoperation because of excessive bleeding. Sternal dehiscence occurred in four patients. One of these four patients died of the complication 10 months after the operation. No patient was lost to follow-up (average 33 months). During follow-up, two sudden deaths and six noncardiac deaths occurred. Two patients had a nonfatal myocardial infarction and 12 had recurrence of angina. There were no late reoperations. One patient underwent a successful percutaneous balloon angioplasty of a native left anterior descending artery. Seventy-four patients, enrolled in prospective angiographic studies, underwent a postoperative recatheterization (average 13.2 months, range 6 to 58 months). Seventy-three of the 74 right internal thoracic artery grafts were patent. In comparison, 74 of 74 of the left internal thoracic artery grafts (106/107 anastomoses) were patent. Maximal stress thallium-201 scintigraphy results, obtained in 25 of those patients, did not reveal ischemia in the area of the circumflex artery.(ABSTRACT TRUNCATED AT 400 WORDS)

Noninvasive Functional Assessment of Left Internal Mammary Artery Grafts by Transcutaneous Doppler Echocardiography

A noninvasive method to assess left internal mammary artery (LIMA) patency and function would be useful because this vessel is frequently used for revascularization of the left anterior descending coronary artery. The purpose of this study was to assess the feasibility of measuring changes in LIMA velocities by transcutaneous Doppler during dipyridamole-induced vasodilation. Twenty-five patients with a LIMA graft anastomosed to the left anterior descending coronary artery were studied at least 1 month after surgery by the use of a 5 MHz transducer placed in the left supraclavicular fossa. Doppler velocity parameters were measured at baseline and after intravenous administration of dipyridamole. Dipyridamole increased mean velocity by 127% +/- 54% (p < 0.001), systolodiastolic velocity time integral by 89% +/- 31% (p < 0.001), and diastolic-to-systolic peak velocity ratio from 0.7 +/- 0.3 to 1.2 +/- 0.4 (p < 0.001). The dipyridamole-to-baseline mean velocity ratio was 2.3 +/- 0.5. We conclude that it is possible to measure dipyridamole-induced changes in LIMA flow velocities and thus obtain an index of LIMA blood velocity reserve by transcutaneous Doppler echocardiography.

Is provisional stenting the effective option? The WIDEST study (Wiktor stent in de novo stenosis)

AIM To compare the immediate and late outcomes of patients treated by a policy of routine stent implantation with routine balloon angioplasty and the use of stents only when an ideal result has not been obtained. METHODS A nine centre, multinational, randomised study of 300 patients with coronary artery disease thought suitable for treatment of a single lesion by balloon angioplasty or stent implantation. Only new lesions in patients who had not undergone previous bypass surgery were included, and totally occluded vessels were excluded. RESULTS The initial procedure was considered successful in 96% of patients. There was more complete angiographic restoration of luminal diameter in patients treated by elective stent (minimum lumen diameter (MLD) 2.68 mm for stentv 2.27 mm for balloon; p < 0.007), but analysis of the subgroup of balloon angioplasty patients who crossed over to stenting showed that they achieved similar results to the elective stent group. Late luminal loss was greater in stented patients than in those undergoing balloon angioplasty only, and by six months the angiographic benefit of stenting had disappeared (MLD 1.90 mm for stent group v 2.00 mm for balloon angioplasty). Angiographic and clinical results in the balloon angioplasty group were assisted by the high crossover rate (30.1%). Both groups had similar symptom relief, with 58.9% of patients improving by two or more angina grades. The need for further revascularisation was also similar in the two groups at one year (18.2% in the stented group v 17.1% in the balloon angioplasty group). Haemorrhagic complications at the local arterial entry site were more common than expected and were distributed equally between the patients receiving full anticoagulation and those receiving antiplatelet treatment only. The results of both Wiktor stent placement and balloon angioplasty were similar to the findings in the stent group in previous randomised studies (Benestent II, STRESS). CONCLUSIONS Provisional stenting appears to offer the same longer term outcome as elective stenting in this selected group of patients. Improvement in the results of conventional balloon angioplasty in the past 10 years means that a policy of obtaining an ideal result without the use of stents appears to be practicable in many of these patients, with consequent cost savings.

Adaptive mechanisms of arterial and venous coronary bypass grafts to an increase in flow demand.

OBJECTIVE To compare the mechanisms by which arterial and venous grafts increase their flow during pacing induced tachycardia, early and later after coronary bypass surgery. DESIGN 43 grafts (13 epigastric artery, 15 mammary artery, 15 saphenous vein) evaluated early (9 (3) days (mean (SD)) after bypass surgery were compared with 41 other grafts (15 epigastric, 11 mammary, 15 saphenous vein) evaluated later after surgery (mean 23 months, range 6 to 168 months) by quantitative angiography and intravascular Doppler velocity analysis during atrial pacing. Controls were 17 normal coronary arteries. RESULTS Baseline graft flow tended to be lower later after surgery than early (41 (16)v 45 (21) ml/min, NS). Blood flow increased during pacing by 30 (16)% early after surgery, less than later after surgery (+46 (18)%, p < 0.001) and less than in normal coronary arteries (+54 (27)%, p < 0.001 v early grafts; NS v late grafts). There was no difference between venous and arterial grafts. No significant vasodilatation was observed during pacing early after surgery in arterial and venous grafts. Later after surgery, significant vasodilatation was observed only in arterial grafts (mammary and epigastric grafts), from 2.41 (0.37) to 2.53 (0.41) mm (+5.1%v basal, p < 0.001). Early after surgery and in venous grafts later after surgery, the increase in flow was entirely due to an increase in velocity. In later arterial grafts, the relative contribution of the increase in velocity to the increase in flow during pacing was lower in arterial grafts (70 (22)%) than in venous grafts (102 (11)%, p < 0.001) and similar to normal coronary arteries (68 (28)%). CONCLUSIONS Early and later after surgery, arterial grafts and venous grafts both increase their flow similarly during pacing. Early arterial grafts and venous grafts increase their flow only through an increase in velocity. Later after surgery, arterial grafts act as more physiological conduits and increase their flow in the same way as normal coronary arteries, through an increase in velocity and calibre mediated by the endothelium.

