Composite Graft Technique Research Articles

Comparison of Cartilage Reinforcement and Push-Through Techniques for the Treatment of Large Perforations.

Objective: To compare the graft success rate and hearing outcomes of endoscopic cartilage reinforcement perichondrium-cartilage composite graft and push-through techniques for the treatment of large marginal perforations. Study Design: Randomized controlled trial. Materials and Methods: A total of 57 large marginal perforations were prospectively randomized to cartilage reinforcement (n = 29) and cartilage push-through technique (n = 28) groups. The graft success rate, audiometric outcomes, and complications were compared between the 2 groups at 6 months. Results: All patients completed 6 months of follow-up. The graft success rate in the cartilage reinforcement group was significantly higher compared to that in the push-through group (100.0% vs 78.6%, P < .01). Residual perforation was observed in 5 (17.9%) patients, and re-perforation in 1 (3.6%) patient, in the push-through group. The preoperative air-bone gap (ABG) was 17.6 ± 3.5 dB in the cartilage reinforcement group and 16.8 ± 8.4 dB in the push-through group (P > .05). Postoperatively, although the postoperative ABG in the cartilage reinforcement group was higher than that in the push-through group, no significant difference was observed (11.8 ± 4.3 dB vs 8.9 ± 2.5 dB, P > .05). Additionally, no significant difference was found in ABG closure between the 2 groups (6.6 ± 1.9 dB vs 7.9 ± 4.7 dB, P > .05). Conclusion: Cartilage reinforcement myringoplasty is a simpler and more useful technique to achieve graft success compared to cartilage-perichondrium push-through for the treatment of large marginal perforations, and it does not affect hearing levels.

Study of Yang's Onion Flap Technique for Release of Scarred Eponychium and Nail Fold Reconstruction in Burn Patients.

Background Abnormalities of fingernail growth and appearance are among the most common deformities encountered after burn injury to the hand. Various techniques used for resurfacing defects include incision of the scarred eponychium and advancement of the distal segment, flap reconstruction-distally, and proximally based transposition/advancement flaps, composite graft techniques, microvascular transfer. In the present study, we used an onion flap to release scarred eponychium and nail fold reconstruction in a single stage without using soft tissue from another area. Materials and methods Forty-four burnt fingers were operated using Yang's onion flap technique. Patients were assessed for flap necrosis, hematoma and infection in the early postoperative period and for donor site scar, nail appearance, and symptomatic relief in a follow-up for at least 4 months. Results The flap was successfully performed on all fingers. Only two fingers had flap necrosis. There was no incidence of hematoma or infection. The donor site scar and nail plate appearance improved and was acceptable to most patients after surgery. There was also significant relief in daily activities in 19 out of 28 symptomatic patients. Conclusion Yang's flap to correct nail deformities in burn patients is feasible in Indian scenario. It is associated with a low complication rate and improved nail appearance. There is also significant symptomatic relief in performing daily activities after surgery.

Endoscopic type 1 tympanoplasty; a composite graft technique for subtotal and total perforations.

Demonstrate feasibility of performing endoscopic transcanal type 1 tympanoplasty in total and subtotal perforations, using an underlay technique that minimizes the risk of anterior medialization of the graft. Compare audiometric and clinical outcomes of this technique with our series of endoscopic tympanoplasty with classical underlay grafts, and with previously reported outcomes of microscopic post-auricular lateral graft tympanoplasty and other transcanal techniques. We describe a surgical technique using an L-shaped cartilage and its perichondrium, with exclusive transcanal endoscopic approach. A retrospective review of patients undergoing this technique at the Centenario University Hospital of Rosario, Argentina between January 2017 and December 2019 was performed, and it was compared with a group of patients who underwent endoscopic tympanoplasty with classical underlay technique in a previous period of time. Patients with smaller perforations and other middle ear pathologies that required other techniques were not included in this study. Minimum follow up was 6months. The main outcome measures were membrane closure rates and hearing results. 73 patients with total or subtotal perforations undergoing endoscopic transcanal tympanoplasty between 2015 and 2019 were included. The group of patients that underwent the technique described showed no anterior medialization of the graft, and better graft take rates. The hearing outcomes were similar in all successful graft patients, with postoperative average air-bone gap of 10db (+ -10dB). Transcanal endoscopic tympanoplasty with the technique described is an excellent option for closure of total and subtotal tympanic perforations. The rate of perforation closure is better than endoscopic tympanoplasty with classical underlay graft with similar audiometric outcome.

