[HSF] To "T" or not to "T"
Tea Acuff
tacuff at swbell.net
Fri Jan 4 16:22:19 EST 2008
Which do you think was the "operative" variable?
;)
tea
----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, January 2, 2008 2:54:16 AM
Subject: Re: [HSF] To "T" or not to "T"
There was the French study EPPAC 1991, which looked at the use Vit K
A + persantin and Vit K A without persantin. Rates were pretty grim!
>I think there was data to show that adding coumadin did not actually help in
>early vein graft closure and the only thing that really helped was Aspirin
>within 6 hours of surgery.
>Prasanna
>
>On Dec 19, 2007 3:21 AM, Zhandong Zhou <zzhoumd at pol.net> wrote:
>
>>
>> The early vein graft failures are usually due to poor vein quality,
>> kinking or slow blood flow which forms thrombus inside the vein. You do not
>> usually see thrombus inside arterial graft. Kinking is also less common with
>> arterial graft. I think coumadin is better than plavix in preventing vein
>> graft closure in early post op period.
>>
>> Z Zhou
>>
>>
>> ----- Original Message -----
>> From: "Tea Acuff" <tacuff at swbell.net>
>> To: <OpenHeart-L at lists.hsforum.com>
>> Sent: Monday, December 17, 2007 2:46 PM
>> Subject: Re: [HSF] To "T" or not to "T"
>>
>>
>> > How is this different than the "causes" we place on Vein graft failure?
>> >
>> > tea
>> >
>> >
>> > ----- Original Message ----
>> > From: "zzhoumd at pol.net" <zzhoumd at pol.net>
>> > To: OpenHeart-L at lists.hsforum.com
>> > Sent: Monday, December 17, 2007 6:45:38 AM
>> > Subject: Re: [HSF] To "T" or not to "T"
>> >
>> >
>> > In my experience and talk to the interventional cardiologists, arterial
>> graft failure is mainly due to technical failure or competitive flow. If one
>> branch become string, there is a reason for it.
>> >
>> > Z Zhou
>> >
>> > Sent via BlackBerry by AT&T
>> >
>> > -----Original Message-----
>> > From: Donald Ross <donross at bigpond.com>
>> >
>> > Date: Mon, 17 Dec 2007 15:54:01
>> > To:OpenHeart-L at lists.hsforum.com
>> > Subject: Re: [HSF] To "T" or not to "T"
>> >
>> >
>> > Tea,
>> > For the LAD I use a SVG form the aorta ( non-clamped of course) and
>> > for other arteries I mostly don't graft if the lesion looks like it
>> > would be amenable to stenting should it cause trouble in the future.
>> > Don
>> >
>> > On 17/12/2007, at 3:34 PM, Tea Acuff wrote:
>> >
>> >> 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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>
>
>--
>Prasanna Simha M
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Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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