[HSF] DES-SVG anastomosis

[Tea Acuff]

Mladen,

Thank you for sharing your experience and your thoughts about it.
tea



----- Original Message ----
From: Mladen Kocica <kocica at sezampro.yu>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, March 19, 2008 9:23:48 PM
Subject: RE: [HSF] DES-SVG anastomosis

Thory, I completely agree with your thoughts. As a matter of fact, I think
that this inflammation was the main reason for such rapid deterioration of
cath findings, producing a really "untouchable" LAD. Also, I know there are
some reports (although rare) of endarterectomies with stents (I suppose BMS)
included, but this one was not of that kind. It became a strut within
amorphous mass of fibrous tissue, without any possibility to imagine a kind
of dissection cleavage plan, for endarterectomy. The only "good" thing,
resulting from this distal inflammation (affecting not only target vessel,
but also the other coronary aretries!) was the "quality" (i.e. thickness) of
adventitial layer, which was quite good to sew through. In conclusion -
post-stenting-inflammatory response of coronary tree is not any kind of
fairy-tale, but reality. Intensity of it, probably varies from patient to
patient, but this is something that both cardiologists and surgeons must take
into account, while speaking about "miracles" of stenting.
I agree about antithrombotic treatment. My rationale was: to cover both
patelets - with aspirin (checking its efficiency with PFA100 test which is
our routine) and fibrin - with heparin (initially) and OAT (later) - because
this "anatomy" is neither "arterial" nor "venous" path, so I want to cover
both predominant mechanisms of thrombogenesis (if it is possible).
Finally - I would like to emphasize again that this case was not presented as
a kind of "template" - but rather as cardiological "candied camera". My
serious proposal would be to start thinking that such cases (if they survive
stents) would be a kind of our future. Therefore, I think its usefull to
think about some "strategy" for stented and diseased vessels (particularly
LAD) in advance. My modest opinion is that we sould start thinking about
revival of open endarterectomy, with as much improvements as possible (both
in surgical technique and postoperative protection and preservation of
reconstructed vessel patency). If cardiac surgeons share this opinion, I will
be very happy. Also, I have to admit that I feel a kind of "nasty" because I
will use the pictures with SVG sewed to stent whenever I want to decrease
gastric pH of interventional cardiologists;).

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Tohru Asai
Sent: Thursday, March 20, 2008 2:44 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] DES-SVG anastomosis


Mladen
A Brave man! I have occasionally encountered multistent cases for CABG. As
Igor mentioned, I also stay away from stented sites and grafting distals with
arterial sequential anastomoses. The advantage of arterial graftings is lower
rate of thrombotic occlusion no matter how small target vessels are. The only
occasion I would use vein grafts is mildly stenotic stented vessel, which is
really a pain in the ass. Maybe I should pinch stent with needle-holders or
something to make real stenosis.

One important thing I found in OR with these cases is the strange quality of
distal target sites. The target artery is not only small in caliber but the
vessel wall appeared to be inflammed or thickened almost always. And
perivascular tissue looks edematous or inflammed as well. Usually I need
extreme concentration and care to construct anastomoses compared to ordinary
cases. Does anybody agree with my impression?

Like Don said, Aspirin in the early postoperative phase may not be as
effective as in preoperative period due to resistance. Additional medications
such as Plavix or even Warfarin should be added.

As we discussed in the thread "Full Metal Jacket", my strategy is
multiarterial sequentials into the distal sites in off-pump fashion. And
early postop validation with MDCT and/or angiograms. Outcomes have been so
far so good. Obviously these are different kind of patients group.
--
Tohru Asai


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