Antispastic Management in Arterial Grafts in Coronary Artery Bypass Grafting Surgery

Abstract

Arterial grafts have long-term patency superior to vein grafts but have a tendency to develop spasm that can lead to potentially life-threatening complications. A perfect antispastic protocol should include advanced surgical technique and adequate pharmacologic methods. All pharmacologic vasodilator drugs relax the vessel through specific mechanisms, and therefore, there is no perfect, single best vasodilator to prevent or treat spasm of the arterial graft against all mechanisms of contraction. One of the choices is to use a combination of pharmacologic vasodilators targeting different mechanisms of spasm to obtain the reliable and best effect.

Comparative Study between the Use of the Radial Artery and the Saphenous Vein in Coronary Artery Bypass Surgery

“…They contain more smooth muscle cells in their walls and are therefore less elastic. They are muscular arteries and more prone to vasospasm because of their higher contractility [4]. Radial arteries have been shown to be associated with a higher degree of arteriosclerosis than the internal thoracic artery, and the presence of vessel calcification, the most common pathology of radial arteries would also preclude its use for CABG.…”

Propofol-Induced Vasodilation: The Cart Before the Horse?

“…The technique may denervate the artery, reducing the risk of spasm, although results are controversial. 4 Patency rates of skeletonized versus pedicle IMA are similar. 9 There also may be benefit in avoiding use of the distal end of the IMA, which has a smaller diameter and greater tendency to spasm.…”

“…3 This is not to say arterial spasm is not important because refractory spasm has been shown to contribute to morbidity and mortality. 3,4 A high index of suspicion, prompt diagnosis, and rapid treatment are needed to prevent harm in cases of graft spasm. Preventative surgical techniques and developments in pharmacologic treatment of arterial spasm have paralleled the use of arterial grafts in CABG surgery, and the authors' findings have relevance in this context.…”

“…Other effective measures described in the literature use a combination of pharmacotherapies (eg, CCBs and nitrate) as intraluminal or topical solutions to terminate critical arterial spasm and sequalae. 4,6 Newer agents also are under investigation and include topical or intravenous carperitide (exogenous atrial natriuretic peptide). 8 All these approaches, again, bring into question the utility of a systemically administered vasodilator such as propofol.…”

“…3 Harvesting with ultrasonic scalpels may help to prevent spasm by decreasing thermal injury, harvesting time, and excessive use of hemostatic clips. 4 Familiarity with a particular surgical group's practice can be helpful in terms of clinical suspicion and treatment factors. Practice changes can be incorporated to further reduce spasm complications and may be equally effective as administering propofol.…”