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ICVTS on-line discussion C The difficult question of diffuse coronary artery disease grading!

PSHC, King Fahd Medical City, Riyadh 11525, Saudi Arabia

An objective method for grading of distal disease in the grafted coronary arteries

eComment: I read with interest the paper by Dr Jalal [1]. First of all I appreciate all his efforts to come up with a solution to this difficult question of grading the diffuse coronary disease. I have a few points to make:

• The definition of diffuse coronary disease needs to be revisited; is it a diffuse non significant distal narrowing or significant single or multiple lesions? In the second scenario, probe measurement of the vessel diameter is impossible because of varying degrees of narrowing.
  
• According to the author's grading system, the severe diffuse coronary disease needs to be surgically treated by enartrectomy, on-lay patch or more than one separate/sequential graft to the same coronary. This is the same group of vessels which were excluded from the study (85 grafts [15.4%]). That means he only included in his study vessels with normal, mild or moderate diffuse distal disease.
  
• The incidence of DM in Dr. Jalal's study is 66.7% which is very high but similar to our patient population. We use very frequently the surgical technique of endartrectomy especially in RCA territory and the technique of two separate grafts in the LAD (LIMA to the proximal vessel and vein graft to the distal segment).
  
• The author's grading system is an intra-operative not a preoperative one, so it will not be helpful in determining treatment strategy ‘surgery versus medical treatment’. As well, it can't be included in any risk scoring system which depends more on preoperative variables. Also the prognosis and longevity of the grafts cannot be predicted and translated to patients preoperatively during the informed consent.
  
• The author used a probe measured vessel diameter to determine the grades of distal vessel disease. What benefit will surgeons gain by this ‘end of operation’ grading system, where surgery is chosen and done?
  
• What are the author's criteria for choosing between conventional CABG (57.5%), OPCAB (26.9%) and OBCAB (15.6%)?
  
• Among the 167 LAD grafts, there were 117 arterial grafts (70%) and 50 venous grafts (30%). Why is the number of arterial grafts low? Though we know that LIMA grafts fare very well even in diffusely diseased LADs.
  
• The distribution of grafts to coronary vessels in the 186 patients in the study was as follows; LAD grafts (167, 89.8%), Diagonal grafts (59, 31.7%), OM grafts (133, 71.5%), RCA & PDA grafts (99, 53.2%). The author mentioned that 74% of patients had three vessel disease, and 13.4% had significant left main stem disease. The number of the grafted vessels compared to the diseased vessels does not match and point more to incomplete revascularization.
  
• The size of a coronary artery as I quote from the discussion of this study depends on the body size, gender, segment of the coronary artery and anatomical dominance of circulation. So a 2 mm metal probe can pass easily through a significantly stenosed 2 mm segment in a male and can not pass through 1.5 mm mildly diseased segment in a short thin lady. I mean using absolute numbers in determining severity of the diffuse disease is not practical.
  

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1. Jalal A. An objective method for grading of distal disease in the grafted coronary arteries. Interact CardioVasc Thorac Surg 2007; 6:451–457.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohamed Fahmy Ibrahim Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ibrahim, M. F. Articles by Refaat, A. Search for Related Content PubMed PubMed Citation Articles by Ibrahim, M. F. Articles by Refaat, A. Related Collections Related Article