Internal thoracic artery malperfusion: fast decision for an additional vein graft has impact on patient outcome.

Background: Internal thoracic artery (ITA) malperfusion has been described as a potentially devastating and lethal complication of coronary artery bypass grafting (CABG). It is our practice to perform an additional vein graft to the distal left anterior descending (LAD) artery in such cases.
Methods: From August 1999 to July 2002, 2877 CABG procedures were performed at our institution. In 65 patients (2.3%) ITA malperfusion was observed. All of them were treated with an additional vein graft to the distal LAD. All patient data were screened for the time interval between the occurrence of ITA malperfusion and the decision to perform an additional vein graft.
Results: Of 65 patients with ITA malperfusion, 54 patients (83%) survived (group 1), 11 patients (17%) died (group 2). There was no difference in preoperative risk status between the groups. Cross clamp time was 88 +/- 4 minutes in group 1 and 104 +/- 11 minutes in group 2 (p = 0.04). Intraoperative ITA flow to LAD was 6 +/- 1 mL/min in group 1 and 10 +/- 5 mL/min in group 2 (p = 0.2). Time between release of cross clamp and second period of cross clamping was 50 +/- 5 minutes in group 1 and 75 +/- 11 minute group 2 (p = 0.02). Time between termination of cardiopulmonary bypass (CPB) and second period of cross clamping was 23 +/- 3 minutes in group 1 and 46 +/- 7 minutes in group 2 (p = 0.003). Vein graft flow to distal LAD was 54 +/- 4 mL/min in group 1 and 52 +/- 12 mL/min in group 2 (p = 0.5). Maximum postoperative troponin I was 35 +/- 11 ng/mL in group 1 and 136 +/- 32 in group 2 (p = 0.003).
Conclusions: Survivors of ITA malperfusion had shorter cross clamp times and less myocardial damage as evidenced by lower postoperative troponin I levels. Time intervals between first and second cross clamp and between termination of CPB and second cross clamp were lower in survivors, thus indicating that a fast decision for an additional vein graft may influence postoperative patient outcome.