Clinical Outcomes of Surgical Repair with a Composite Graft for Abdominal Aortic Aneurysm Accompanied by Iliac Artery Aneurysm.

BackgroundIliac artery aneurysm is frequently found in patients undergoing surgical repair of an abdominal aortic aneurysm. The use of commercial bifurcated grafts is insufficient for aorto-biiliac replacement with complete iliac artery aneurysm resection. We evaluated the effectiveness of handmade composite grafts for this purpose.MethodsA total of 233 patients underwent open surgery for abdominal aortic aneurysm between 2003 and 2019, including 155 patients (67%) treated with commercial grafts and 78 patients (33%) treated with handmade composite grafts. Their operative characteristics, postoperative outcomes, and late outcomes were retrospectively reviewed.ResultsThe early mortality rate did not differ significantly between the groups. On average, the handmade composite graft technique took approximately 15 minutes longer than the commercial graft technique (p=0.037). Among patients who underwent elective surgery, no significant differences between the conventional and composite groups were observed in the major outcomes, including red blood cell transfusion volume (2.8±4.7 units vs. 3.1±4.7 units, respectively; p=0.680), reoperation for bleeding (2.7% vs. 3.1%, respectively; p>0.999), bowel ischemia (0% vs. 1.6%, respectively; p=0.364), and intensive care unit stay duration (1.9±6.6 days vs. 1.6±2.4 days, respectively; p=0.680). The incidence of target vessel occlusion also did not differ significantly between groups.ConclusionThe increased technical demand involved with handmade composite grafting did not negatively impact the outcomes. This technique may be a viable option because it overcomes problems associated with commercial grafts.

Development of an invasive ductal carcinoma in a contralateral composite nipple graft after an autologous breast reconstruction: a case report

BackgroundNipple-areola complex (NAC) reconstruction is a technique used in breast reconstructive surgery, which is performed during the final stage of breast reconstruction after total mastectomy of primary breast cancer. Composite nipple grafts utilizing the contralateral NAC are common; however, to our knowledge, there are no reports of new primary invasive ductal carcinoma development within the graft. Here, we describe one such case for the first time.Case presentationA 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of right nipple erosion. She had undergone total mastectomy of the right breast following a breast cancer diagnosis 15 years ago, at which time tumor biological profiling revealed the following: estrogen receptor (ER), positive; progesterone receptor (PgR), negative; and human epidermal growth factor receptor 2 (HER2), undetermined. She received adjuvant chemotherapy and endocrine therapy. She defaulted endocrine therapy for a few years, and 7 years after surgery, she underwent autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. In the following year, NAC reconstruction was performed using a composite graft technique. Seven years after the NAC reconstruction, erosion appeared on the nipple grafted from its contralateral counterpart; scrape cytology revealed malignancy. The skin on the right side of her chest around the NAC and subcutaneous fat tissue consisted of transferred tissue from the abdomen, as the DIEP flap and grafted nipple were located on the graft skin. The right nipple carcinoma arose from the tissue taken from the left nipple. Magnetic resonance imaging (MRI) or computed tomography showed no malignant findings in the left breast. As the malignant lesion seemed limited to the area around the grafted right nipple on MRI, surgical resection with sufficient lateral and deep margins was performed around the right nipple. Pathological findings revealed invasive ductal carcinoma with comedo ductal components infiltrating the graft skin and underlying adipose tissue. Immunohistochemistry revealed positive for ER, PgR, and HER2.ConclusionsTo our knowledge, this is the first case involving the development of invasive ductal carcinoma in a nipple graft constructed on the skin of a DIEP flap, with the origin from the contralateral breast’s nipple.

