Transit-time flowmetry measurement features of coronary bypass grafts after multiple percutaneous coronary interventions

The functionality of coronary bypass grafts after surgical myocardial revascularization in patients with coronary heart disease directly depends on the state of the target coronary arteries. In the presence of widespread and diff use atherosclerotic lesions or microcirculatory dysfunctions, a high frequency of coronary bypass dysfunctions is noted in the near future. In some cases, shunt dysfunction can lead to severe hemodynamic instability, accompanied by acute circulatory disorders.

Aim: To assess the function of coronary bypass grafts during myocardial revascularization using the method of ultrasonic flowmetry in patients with and without a history of multiple percutaneous coronary interventions (PCI).

Material and methods. The retrospective study included 47 patients who underwent coronary artery bypass surgery. A total of 145 coronary bypass grafts were performed. All patients were divided into 2 groups. Group 1 (PCI group) included patients after multiple previous PCI (n = 25; 74 coronary bypass grafts), group 2 (without PCI) included patients without previous PCI (n = 22; 71 coronary bypass grafts). All patients underwent intraoperative ultrasonic flowmetry of coronary bypass grafts using the VeriQ system (Medistim, Norway).

Results. When analyzing the status of coronary bypass grafts in patients after multiple PCI, a significantly low mean volumetric blood flow rate was noted (29.5 ± 8.3 ml/min and 48.2 ± 11.6 ml/min, respectively, p = 0.0001) and lower diastolic filling (55.2 ± 8.2% and 71.9 ± 7.1%, p = 0.0001). Also in the group of patients after multiple PCI, there were 2 (2.7%) cases of revision of the distal anastomosis due to a high pulsatile index and low volumetric blood flow velocity. However, no such events were noted in the group without PCI.

Conclusions. Previous percutaneous coronary interventions are compromising factors for the state of the coronary bed, which reduces the functional status of coronary bypass grafts and may increase the perioperative risk of surgical myocardial revascularization.

1. Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U. et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40(2):87–165. DOI: 10.1093/eurheartj/ehy394.

2. Hakamada K., Sakaguchi G., Marui A., Arai Y., Nagasawa A., Tsumaru S. et al. Effect of multiple prior percutaneous coronary interventions on out-comes after coronary artery bypass grafting. Circ. J. 2021;85(6):850–856. DOI: 10.1253/circj.CJ-20-0421.

3. O’Brien S.M., Feng L., He X. Xian Y., Jacobs J.P., Badhwar V. et al.; The Society of Thoracic Surgeons 2018. Adult Cardiac Surgery Risk Models: Part 2 – Statistical methods and results. Ann. Thorac. Surg. 2018;105(5):1419–1428. DOI: 10.1016/j.athoracsur.2018.03.003.

4. Schram H.C.F., Hemradj V.V., Hermanides R.S., Kedhi E., Ottervanger J.P. Zwolle Myocardial Infarction Study Group. Coronary artery ectasia, an independent predictor of no-reflow after primary PCI for ST-elevation myocardial infarction. Int. J. Cardiol. 2018;265:12–17. DOI: 10.1016/j.ijcard.2018.04.120.

5. Plass Ch.A., Sabdyusheva-Litschauer I., Bernhart A., Samaha E., Petnehazy O., Szentirmai E. et al. Time course of endothelium-dependent and-independent coronary vasomotor response to coronary balloons and stents. JACC Cardiovasc. Interv. 2012;5(7):741–751. DOI: 10.1016/j.jcin.2012.03.021.

6. Gaba P., Gersh B.J., Ali Z.A., Moses J.W., Stone G.W. Complete versus incomplete coronary revascularization: definitions, assessment and out-comes. Nat. Rev. Cardiol. 2021;18(3):155–168. DOI: 10.1038/s41569-020-00457-5.

7. Zhao D.X., Leacche M., Balaguer J.M., Boudoulas K.D., Damp J.A., Greelish J.P. et al. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J. Am. Coll. Cardiol. 2009;53(3):232–241. DOI: 10.1016/j.jacc.2008.10.011.

8. Thielmann M., Massoudy P., Jaeger B.R., Neuhauser M., Marggraf G., Sack S. et al. Emergency re-revascularization with percutaneous coronary intervention, reoperation, or conservative treatment in patients with acute perioperative graft failure following coronary artery bypass surgery. Eur. J. Cardiothorac. Surg. 2006;30(1):117–125. DOI: 10.1016/j.ejcts.2006.03.062.

9. Niclauss L. Techniques and standards in intraoperative graft verification by transit time flow measurement after coronary artery bypass graft surgery: a critical review. Eur. J. Cardiothorac. Surg. 2016;51(1):26–33. DOI: 10.1093/ejcts/ezw203.

10. Honda K., Okamura Y., Nishimura Y., Uchita S., Yuzaki M., Kaneko M. et al. Graft flow assessment using a transit time flow meter in fractional flow reserve–guided coronary artery bypass surgery. J. Thorac. Cardiovasc. Surg. 2015;149(6):1622–1628. DOI: 10.1016/j.jtcvs.2015.02.050.

11. Crea F., Bairey Merz C.N., Beltrame J.F., Berry C., Camici P.G., Kaski J.C. et al. Mechanisms and diagnostic evaluation of persistent or recurrent angina following percutaneous coronary revascularization. Eur. Heart J. 2019;40(29):2455–2462. DOI: 10.1093/eurheartj/ehy857.

12. Selvanayagam J.B., Cheng A.S., Jerosch-Herold M., Rahimi K., Porto I., van Gaal W. et al. Effect of distal embolization on myocardial perfusion reserve after percutaneous coronary intervention: a quantitative magnetic resonance perfusion study. Circulation. 2007;116(13):1458–1464. DOI: 10.1161/CIRCULATIONAHA. 106.671909.

13. Todorov S.S., Deribas V.Yu., Kazmin A.S., Todorov (jr.) S.S. Morphological and molecular biological changes in the coronary arteries after stenting. Cardiology. 2021;61(7):79–84. (In Russ.) DOI: 10.18087/cardio.2021.7.n1211.

14. Zatolokin V.V., Vechersky Yu.V., Manvelyan D.V., Afanasieva N.L. Optimized technique for intraoperative graft verification by ultrasonic flowmetry during coronary artery bypass surgery. The Siberian Journal of Clinical and Experimental Medicine. 2021;36(1):92–100. (In Russ.) DOI: 10.29001/2073-8552-2021-36-1-92-100.