Sequential Bypass Grafting on the Beating Heart:
Blood Flow Characteristics
CARDIOVASCULAR
Marek Gwozdziewicz, MD, PhD, Petr Nemec, MD, PhD, Martin imek, MD,
Roman Hajek, MD, and Martin Troubil, MD
Department of Cardiac Surgery, University Hospital, Olomouc, Czech Republic
Background. The sequential bypass technique is a
routine method of myocardial revascularization. The aim
of this study was to determine flow characteristics of
individual and sequential bypass grafts created on the
beating heart.
Methods. Between January 2003 and February 2004, a
consecutive series of 50 patients underwent off-pump
coronary bypass surgery with at least one venous sequen-
tial coronary graft. During the procedure, flow values and
pulsatility indexes were measured in both segments of
the sequential graft using a CardioMed transit time flow
meter (CM 4008; Medi-Stim, Oslo, Norway). The flow
values were simultaneously compared with those of
individual venous grafts sutured to the same coronary
arteries.
Results. The mean flow through the distal anastomosis
T he sequential bypass technique is a well-known
method for myocardial revascularization [13].
However, the patency of the distal end-to-side anasto-
mosis has been questioned by some authors and shown
to be inferior to that of an individual graft [4]. It has also
been shown that the off pump coronary technique can
reduce graft patency [5].
While arterial revascularization is becoming more pop-
ular in coronary surgery [6, 7], the application of the
sequential technique, which is often obligatory in com-
plete arterial revascularization, should be considered
safe.
In most of the studies comparing sequential to individ-
ual grafts, the major limiting factor was that grafts were
sutured to two different coronary territories [2]. This
study was designed to compare using intraoperative
measurement of blood flow and pulsatility index (PI)
blood flow through an individual venous bypass with
that in a distal segment of the sequential venous bypass
performed on the beating heart. The operative protocol
allowing for transformation of an individual graft to a
sequential one enabled us to quantitatively compare
these two types of bypass.
Accepted for publication Dec 20, 2005.
Address correspondence to Dr Gwozdziewicz, University Hospital Olo-
mouc, I. P. Pavlova 6, Olomouc 775 15, Czech Republic; e-mail:
gwozdziewicz@email.cz.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
(individual bypass; D1) was 37.4 mL/min, and this was
not significantly influenced by the creation of a proximal
sequential anastomosis (D2, 39.0 mL/min). In 32% of the
patients, the sequential bypass was unwittingly con-
nected proximally to a larger coronary bed; despite this,
the flow in its distal segment was not less than that in the
individual bypass.
Conclusions. The blood flow through an individual
bypass is comparable with that through the distal seg-
ment (end-to-side anastomosis) of a sequential bypass.
The grafting of a sequential bypass proximally to the
larger artery (coronary bed) in sequence does not appear
to have a significant effect on the blood flow in the distal
segment of a sequential bypass.
(Ann Thorac Surg 2006;82:620 3)
2006 by The Society of Thoracic Surgeons
Material and Methods
From January 2003 to February 2004, 841 patients with
ischemic heart disease underwent coronary surgery in
our department. An off-pump coronary bypass was per-
formed on 287 patients (34.1%), of whom 50 consecutive
patients (17.4%) had at least one venous sequential aor-
tocoronary bypass graft. This group constituted the study
cohort, and comprised 36 men (72%) and 14 women (28%)
with a mean age of 69.7 years (range, 48 to 84). The
clinical data of the patients are listed in Table 1. All
operations were performed by the same surgeon. This
study received approval from the Institutional Review
Board of University Hospital Olomouc, and informed
consent was obtained from all patients.
A median sternotomy was used for surgical access in
all cases. Systemic heparinization with 10,000 U heparin
was performed before cardiac manipulation. Hemody-
namic stability was achieved by preload management
(intravenous fluid administration or the Trendelenburg
position, or both) and with vasoactive agents when indi-
cated. The heart was stabilized using two mechanical
suction-based tissue stabilizers (Axius Vacuum 2 and
Axius Expose 3; Guidant, Santa Clara, California) and
one modified Lima pericardial traction stitch [8]. After
arteriotomy, an intraluminal shunt (Axius coronary
shunt; Guidant, or Medtronic, Minneapolis, Minnesota)
was inserted to maintain distal myocardial perfusion; it
was removed before the completion of anastomosis. After
the completion of an individual mammary-to-left ante-
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doi:10.1016/j.athoracsur.2005.12.069
Ann Thorac Surg GWOZDZIEWICZ ET AL 621
2006;82:620 3 OPCABG SEQUENTIAL CORONARY BYPASS