Left anterior descending artery revascularization with the right internal thoracic artery T-graft: the 'reverse composite' configuration.

The use of bilateral internal thoracic artery graft for myocardial revascularization has improved the long-term survival and decreased the rate of repeat interventions in patients. A key technical factor for complete arterial revascularization is sufficient length of the internal thoracic artery (ITA) graft. The purpose of this study was to compare early and long-term outcomes of 'standard composite' grafting and 'reverse composite' grafting. In the former, the left ITA (LITA) is connected to the left anterior descending artery, and the right ITA is connected end-to-side to the LITA for revascularization of the left circumflex artery. In 'reverse composite' grafting, the LITA is connected to the left circumflex artery, and the right ITA is connected end-to-side to the LITA, for revascularization of the left anterior descending artery. We compared the outcomes of 1365 patients who underwent coronary artery bypass grafting in Tel-Aviv Sourasky Medical Centre, using bilateral ITA as standard composite versus 'reverse composite' grafts, between January 1996 and December 2011. A propensity score matching analysis compared 132 pairs of patients who underwent bilateral ITA by the 2 modes. Twelve hundred and thirty patients underwent standard 'composite' grafts and 135 underwent 'reverse composite' grafts. Early mortality and early adverse effects did not differ significantly between the groups. After matching, the difference in late mortality between the groups was not statistically significant. This study suggests that revascularization of the left anterior descending with the right ITA, arising from an in situ LITA, is safe and provides early outcomes and long-term survival that are not significantly different from those of the standard composite grafting technique. However, there was evidence of better survival in the standard composite group.

Use of Composite Graft in Patients with Coronary Artery Diseases Concomitant with Porcelain Aorta: A Safe Technique and case series in Severe Aortic Calcification

Background:Surgery in patients with severe calcification of the aorta, also known as “porcelain aorta”, is challenging for cardiac surgeons. In this study, we evaluated the efficacy of composite grafts in avoidance of aortic manipulation among patients with porcelain aorta undergoing coronary artery bypass grafting (CABG). Objectives: The aim of current study was to investigate of use of composite graft in patients with coronary artery diseases concomitant with porclain aorta. Methods: Ten patients among admitted ones for CABG over 3 years showed severe calcification of the aorta. We used a composite graft for revascularization of the target vessel without manipulation of the aorta. In patients with CAD and porcelain aorta, off-pump CABG was applied to avoid cannulation of the aorta. Moreover, a composite graft was used for internal mammary artery (unilateral/bilateral) to avoid partial clamping of the aorta. Results: Among ten patients with the mean age of 72.5 years seven patients were male and 3 were female. The most common risk factors were diabetes (6 patients), hypertension (5 patients), smoking (5 patients), and hyperlipidemia. Four patients had thetwo-vessel disease, while the remaining had thesix-vessel disease. In the intraoperative and postoperative periods, no hemodynamic instability was reported in any of the patients. Similarly, no ischemic complications due to femoral artery cannulation (lower limb ischemia) were reported. Based on the findings, no neurologic complications occurred in the early postoperative period and 12-month follow-up (causing no neurologic deficits). Postoperative evaluation of the grafts via computed tomography showed sufficient patency in all patients. Conclusion: Coronary artery disease, concomitant with severe calcification of the aorta, is a challenging condition for cardiac surgeons, given the higher risk of atheroembolic events and serious morbidity. Although multiple techniques have been described for avoiding manipulation of the aorta in these patients, the composite graft technique may be a simple and safe procedure with reduced ri sk of cerebrovascular events due to atheroembolism.

