To Achieve 100% of Intraoperative Graft Patency: Significance of Double-Check Estimation using both TTFM and SPY System
Masao Takahashi1, Keisuke Miyajima1, Hirotaro Sugiyama1, Toshihiro Ishikawa2, Kazuyoshi Hatada2.
1Hiratsuka Kyosai Heart center, Hiratsuka, Japan, 2Odawara Municipal Hospital, Odawara, Japan.
OBJECTIVE: In Japan, MIDCAB surgery was introduced in 1996, and OPCAB via median sternotomy in 1998. Back then, TTFM had been only the evaluating method for intraoperative graft patency. The SPY System, the first commercially available fluorescence angiographic device, has been introduced in our institute since 2002. Double-Check Estimation using both TTFM and SPY System was routinely performed for 15 years. METHODS:
In our institute, 100 % of isolated coronary patients was performed off pump CABG. Our basic grafting strategy are 1: LITA to LAD, 2: distal RCA grafting using SVG/RA, 3: proximal aortic anastomosis of the SVG to RCAs, 4: distal CX grafting using RA/SVG, and then 5: proximal anastomosis of the RA/SVG to CXs. Just after completion of each graft revascularization, flow measurement was performed using TTFM. After graft flow and PI were checked up, we can move to the next grafting. Even when the flow was less than 10 ml/min and/or PI was more than 5.0, we may move to the next grafting if the hemodynamics are stable. After all graft anastomoses were completed, image evaluation using SPY System is routinely performed for LAD, RCA, CX, and the proximal aortic area before Protamine administration. It takes just 3 to 5 minutes to achieve 4 times recording of SPY images. If the SPY image was unfavorable, anastomotic revision should be done. And then checkup again using both TTFM and SPY System.
Since May 2016, ICG-DIM (Indocyanine Green Direct Injection Method) has been initiated especially for the small coronary. After distal anastomosis of the free graft is completed, diluted ICG mixed with blood is injected directly into the graft while SPY is recording. RESULTS:
Even when the TTFM showed normal pattern, only SPY image could detect the graft occlusion. ICG-DIM was very useful to reveal the graft patency, especially when the target artery was very small around 1mm diameter or when the anastomosis was performed by an inexperienced resident.
Using the SPY system, technical error can be avoided intra-operatively while the chest is open. Double-Check using both TTFM and SPY may achieve higher quality control of CABG surgery.
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