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1168 CASE REPORT DOHMEN ET AL ENDOTHELIAL CELL-SEEDED BOVINE IMA References FEATURE ARTICLES 1. Laube HR, Duwe J, Rutsch W, Konertz W. Clinical experience with autologous endothelial cell-seeded polytetrafluorethylene coronary artery bypass grafts. J Thorac Cardiovasc Surg 2000;120:134 – 41. 2. Tiwari A, Salacinski HJ, Hamilton G, Seifalian AM. Tissue engineering of vascular bypass grafts: role of endothelial cell extraction. Eur J Vasc Endovasc Surg 2001;21:193–201. 3. Kleisli T, Cheng W, Jacobs MJ, et al. In the current era, complete revascularization improves survival after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2005;129: 1283–91. 4. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990;49:210 –9. 5. Sajja LR, Mannam G, Pantula NR, Sompalli S. Role of radial artery graft in coronary artery bypass grafting. Ann Thorac Surg 2005;79:2180 – 8. 6. Hirose H, Amano A, Takanashi S, Takahashi A. Coronary artery bypass grafting using the gastroepiploic artery: 1,000 cases. Ann Thorac Surg 2002;73:1371–9. 7. Herring M, Gardner A, Glover J. A single-staged technique for seeding vascular grafts with autogenous endothelium. Surgery 1978;84:498–504. 8. Deutsch M, Meinhart J, Fischlein T, Preiss P, Zilla P. Clinical autologous in vitro endothelialization of infrainguinal ePTFE grafts in 100 patients: a 9-year experience. Surgery 1999;126:847–55. 9. Lembcke A, Hein PA, Dohmen PM, et al. Pictorial review: electron beam computed tomography and multislice spiral computed tomography for cardiac imaging. Eur J Radiol 2006;57:356 – 67. Endothelial Cell-Seeded Bovine Internal Mammary Artery for Complete Revascularization Pascal M. Dohmen, MD, PhD, Davide Gabbieri, MD, Alexander Lembcke, MD, and Wolfgang Konertz, MD, PhD Department of Cardiovascular Surgery, Radiology, Charité Hospital, Medical University Berlin, Berlin, Germany We present a 79-year-old woman with coronary heart disease who underwent complete revascularization by using a No-React bovine internal mammary artery seeded with autologous endothelial cells. Her postoperative course was uneventful, and the patient was recently in New York Heart Association functional class I. Multislice computed tomography imaging showed patent grafts at 20 months of follow-up. (Ann Thorac Surg 2007;83:1168 –9) © 2007 by The Society of Thoracic Surgeons T he lack of adequate autologous graft material during coronary bypass surgery has forced surgeons to evaluate alternative graft materials. Bovine internal mammary arteries were investigated many years ago with poor results [1]. In a previous experiment, we were able to Accepted for publication Aug 1, 2006. Address correspondence to Dr Dohmen, Department of Cardiovascular Surgery, Charité Hospital, Medical University Berlin, Luisenstrasse 13, D-10117 Berlin; e-mail: [email protected]. © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc Ann Thorac Surg 2007;83:1168 –9 show that the No-React Shellhigh bovine internal mammary artery (NR-SIMA; Shellhigh Inc, Union, NJ) can be seeded with endothelial cells [2]. This report evaluates the implantation of a seeded NR-SIMA for complete revascularization in a patient with angina pectoris. A 79-year-old woman presented at our hospital with angina pectoris. Her medical history included arterial hypertension, peripheral arterial vascular disease, esophageal reflux, and severe bilateral varicosis. Transthoracic echocardiography showed a normal left ventricular ejection fraction and no valvular disease. Angiography revealed general arteriosclerosis with significant stenoses at the proximal left anterior descending, first diagonal, proximal circumflex, and medial right coronary arteries. Because we lacked suitable autologous graft material owing to a positive Allen test and prior bilateral saphenectomy (due to varicosis), we decided to use a seeded NR-SIMA, for complete revascularization. After institutional review board approval and informed consent were obtained, an 8-cm skin vein from the right forearm was taken in March 2004. Endothelial cells were harvested and cultured as previously described [3]. The NR-SIMA was selected because previous studies had shown that this graft provided a higher density of endothelial cells after seeding compared with expanded polytetrafluoroethylene (ePTFE) grafts [2]. In April 2004, the patient underwent grafting using the left internal mammary artery to the left descending artery (including endarterectomy), the right vena saphena parva as a sequential bypass for the first diagonal and circumflex artery, and the seeded NR-SIMA to bypass the right coronary artery. The internal diameters were left descending artery, 1.0 mm; first diagonal artery, 1.5 mm; circumflex artery, 1.5 mm; and right coronary artery, 2.5 mm. A no-touch technique was used during implantation to avoid endothelial cell loss resulting from manipulation. During the postoperative period, the patient experienced arterial bleeding of a duodenal ulceration, which needed to be treated interventionally. The patient was sent home on postoperative day 19 in good health. During follow-up, the patient did not have any adverse events or restrictions. Patency of the grafts was evaluated by a noninvasive multislice computed tomography scan at discharge and at 20 months’ postoperatively. All grafts were patent at both intervals (Fig 1). Comment Alternative grafts for performing complete revascularization, when no or insufficient autologous graft material is available, needs to be investigated. Scott and colleagues [4] showed the