New Left Lobe Transplantation Procedure with Caval Reconstruction Using an Inverted Composite Graft for Chronic Budd-Chiari Syndrome in Living-Donor Liver Transplantation—A Case Report

When the Budd-Chiari syndrome (BCS) lesion extends to the inferior vena cava (IVC) or the orifices of the hepatic vein, the thickened IVC and/or hepatic vein wall must be removed and IVC reconstruction is required in living-donor liver transplantation (LDLT). In various reports about IVC resection in LDLT for BCS, there are none about left lobe liver transplantation with reconstruction of the retrohepatic IVC (rhIVC). To overcome removal and reconstruction of the rhIVC in LDLT for BCS, we introduced a composite IVC graft that is applicable to both right and left lobe partial liver grafts for LDLT for BCS. Pathogenic IVC was removed together with the native liver between the lower edge of the right atrium and 5 cm above the renal vein junction with the use of venovenous bypass. The e-polytetrafluoroethylene graft was anastomosed to the suprarenal intact IVC. Then the native part was detached at the level of just above the renal junction. The composite graft was inverted and a half rim of the native part of the graft was anastomosed to the posterior wall of the right atrium. Next, the common venous orifice of the left lobe graft was anastomosed to the wall defect which was composed of the anterior wall of the right atrium and the distal end of the native part of the composite graft. In conclusion, our inverted composite graft technique will overcome the weak points of LDLT for BCS, such as incomplete removal of the pathogenic caval wall and reconstruction of the rhIVC.

Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction.

Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less. The anatomic study determined the cis-male nipple to be positioned on average 2.5cm medial to the lateral border of the pectoralis muscle and 2.4cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae. Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Diamond Intermediate Anastomotic Technique for Improving Outcomes in Composite Sequential Bypass Grafting in Critical Limb Ischaemic

Objective: To describe and pilot a modified composite sequential bypass graft technique using a synthetic-vein graft combination linked via a common intermediate anastomosis to native artery in a diamond configuration.

Assessment of left internal mammary artery to left anterior descending flow in composite arterial bypass grafting

Objectives The aim of the study was to achieve arterial myocardial revascularization using the 'Y-graft or T-graft' techniques and to measure intraoperative graft flow by transit-time flowmetry. Background Composite grafting techniques for coronary artery bypass grafts have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery. In this study, we evaluated composite grafting techniques by intraoperative measurement graft flow by transit-time flowmetry. Materials and methods Fifty patients who underwent coronary artery bypass grafting during a time period of 24 months were enrolled in this prospective study. All patients received sequential grafting using both internal thoracic arteries and left radial artery joined as a composite Y or T graft. Intraoperative left internal mammary artery (LIMA) flow was measured by transit-time flowmetry. Results This study provided evidence that the LIMA limb of a composite Y or T graft had intraoperative increase in mean flow, and there was statistical significance ( P Conclusion LIMA has the potential to provide sufficient blood flow to revascularize left coronary system.

A novel composite coronary bypass graft strategy: the saphenous vein bridge—a pilot study

The aim of this pilot study was to describe and assess the safety of a novel composite graft technique for coronary artery bypass grafting (CABG) surgery. A saphenous vein is grafted to the left anterior descending artery (LAD) and other anterolateral coronary arteries, creating a saphenous vein bridge (SVB) and the left internal mammary artery (LIMA) is anastomosed to the SVB, distributing the blood flow distally (LIMA-SVB). All patients who underwent CABG with the LIMA-SVB between 2005 and 2008 at our centre were enrolled in this study. Perioperative data were retrospectively collected from hospital charts, and the clinical follow-up was completed by telephone interview. Graft patency was assessed by computed tomography angiography (CTA) in patients with the longest follow-up time (n = 20). A total of 256 patients (mean age: 67 ± 12 years; 79% male) received 4.0 ± 1.0 grafts, including 2.2 ± 0.4 distal grafts provided by the LIMA-SVB. Nine (3.5%) deaths and 4 (1.6%) myocardial infarctions (MIs) were noted in the perioperative period. With a median follow-up time of 36 months [inter-quartile range 31-44], 1 (0.5%) MI and 2 (1.0%) strokes were reported. At 51 months post-surgery [47-53], CTA demonstrated a LIMA pedicle (n = 20) and SVB (n = 42) patency rate of 100 and 93%, respectively. Specifically, the LIMA-SVB patency rate was 100% to the LAD and 85% to diagonal arteries. Aortocoronary vein grafts (n = 38) patency rate in the same patients was 87%. Revascularization of the anterolateral territory using the LIMA-SVB is a promising approach considering its clinical safety and favourable patency rate results. A prospective randomized clinical trial is underway to compare this technique to conventional CABG.