Table 1. Clinical Profile of Patients surements were repeated after the administration of 6 mg
saline-diluted papaverine (p) into the graft when the
No. (%) of
Variable Patients maximal flow (D1p, D2p, Pp, Tp) was estimated. This
provided assessment of the flow reserve. To test the
Coronary artery disease quality of the sutured anastomoses, in addition to flow

CARDIOVASCULAR
Left main 11 (22) measurement, PIs were recorded [9, 10]. The PI equals
Triple vessel 40 (80) the difference between the maximum (systolic) and min-
Hypertension 41 (82) imum (diastolic) blood flows divided by the mean flow,
Hyperlipidemia 29 (58) and its value should not exceed 5.0, in the case of a
Diabetes mellitus 22 (44) well-constructed bypass [10].
Stroke 7 (14) For each recording, attempts were made to maintain
Obesity 10 (20) the mean arterial pressure at 70 mm Hg.
Previous percutaneous coronary 4 (8) The recorded data were statistically analyzed using
intervention Statistica 6.0 software (StatSoft, Tulsa, Oklahoma). The
Left ventricular ejection fraction 52% (30%65%) recorded variables were compared using analysis of
variance (ANOVA) for dependent measurements, and
pairs of flow values and PIs were subsequently tested
rior descending artery (LAD) bypass, the construction of using Scheffes test. Differences among the pairs were
a venous sequential graft was commenced. assessed by the Sign test. Correlations between variables
To create an individual venous aortocoronary bypass, a were evaluated by Pearsons correlation coefficient.
distal (end-to-side) coronary anastomosis was per-
formed, followed by a proximal vein-to-ascending aorta
Results
anastomosis. At the same time, the first measurement
(D1) of coronary flow through the distal anastomosis A mean of 3.6 grafts per patient were completed in our 50
(individual bypass) was made using the CardioMed tran- patients. All grafted vessels had significant (70%) prox-
sit time flow meter (CM 4008; Medi-Stim, Oslo, Norway imal stenosis. Because both an individual bypass and the
[Fig 1]). distal segment of a sequential graft were anastomosed to
The operation continued with suturing of the proximal, the same coronary arteries, no attempt was made to
sequential, side-to-side anastomosis to another coronary statistically evaluate the effect of the degree of stenosis or
artery. This transformed the previous individual bypass the diameter of native coronary arteries on differences in
into a sequential one. At that point, blood flow through flow.
the distal (D2) and proximal (P) anastomoses and the Each patient received an individual mammary artery-
whole sequential graft (T) was measured. All the mea- to-LAD bypass as one of the grafts. Table 2 lists the types

Fig 1. Diagrams of the flow measurements. (A) Individual graft with the measurement of the flow through the distal anastomosis (D1, D1p).
(B) Sequential bypass graft with flow measurements in the distal (D2, D2p) and proximal (P, Pp) anastomoses, and total bypass flow assess-
ment (T, Tp). The flow was recorded before and after the administration of papaverine (p). The proximal flows (P, Pp) were measured after
clamping the vein with a bulldog clamp behind the side-to-side anastomosis (not shown).
 622 GWOZDZIEWICZ ET AL Ann Thorac Surg
OPCABG SEQUENTIAL CORONARY BYPASS 2006;82:620 3

Table 2. Types of Sequential Graft Used in 50 Patients ration of the right ventricle during the intramyocardial
preparation of the LAD. One patient required repeat
No. (%) of
Coronary Arteries Patients surgery owing to bleeding. There were five wound com-
plications, two with complete sternum dehiscence. One
Circumflex and obtuse marginal 3 (6) patient suffered a mild pulmonary embolism. The post-
CARDIOVASCULAR

