J Thorac Cardiovasc Surg 1999;117:1226-1227
© 1999 Mosby, Inc.
Reply to the Editor:
Antonio Maria Calafiore
Department of Cardiac Surgery
San Camillo de' Lellis Hospital
ViaForlanini 50
Chieti 66100, Italy
The relatively high number of patients with multiple-vessel diseasein the population that underwent single LAD grafting described in our recentarticle (J Thorac Cardiovasc Surg 1998;115:763-71) disturbed more than onesurgeon. The idea to leave a diseased coronary vessel ungrafted seems to bea strategic mistake.
However, the inclusion of this "very select group" of patientsdepends on the definition of "diseased vessel" and of "completerevascularization."
My definition of "diseased vessel" is the following: A vesselis considered "diseased" if it is the main vessel of the territoryor if a side branch of it is occluded or if it has a lesion equal to or greaterthan 70%. If a circumflex artery or a right coronary artery has a short andsmall posterolateral branch with such lesions, the circumflex artery or theright coronary artery has to be defined as "diseased." In Fig1, a coronary angiogram is shown in which the LAD has severe disease; thehuge marginal branch is free of significant lesions, but the distal circumflexartery shows a severe stenosis followed by a small terminal branch. This patient has 2-vessel disease,but I would never graft this small branch which, in my opinion, has no influenceon the patient's future. I certainly would never use cardiopulmonary bypassfor such a purpose.
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Fig. 1 Coronary angiogram showing a severelydiseased LAD. The huge marginal branch is free of significant lesions, butthe distal circumflex artery shows a severe stenosis followed by a small terminalbranch.
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The concept of "complete revascularization" needs a morethorough analysis. If with this term we mean that any lesion that causes ischemiato the patient should be grafted, I fully agree. If this definition also includesthe necessity to graft major and important coronary vessels supplying a hugeterritory and with a significant (
70%) lesion, even if there is no clearlydemonstrated ischemia, when concomitant grafting to other surely ischemicterritories is performed, I fully agree. But if with this term we state thatany stenotic vessel has to be grafted, regardless of its importance and size,without any demonstration of ischemia in the territory, this definition of"complete revascularization" has to be forgotten. Today we haveat our disposition many tools to properly investigate the importance of astenosis, and complete revascularization (interventional, surgical, or combined)of all ischemic territories is always our goal. However, the timing can changeand the strategy can differ from patient to patient.
In our article I thought that the real problem was focused not on thesurgical indication (single LAD disease or multiple-vessel disease), whichcan be debatable, but on the future of the graft. (Is this approach able toguarantee satisfying permeability of the graft? Can this strategy be consideredsafe and reproducible?) For this reason I mixed all my patients, but the patientswith "multiple-vessel disease" in this group, with only a fewexceptions (hybrid procedures), are not the same patients we operate on everyday in our daily practice.
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