RhBMP-2/ACS Grafts Versus Autogenous Cancellous Marrow Grafts in Large Vertical Defects of the Maxilla: An Unsponsored Randomized Open-Label Clinical Trial

This study compared the histologic parameters and outcomes of two types of grafts in large vertical maxillary defects: a composite graft of recombinant human bone morphogenetic protein-2/acellular collagen sponge (rhBMP-2/ACS), crushed cancellous freeze-dried allogeneic bone (CCFDAB), and platelet-rich plasma (PRP); and size-matched 100% autogenous grafts. Twenty patients each were treated with a composite graft, which contained 1.05 mg rhBMP-2/ACS per two-tooth segment together with CCFDAB and PRP, or a 100% autogenous graft prior to implant placement. Grafting material was contained within a titanium mesh crib. Two grafts in each group were lost as a result of early mesh exposure and infection. Three grafts in each group developed a late exposure of the mesh that did not affect bone regeneration. The remaining 18 autogenous grafts all regenerated sufficient bone for implant restoration (100%), and 17 of 18 (97.4%) of the composite grafts regenerated sufficient bone for implant restoration. The autogenous grafts included 54% ± 10% of new viable bone but also included residual nonviable graft particles. The composite grafts contained 59% ± 12% viable new bone and no remaining nonviable bone particles. The composite grafting technique resulted in less blood loss and shorter surgical time but greater and longer-lasting edema. The costs of both grafts were nearly equal. A composite graft of rhBMP-2/ACS-CCFDAB-PRP regenerates bone in large vertical ridge augmentations as predictably as 100% autogenous graft with less morbidity, equal cost, and more viable new bone formation without residual nonviable bone particles, but with more edema. This composite graft represents an in situ tissue engineering concept that is able to achieve results equivalent to autogenous grafts in large vertical ridge augmentations without donor bone harvesting.

Reducing Donor Site Morbidity When Reconstructing the Nipple Using a Composite Nipple Graft

BackgroundNumerous procedures are available for nipple reconstruction without a single gold standard. This study presents a method for reducing donor-site morbidity in nipple reconstruction using a composite nipple graft after transverse rectus abdominis musculocutaneous flap breast reconstruction.MethodsThirty-five patients who underwent nipple reconstruction using a composite nipple graft technique between July of 2001 and December of 2009 were enrolled in this study. To reduce the donor site morbidity, the superior or superior-medial half dome harvesting technique was applied preserving the lateral cutaneous branch of the fourth intercostal nerves. The patients were asked to complete a previously validated survey to rate the color and projection of both nipples, along with the sensation and contractility of the donor nipple; and whether, in retrospect, they would undergo the procedure again. To compare projection, we performed a retrospective chart review of all the identifiable patients who underwent nipple reconstruction using the modified top hat flap technique by the same surgeon and during the same period.ResultsThirty-five patients were identified who underwent nipple reconstruction using a composite nipple graft. Of those, 29 patients (82.9%) responded to the survey. Overall, we received favorable responses to the donor site morbidity. Projection at postoperative 6 months and 1 year was compared with the immediate postoperative results, as well as with the results of nipples reconstructed using the modified top hat flap.ConclusionsThe technique used to harvest donor tissue is important. Preserving innervation of the nipple while harvesting can reduce donor site morbidity.

