title: Predictors of early graft failure after coronary artery bypass grafting for chronic total occlusion.
abstract: Little is known regarding the transit-time flow measurement (TTFM) variables in grafts anastomosed to chronically totally occluded vessels (CTOs). We aimed to establish the TTFM cut-off values for detecting graft failure in bypass grafts anastomosed to chronically totally occluded arteries and clarify the relationship between early graft failure and the grade of collateral circulation/regional wall motion of the CTO territory.
  
  
  
  Among 491 patients who underwent isolated coronary artery bypass grafting (CABG) from 2009 to 2015, 196 cases with CTOs underwent postoperative coronary angiography within 1 month after CABG. Two hundred and forty-one CTOs in all patients were examined. Thirty-two CTOs (13%) were not bypassed and 214 conduits were anastomosed to CTOs and underwent intraoperative TTFM. Arterial conduits and saphenous vein grafts (SVGs) were used in 102 and 112 cases, respectively. Among the arterial conduit procedures that were performed, 78 involved the left internal thoracic artery (LITA), 10 involved the right internal thoracic artery (RITA) and 14 involved the right gastroepiploic artery (rGEA). Any graft showing Fitzgibbon type B or O lesions on angiography was considered to be a failing graft.
  
  
  
  The insufficiency rates for LITA, RITA, rGEA and SVG procedures were 5.1, 10, 14.3 and 7.1%, respectively. The TTFM variables recorded in failing grafts had a significantly lower mean flow (Qmean) and higher pulsatility index (PI) compared with patent grafts. Furthermore, akinetic or dyskinetic wall motion in the territory of bypassed CTOs was observed at a significantly higher rate in failing grafts. A multivariable regression analysis and receiver operating characteristic analysis revealed good predictors of early graft failure as follows: a Qmean value of < 11.5 ml/min for arterial conduits, a PI value of >5.85 and akinetic/dyskinetic wall motion in the CTO territory for SVGs. The Rentrop collateral grade was not associated with early graft failure.
  
  
  
  The Qmean value and PI value by the TTFM are useful to detect early graft failure in conduits anastomosed to CTOs. The collateral grade is not associated with graft failure; however, bypass grafting to CTOs with akinetic/dyskinetic wall motion should be carefully considered.
authors.affiliation: Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan hoshima@med.nagoya-u.ac.jp.
authors.forename: Hideki
authors.initials: H
authors.lastname: Oshima
authors.affiliation: Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Tokuda
authors.affiliation: Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Yoshimori
authors.initials: Y
authors.lastname: Araki
authors.affiliation: Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Ishii
authors.affiliation: Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Toyoaki
authors.initials: T
authors.lastname: Murohara
authors.affiliation: Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan.
authors.forename: Yukio
authors.initials: Y
authors.lastname: Ozaki
authors.affiliation: Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Akihiko
authors.initials: A
authors.lastname: Usui
mesh_terms: D000368:Aged; D003097:Collateral Circulation; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000379:methods; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D024405:Gastroepiploic Artery / Q000637:transplantation; D006085:Graft Survival; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency
keywords: Chronic total occlusion; Coronary artery bypass grafting; Graft failure; Rentrop collateral grade; Transit-time flow measurement