Circumflex and diagonal
Obtuse marginal 1 and obtuse marginal 2
Obtuse marginal and high marginal
Obtuse marginal and diagonal
Diagonal and high marginal
Posterior descending and high marginal
Posterior descending and obtuse marginal
Posterior descending and right posterolateral
Right posterolateral and obtuse marginal
of sequential bypass used. None of the sequential grafts
required revision owing to technical errors.
Table 3 lists the blood flow values in relation to
hemodynamic parameters in a group of 50 consecutive
patients. The mean flow through the distal anastomoses
(individual bypass) before papaverine administration
(D1) was 37.4 mL/min. After the creation of a proximal
side-to-side anastomosis, the blood flow through the
distal anastomosis (D2) was 39.0 mL/min (p 0.9). A
similar relationship between the groups of flow values
was found after papaverine administration (D1p and
D2p). The mean flow through the proximal anastomoses
(P) of the sequential bypass was 36.9 mL/min. The mean
total flow through the sequential graft (T) was 69.4
mL/min.
The increase in blood flow through the proximal anas-
tomosis of the sequential bypass after papaverin admin-
istration was larger than the increase in flow through its
distal anastomosis in 32% of the patients. We believe that
the measurement /degreeof the flow increase may be
related to the capacity of the coronary bed (which is
responding to papaverine) supplied by the grafted coro-
nary artery.
All PI values remained within the normal range, thus
confirming the good patency of the sutured anastomoses.
No deaths occurred in our cohort. One patient had to
be converted to the on-pump procedure owing to perfo-
5 (10) operative course in the remaining 45 patients was
6 (12) uneventful.
9 (18)
21 (42)
Comment
1 (2)
1 (2) The advantages of the sequential bypass technique over
1 (2) individual bypass conduit surgery have been reported
1 (2) previously [13].
2 (4) To assess the quality of sequential bypasses performed
on the beating heart, and to determine whether a con-
struction of a proximal side-to-side anastomosis alters
flow across the distal end-to-side anastomosis, we mea-
sured the blood flow and PI in an individual bypass, and
then in both segments of a sequential graft. An individual
bypass was first constructed using the off-pump tech-
nique, which was subsequently transformed into a se-
quential type by creating side-to-side anastomosis. That
allowed us to maintain the same pathophysiologic con-
ditions in relation to vascular resistance, which was
crucial for measuring the blood flow.
Our main goal in coronary surgery is to provide a
long-lasting reconstruction of the coronary artery system
with good graft patency. One of the recommended prin-
ciples that should guarantee good patency of sequential
grafts is suturing the last anastomosis in the sequence
onto the largest vessel (coronary bed). That was not the
case in 32% of our patients. The flow capacity of a
coronary bed observed during papaverine-induced flow
measurement was not consistent with prior angiographic
estimation in these patients. Despite this, the blood flow
in the distal segment of the sequential bypass was not
less than that in the individual bypass.
In our 50 consecutive patients, we have proved that the
flow through an individual bypass was comparable with
that through the distal segment (end-to-side anastomo-
sis) of a sequential bypass (p 0.9), and this remained
unchanged after papaverine administration. The experi-
mental studies of Rittgers and coworkers [11] and Mey-

Table 3. Blood Flow Through Anastomoses of Individual and Sequential Bypass, and Related Hemodynamic Variables in 50
Consecutive Patients
Flow SD MAP SD HR SD
(mL. min1) PI SD (mm Hg) (min1)

D1 37.4 24.6 2.5 0.9 69.2 7.8 72.5 15.4

D1p 73.2 36.4 1.5 0.4 69.2 7.4 71.8 15.9
D2 39.0 23.7 2.3 1.0 70.9 9.2 75.6 17.1
D2p 69.5 33.7 1.6 0.4 70.4 9.3 75.6 17.3
P 36.9 18.7 2.4 0.9 70.6 9.0 75.1 17.1
Pp 54.7 22.0 1.6 0.4 70.1 9.0 76.6 17.0
T 69.4 29.0 1.8 0.4 70.6 9.1 75.2 17.5
Tp 109.2 42.7 1.5 0.3 70.7 9.4 76.3 16.6

D1, D1p, D2, D2p, P, Pp, T, Tp flows through the anastomoses of the individual and sequential grafts without and with papaverine (p); HR heart
rate; MAP mean arterial pressure; mean value; PI pulsatility index.
Ann Thorac Surg
2006;82:620 3
erson and colleagues [12] have shown that it is bypass
flow (namely, the wall shear stress) that determines the
degree of intimal proliferation, which may lead to bypass
closure. Comparable blood flows through an individual
bypass with those across end-to-side anastomosis of the
sequential graft performed on a beating heart might
predict similar patency of both types of bypass.
The long-term patency of sequential off-pump by-
passes has not been reported yet. A meticulous operative
technique and intraoperative blood flow measurement in
sutured grafts may disclose the presence of insufficient
flow due to technical errors, and prevent early bypass
closure. The grafting of a sequential bypass proximally to
the larger artery in sequence does not appear to have a
significant effect on the blood flow in the distal segment
of a sequential bypass.
We gratefully acknowledge the contribution of Zdenka
Michalikov, who prepared the diagrams for this article.
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