The use of acellular human dermis composite graft for upper eyelid reconstruction in ocular injury

Repair of the upper lid is more difficult because of the unique anatomic requirements of the upper eyelid. The eyelid must remain pliable, allow for retraction and protraction, and also have a mucous membrane on the posterior surface. A number of procedures are available to repair large to total upper eyelid defects. These surgical techniques include lower lid switch flaps and lower lid bridge flaps. However, these procedures have several disadvantages, such as the partial or total sacrifice of the lower lid and the need for secondary correction. The authors present a new surgical technique using composite graft of acellular dermis and split-thickness buccal mucosa in the reconstruction of traumatic full-thickness upper eyelid defects to achieve satisfactory functional and esthetic results. In this retrospective case series, eight patients requiring full-thickness upper eyelid reconstruction were evaluated. Defect size ranged from 20 mm to 28 mm horizontally and from 5 mm to 8 mm vertically. For eyelid reconstruction, the acellular dermis composite graft was sutured into the posterior lamella defect; the anterior lamella was repaired with a bipedicled orbicularis flap and a free skin graft. Acellular dermis composite grafts achieved complete resolution of lagophthalmos and follow-up of 6 months to 31 months revealed a good outcome in all eight cases. No adverse situation of the grafts viability was encountered. Postoperative complications occurred in two patients; one had eyelid margin notching and the other had a mild ptosis. The acellular dermis composite graft is a good match for the posterior lamella of the eyelid in terms of texture and contour. The acellular dermis composite graft technique is useful for the reconstruction of large upper eyelid defects resulting from burns or trauma because this method results in complete repair of defects without causing notable deformity.

39 A randomised controlled trial comparing conventional coronary artery bypass graft surgery with a composite arterial graft technique

Background Composite (Y/T) coronary artery bypass graft surgery (CABG) confers full arterial revascularisation, and “hands off” aorta compared to conventional bypass graft surgery. However, the composite surgical configuration could lead to preferential blood flow down one arm than the other (left internal mammary artery LIMA or radial artery RA) with its potential impact on graft patency. Aim To investigate the impact of bypass graft configuration on short-term grafts patency and cardiac related quality of life. Methods and Results This is a single centre randomised, controlled trial Between March 2006 and July 2007, 322 patients undergoing isolated bypass graft surgery at our institution were screened and 89 (27%) met the inclusion criteria and were randomised. Patients were allocated to conventional (conv n=46) or composite (comp n=43). The two primary end points were graft patency defined as (Thrombolysis In Myocardial Infarction) TIMI III flow in distal anastomosis at angiography 12–24 months after surgery, and cardiac-related health status assesses by Seattle angina questionnaire (SAQ). Baseline characteristics were similar between the two groups apart from diabetes where there were more diabetic patients in the composite arm than the conventional one (15(35%) vs 5(11%) p Conclusions In our randomised trial, composite bypass graft surgery was associated with higher graft failure rate at 12–24 months after surgery compared to conventional type. This difference may be due to the composite conduit configuration. Further blood flow characteristics study in this configuration can help understand such an important finding and its implication on our clinical practice. Despite the difference in graft patency there were no differences in physical limitation, angina stability, angina frequency, or quality of life between the two groups.

Increased Graft Occlusion or String Sign in Composite Arterial Grafting for Mildly Stenosed Target Vessels

Composite grafting is a useful technique that avoids the need for aortic manipulation and enables a wide range of target vessels to be revascularized, effectively using the limited arterial grafts available. However, it has not been clarified whether composite grafting can achieve angiographic outcomes equivalent to those obtained with individual grafting for specific target vessels. We retrospectively reviewed 830 distal arterial graft anastomoses in 256 patients who underwent off-pump coronary artery bypass surgery and also underwent 1-year follow-up coronary angiograms. Four hundred and ten anastomoses using a composite grafting technique were compared with 420 anastomoses using individual grafting. In target vessels with mild stenosis, the incidence of graft occlusion or string sign was significantly higher in composite internal thoracic arteries (ITA) than in individual ITA grafts (composite 20.3% versus individual 7.3%; p = 0.018) and showed a higher tendency in composite radial arteries (RA) than in individual RA grafts (59.3% versus 36.4%, p = 0.09). In contrast, the incidence was similar between composite and individual ITA grafts (5.7% versus 3.3%, p = 0.278) and composite and individual RA grafts (11.5% versus 29.6%, p = 0.297) in target vessels with severe stenosis. The angiographic outcomes of composite grafts were closely related to the severity of stenosis of the target coronary artery. In target vessels with mild stenosis, composite grafting resulted in a higher incidence of graft occlusion or string sign than individual grafting did.

