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CARDIAC SURGERY

Improving the Quality of Coronary Bypass Surgery With Intraoperative Angiography

Validation of a New Technique

Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada

Manuscript received February 25, 2005; revised manuscript received May 16, 2005, accepted May 31, 2005.

^_* Reprint requests and correspondence: Dr. Nimesh D. Desai, Sunnybrook and Women's College HSC, Cardiac Surgery, 2075 Bayview Avenue, Room H410, Toronto, Ontario, M4N 3M5 (Email: nimesh.desai{at}utoronto.ca).

OBJECTIVES: We report a comprehensive assessment and validation of a new intraoperative angiography technique.

BACKGROUND: Technical problems at the site of the distal anastomosis compromise an underappreciated proportion of coronary bypass grafts. The absence of a systematic, validated technique to verify graft patency in the operating room represents a significant breach in quality assurance.

METHODS: Fluorescent indocyanine green (ICG) dye is excited with dispersed laser light to create an angiographic depiction of the graft, native vessel, and anastomosis. One-hundred twenty patients underwent ICG angiography. Angiograms were reviewed for reliability and validity studies.

RESULTS: A total of 348 coronary bypass grafts were studied. Each ICG angiogram took 2.2 ± 1.1 min to perform. The ICG angiography found 4.2% of patients had significant graft problems requiring major revision. Quality of visualization was rated according to a seven-point Likert scale (1 = worst, 7 = best). Among conduits, saphenous veins were best visualized (mean score ± standard deviation), 6.4 ± 1.5 versus 5.5 ± 1.9 for internal mammary arteries and 4.4 ± 2.3 for radial arteries (p = 0.02). Location of distal anastomosis did not influence quality of visualization. There was high inter-rater reliability for graft revision (kappa = 1.0) and graft patency (kappa = 0.97) between surgeons. Sensitivity and specificity of the ICG angiograms for graft stenosis >50% was 100% among 22 grafts also studied with X-ray angiography.

CONCLUSIONS: Information from ICG angiograms led to graft revisions for technical problems in 4.2% of patients that would have otherwise gone unrecognized. Intraoperative angiography is an emerging tool for improving the quality of coronary bypass surgery.

Abbreviations and Acronyms   ICG = indocyanine green   TIMI = Thrombolysis In Myocardial Infarction

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