Flow-mediated vasodilation during pacing of the free epigastric artery bypass graft early and late postoperatively

OBJECTIVES The free epigastric artery bypass graft is proposed as an alternative conduit to the saphenous vein graft, known for its high rate of attrition. The aim of our study was to assess its endothelial function in vivo. BACKGROUND The endothelium of arterial bypass grafts plays a role in both the performance and the patency of such grafts. METHODS We studied 73 epigastric grafts early (mean +/- SD 10 +/- 3 days) and 36 late (12 +/- 5 months) after coronary bypass surgery with quantitative angiography at rest, after 2 min of atrial pacing (130 beats/min) and after injection of isosorbide dinitrate (1 to 2 mg) into the graft. RESULTS At rest, mean epigastric graft diameter was lower in the late than in the early postoperative period (2.26 +/- 0.39 vs. 2.61 +/- 0.49 mm, p < 0.001). Early after operation, epigastric grafts with a small or an intermediate runoff, but not those with a large runoff, were capable of vasodilation with nitrates (+0.09 +/- 0.10 mm). Late after operation, vasodilation after administration of isosorbide dinitrate was similar in epigastric grafts with a large runoff and in those with a small or intermediate runoff (+ 0.23 +/- 0.09 vs. +0.23 +/- 0.18 mm). Significant vasodilation during pacing was observed late (+4 +/- 9%, p < 0.01) but not early postoperatively, except in a subset of patients with grafts capable of vasodilation after nitrates. A correlation between the response to nitrates and the response during pacing was observed early (r = 0.579, p < 0.001) and late postoperatively (r = 0.530, p = 0.02). CONCLUSIONS Flow-mediated vasodilation during pacing was observed in most epigastric grafts late, but not early, after operation. This endothelium-dependent dilation was correlated with the importance of the vasodilation observed with nitrates (endothelium-independent), which was related to the importance of the runoff only in the early postoperative period. The ability of epigastric grafts late postoperatively to dynamically adapt their dimensions to an acute increase in demand could contribute to the good functional results of this new alternative arterial graft.

The STIB score: a simple clinical test to predict clopidogrel resistance.

Background High platelet reactivity (HPR) to clopidogrel is associated with an increased risk of ischaemic complications during and after coronary interventions and concerns up to 50% of patients undergoing PCI. Aim of the study The aim of the study was to identify patients with HPR to clopidogrel using bedside clinical information obtained in the Stent Thrombosis In Belgium (STIB) trial. Methods Data on platelet reactivity using the VerifyNow® point-of-care assay were obtained in 844 patients undergoing PCI for stable coronary artery disease 12 to 24 hours after a 600-mg loading dose of clopidogrel was given. Demographic, clinical and baseline routine biological tests were obtained and compared with P2Y12 reaction units (PRU). Patients with PRU > 230 (HPR) were considered as non-responders to clopidogrel. Results HPR was observed in 424/844 pts. Age, weight, body mass index (BMI), HPR to aspirin, diabetes, renal failure (MDRD < 60 ml/min), haemoglobin (Hb), haematocrit, fi brinogen, glycaemia and glycated haemoglobin were associated with HPR to clopidogrel. In multivariate analysis, only Hb (OR: 0.77), BMI (OR: 1.06) and diabetes (OR: 1.62) emerged as independent risk factors. Hb < 13.9 g/dl, BMI > 28 kg/m2 and presence of diabetes were equally associated to predict HPR and can be added to derive a simple score to predict clopidogrel resistance. Although 38.5% of patients without a single clinical predictor still have HPR, 2/3 patients with 2 or 3 risk factors are resistant to clopidogrel. Conclusions STIB HPR score allows identifi cation of patients with a high probability of resistance to clopidogrel based on diabetes, Hb < 13.9 g/dl and BMI < 28 kg/m2. This bedside clinical test could be useful for the identifi cation of patients in whom another P2Y12 inhibitor should be recommended before and after PCI.

Unusual pitfall of use of retrograde cardioplegia.

The use of retrograde cardioplegia can lead to several complications, mainly related to injuries during the cannulation of the coronary sinus. We herein present a case report of injury to the right coronary artery related to kinking due to the pursestring on the right atrium.

RADIAL ARTERY PATENCY AFTER TRANSRADIAL ACCESS: EFFECTIVE AND EASY WAY TO REDUCE THE RADIAL ARTERY OCCLUSION RATE, RESULTS OF THE CRASOC (COMPRESSION OF RADIAL ARTERIES WITHOUT OCCLUSION) STUDY

Methods: From January 2009 to June 2011, we randomized 2107 TRA to low (13cc of air) versus ultra low (10 cc) inflation volume in the TR BandTM compression device. If bleeding occurred, 2 cc were added. After device positioning, type of compression was assessed (“patent hemostasis” or not). Compression was maintained for at least 4 hours. Radial artery patency was evaluated at 24 h by pulse oximetry during ulnar compression. Factors related to patency defined as positive pulse oximetry (PPO) were analyzed.