Y grafting for coronary artery bypass: is it as good as single grafting?

The use of multiple arterial grafting has gained popularity in recent years due to its clinical advantages when compared with conventional CABG surgery. The purpose of the present review is to focus in particular on the safety and efficacy of composite Y grafting in coronary surgery. Several studies demonstrated mid-term and long-term benefits of total arterial myocardial revascularization when compared with conventional CABG, that is utilizing the left internal mammary artery and multiple veins. Nevertheless, there have been concerns whether it is safe to have a single inflow rather than multiple aorto-coronary grafts. There is evidence in literature that composite arterial grafting is nowadays a well established technique, and several configurations can be performed according to the specific patients' needs. Moreover, the use of Y grafting completely avoids aortic manipulation, especially when used in association with the off-pump technique. Composite Y grafting with the exclusive use of arterial conduits is a well tolerated and effective technique. The choice of the second arterial conduit should be tailored according to the specific patients' characteristics. The association of composite arterial grafting and off-pump technique allows a no-touch technique of the ascending aorta, thereby also minimizing the risk of neurological events.

The Composite Aortic Wall Graft Technique: An Option for a Short Coronary Artery Bypass Graft

SUMMARYDuring coronary artery bypass graft (CABG) surgery, the saphenous vein is sutured through its proximal segment to the aorta. Intimal hyperplasia is one of the possible causes of graft occlusion. Notably, blood turbulence can induce wall shear stress that may also play an important role in this process.OBJECTIVEWe propose a new technique for performing proximal anastomosis to avoid CABG failure.METHODAn 80 kg pig was subjected to open heart surgery. Four stitches were placed in the anterior ascending aorta, which formed a 2 cm by 4 cm patch. This patch was isolated through the application of a tangential clamp that was oriented parallel to the axis of the aorta. After releasing the patch, which was held to the aorta through its cranial end pedicle, the rims were sutured to each other creating a conduit with a length of 4 cm and an internal diameter of 4 mm. The rest of the aortotomy was closed by placing a direct suture between its rims.RESULTThis novel technique created an “in situ” aortic wall graft that was 4 cm long and characterized as being of uniform 4 mm caliber.

Development of a Composite Degradable/Nondegradable Tissue‐engineered Vascular Graft

The present study aimed to determine the feasibility of constructing a reinforced autologous vascular graft by combining the advantages of fibrin gel as an autologous cell carrier material with the inherent mechanical strength of an integrated mesh structure. It was hypothesized that the mesh and dynamic culture conditions could be combined to generate mechanically stable and implantable vascular grafts within a shorter cultivation period than traditional methods. A two-step moulding technique was developed to integrate a polyvinylidene fluoride (PVDF) mesh (pore size: 1-2 mm) in the wall of a fibrin-based vascular graft (I.D. 5 mm) seeded with carotid myofibroblasts. The graft was cultured under increasing physiological flow conditions for 2 weeks. Histology, burst strength, and suture retention strength were evaluated. Cell growth and tissue development was excellent within the fibrin gel matrix surrounding the PVDF fibers, and tissue structure demonstrated remarkable similarity to native tissue. The grafts were successfully subjected to physiological flow rates and pressure gradients from the outset, and mechanical properties were enhanced by the mesh structure. Mean suture retention strength of the graft tissue was 6.3 N and the burst strength was 236 mm Hg. Using the vascular composite graft technique, the production of tissue engineered, small-caliber vascular grafts with good mechanical properties within a conditioning period of 14 days is feasible.