title: Predictors and prevention of flow insufficiency due to limited flow demand.
abstract: BACKGROUND
  We investigated the impacts of flow demand and native coronary stenosis on graft flow and patency.
  
  
  METHODS
  We reviewed the angiograms of 549 bypass grafts in 301 patients who underwent off-pump coronary artery bypass grafting since 2007. Grafts consisted of 237 internal thoracic artery to left anterior descending artery; 97 internal thoracic artery and 52 saphenous vein grafts to left circumflex artery; and 109 gastroepiploic artery and 54 saphenous vein grafts to right coronary artery. We selected only individual bypass grafts created as the sole bypass graft to the coronary vascular region. Flow insufficiency was defined as ≤ 20 ml/min measured intraoperatively. When a significant difference in the incidence of flow insufficiency or "not functional" occurred between higher and lower values rather than the particular minimal luminal diameter value, the highest value was defined as the cut-off minimal luminal diameter. Distal lesions were defined as stenosis at segment #4, 7, 8, 12, 13, 14, or 15.
  
  
  RESULTS
  Flow insufficiency was found in 112/549 (20.4%) bypass grafts. For internal thoracic artery to left circumflex artery grafts, the cut-off minimal luminal diameter for proximal and distal lesions was 1.25 mm and 0.75 mm, respectively. For gastroepiploic artery to right coronary artery grafts, the cut-off minimal luminal diameter was 0.82 mm for proximal lesions (p = 0.005), while 10 (71%) of 14 gastroepiploic artery grafts for distal lesions presented with flow insufficiency. Univariate and multivariate analysis identified a distal lesion (odds ratio (OR): 3.12, p < 0.0001); minimal luminal diameter greater than the cut-off value (OR: 3.64, p < 0.0001); right coronary artery (OR: 18.2, p = 0.0002) and left circumflex artery (OR; 2.29, p = 0.009) grafting; and a history of myocardial infarction in the grafted region (OR: 2.21, p = 0.02) as significant predictors of flow insufficiency.
  
  
  CONCLUSIONS
  Both competitive flow and insufficient flow demand cause graft failure. For distal lesions, more severe stenosis is necessary to avoid graft failure, compared with proximal lesions. A revascularization strategy for distal lesions should be discussed separately from that for proximal lesions.
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. hn00504@ybb.ne.jp.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Nakajima
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. iguchi27@saitama-med.ac.jp.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Iguchi
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. m_tabata@saitama-med.ac.jp.
authors.forename: Mimiko
authors.initials: M
authors.lastname: Tabata
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. hkoike@saitama-med.ac.jp.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Koike
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. komorita@saitama-med.ac.jp.
authors.forename: Kozo
authors.initials: K
authors.lastname: Morita
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. ken_t10@saitama-med.ac.jp.
authors.forename: Ken
authors.initials: K
authors.lastname: Takahashi
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. tasakura@saitama-med.ac.jp.
authors.forename: Toshihisa
authors.initials: T
authors.lastname: Asakura
authors.affiliation: The Department of Cardiology, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. snishi@saitama-med.ac.jp.
authors.forename: Shigeyuki
authors.initials: S
authors.lastname: Nishimura
authors.affiliation: The Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan. hniinami@saitama-med.ac.jp.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Niinami
mesh_terms: D000368:Aged; D017023:Coronary Angiography; D047549:Coronary Artery Bypass, Off-Pump; D023903:Coronary Restenosis / Q000000981:diagnostic imaging* / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D012501:Saphenous Vein / Q000000981:diagnostic imaging*; D014654:Vascular Patency