[HSF] To "T" or not to "T"

[Tea Acuff]

And what do you do with other 50-75% lesions in large distribution vessels?

tea


----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, December 16, 2007 10:13:39 PM
Subject: Re: [HSF] To "T" or not to "T"

Tohru,
Nobody can argue with surgeons who has such a high incidence of early  
recaths as yourself.
However, I was intrigued by your observation that the lima to LAD was  
more likely to go down distally  if it supported a T graft.
How often do you see this and are you sure the cause wasn't a non  
significant LAD lesion?

This is an important question for me as I have put 944 arteries  onto  
the LMA as T grafts. ( 617 radials, the rest rimas )
I only get a recath if the clinical result is sub-optimal and  
fortunately that is rare. ( Usually the grafts are patent)
If, as you say, there are a lot of graft occlusions which have no  
clinical consequence then I probably have my fair share.
Hopefully they are associated with non significant lesions which  
explains my blissful ignorance.
Don


> Dave
> I appreciate your detailed comment. I agree in-situ RIMA is better  
> than RGEA
> but in-situ RIMA has limitation to reach target sites, such as PDA  
> and low
> marginals in many patients. These targets are not good for in-situ  
> RIMA but
> it consistently reaches anywhere in LAD and proximal parts of  
> marginal and
> ramus ( via oblique sinus). RIMA's patency is reported to be  
> excellent, as
> good as LIMA's, when it is used in in-situ fashion for grafting left
> coronary territories. And free RIMA is not consistently as good as  
> in-situ
> LIMA. So free RIMA branching off LIMA is not the best. I can tell  
> you that
> even I see a few cases of distal LIMA after giving RIMA off became  
> string at
> a few years after CABG. Whereas in-situ RIMA-LAD, in-situ LIMA-OM, and
> in-situ RIMA-OM are consistently good in mid and long term. This is  
> not only
> my opinion, but most Japanese surgeons ( who live in a strange  
> country) know
> it as a sort of common sense with watching many angiograms, I guess.
>
> I tell you that there were many patient recovering uneventfully  
> with their
> postop angiogram demonstrating graft occlusions! So how can you  
> know you are
> doing all right. I personally could achieve more than 95% patency  
> including
> vein graft in early postop angiograms, mostly due to avoiding
> multi-branching composite configuration.
>
> I am aware that some are concerned about RIMA crossing midline  
> anteriorly,
> but I don't mind to perform resternotomy ( actually did several  
> cases for
> redo cab, aortic arch, AVR, mitral, tricuspid cases) as long as I  
> did the
> first operation. I usually make vertical slit hole just anterior to  
> SVC to
> enter pericardial space, in-situ RIMA easily reach distal LAD  
> almost always.
> They did very well without entry problem at all in my experience.
> Surprisingly skeletonized IMA and GEA conduits looked as if they  
> had been
> harvested yesterday. I recommend you not to make y composite LIMA  
> and RIMA
> routinely. I know it is not as good as you expect from my "strange"  
> upside
> down countryman view.
>
> Problems of arterial conduits are more related to flow competition.  
> Once it
> stringed, nobody can tell that it may come back when the native  
> stenosis
> becomes critical. There are a few reports of re-growing of "string  
> sign",
> but clinically many recurred angina or MACE in real (strange) world.
>
> Only 75% stenosis of proximal RCA is not consistently good for any  
> arterial
> conduits. I had seen many early postop angiograms of shrinked RIMA,  
> RA,
> RGEA. Obviously saphenous vein is the best in the situation, unless  
> you tie
> off RCA, which I have never done.
>
> Well, my logic became too long! In summary, I often do  
> RIMA,LIMA,GEA all
> in-situ skeletonized with some sequential graftings to young but  
> severe
> diffuse 3vessel disease. SV is still useful in moderately stenotic  
> large
> target vessels or hemodynamically unstable bad urgent cases.
> ---
> Tohru
>
>
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