long-term impact of complete coronary revascularization. At 20 years after surgery, the survival rate for incomplete revascularization was 53%, but survival for those who had undergone complete revascularization was 70%. The most common reasons for incomplete revascularization were the presence of small diameter ves0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.08.003 Fig 1. Multislice computed tomography after 20 months of implantation shows a patent mammary artery at the left anterior descending coronary artery, vena saphena parva sequential at the first diagonal, and circumflex artery and the Shellhigh No-React bovine internal mammary artery (NR-SIMA) at the right coronary artery. sels and severe calcification, followed by nonavailability of a suitable autologous conduit. These data were supported by Osswald and colleagues [5], who showed similar results. In their study, 180-day mortality was significantly higher (24%; p ⫽ 0.005) in patients with incomplete revascularization compared with those who underwent complete revascularization (15%). Alternative grafts are therefore needed for those situations in which autologous material is not available or the quality of such graft material does not permit its use. An ideal artificial graft for coronary bypass surgery should have a small diameter, be easy to implant, and have “off-the-shelf” availability. Craig and colleagues [1] presented a study of 7 patients who underwent implantation of a bovine internal mammary artery treated by dialdehyde and sterilized with ethanol and propylene oxide (Bioflow, Biovascular Inc, St Paul, MN). All 11 examined grafts were occluded at a mean follow-up of 19 months after implantation, despite the target vessels being at least 1.5 mm in diameter. Among the remaining patients, each of whom refused to be reevaluated, 42.8% experienced recurrent angina pectoris. Mitchell and colleagues [6] reported an angiographic study of the Bioflow, with a patency rate of 15.8% at a mean follow-up of 9.5 months (range, 3 to 23 months). The dialdehyde tanning procedure removes the dendritic cells and renders immunogenicity, but inevitably, the lack of endothelial cells means that collagen is exposed to blood circulation, creating a thrombogenic surface [6]. The No-React treatment is a heparin-based detoxification process that further stabilizes tissue cross-linking and prevents the release of aldehydes [7]. No-React CASE REPORT DOHMEN ET AL ENDOTHELIAL CELL-SEEDED BOVINE IMA 1169 treated tissue has been shown to inhibit calcification and inflammatory reactions and resist infection while preserving cellular and connective tissue structures, which denotes its biocompatibility [8]. A previous in vitro study performed at our institute confirms this statement, that No-React treated bovine internal mammary arteries can be seeded with endothelial cells. We were, furthermore, able to show that the endothelial cell density of the seeded NR-SIMA graft was significantly higher than ePTFE grafts. Encouraged by these results and an in vivo study, we implanted the seeded NR-SIMA in a patient with insufficient autologous graft availability to perform complete revascularization. After 20 months of follow-up, the mammary artery and the vena saphena parva were both patent. Furthermore, the NR-SIMA was also patent, and the patient was in New York Heart Association functional class I, without any restrictions. This excellent clinical result notwithstanding, this new technique has some restrictions. For the moment, this treatment is only available for patients with stable angina pectoris, because the waiting time for a seeded NR-SIMA graft is 4 to 6 weeks. A cell-culturing modification we have performed has lead to a reduction of this waiting time by 2 weeks. Nevertheless, new cell sources need to be evaluated, such as progenitor cells, which have more growth potential. This is under investigation and should, in the future, allow time to treat patients with unstable angina pectoris. In conclusion, this alternative can be safely used in patients with stable angina pectoris in which elective bypass surgery can be performed. References 1. Craig SR, Walker WS. The use of bovine internal mammary artery (Bioflow) grafts in coronary artery surgery. Eur J Cardiothorac Surg 1994;8:43–5. 2. Dohmen PM, Posner S, Erdbruegger W, Konertz W. Human endothelial cell seeding with the No-React treated internal mammary arteries: perspective for the planned study and outlook for the future. Cardiovasc Sci Forum 2006;3:8 –12. 3. Laube HR, Duwe J, Rutsch W, Konertz W. Clinical experience with autologous endothelial cell-seeded polytetrafluoroethylene coronary artery bypass grafts. J Thorac Cardiovasc Surg 2000;120:134 – 41. 4. Scott R, Blackstone E, McCarthy PM, et al. Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization. J Thorac Cardiovasc Surg 2000;120:173– 84. 5. Osswald BR, Blackstone EH, Tochtermann U, et al. Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients? Eur J Cardiothorac Surg 2001;20:120 – 6. 6. Mitchell IM, Essop AR, Scott JP, et al. Bovine internal mammary artery as a conduit for coronary revascularization: longterm results. Ann Thorac Surg 1993;55:120 –2. 7. Abolhoda A, Yu S, Oyarzun JR, McCormick JR, Bogden JD, Gabbay S. Calcification of bovine pericardium: glutaraldehyde versus No-React biomodification. Ann Thorac Surg 1996;62:169 –74. 8. Reddy SL, Pillia J, Mitchell L, et al. First report of no-react bovine internal mammary artery performance and patency. Heart Surg Forum 2004;7:E446 –9. FEATURE ARTICLES Ann Thorac Surg 2007;83:1168 –9