**3. History**

The idea that the mammalian myocardium could be nourished by means of a flow of blood from the coronary venous system, acting as an alternative myocardial perfusion way because it would not be affected by atherosclerosis, was proposed by Pratt in 1898 [7]. However, few clinical trials and long-term outcome data have been presented and clinical use of venous arterialization has rarely been reported. Further experiments were made in 1943, in which the coronary sinus in a canine model was arterialized by using an autologous carotid artery as a conduit between the dogs descending aorta and the coronary sinus. In 1948, Beck and colleagues first carried out blobally retroperfusion by CVBG through coronary sinus[8]. These

**Figure 2.** Mature plaque in the blocked coronary artery

the true arterial lumen (Figure 2)., patients with a long diffuse lesion can be treated very efficiently. But sometimes long, severe diffuse coronary artery stenosis isn't recommended for surgical treatment because of its low patency and more postoperative complications [6].

The idea that the mammalian myocardium could be nourished by means of a flow of blood from the coronary venous system, acting as an alternative myocardial perfusion way because it would not be affected by atherosclerosis, was proposed by Pratt in 1898 [7]. However, few clinical trials and long-term outcome data have been presented and clinical use of venous arterialization has rarely been reported. Further experiments were made in 1943, in which the coronary sinus in a canine model was arterialized by using an autologous carotid artery as a conduit between the dogs descending aorta and the coronary sinus. In 1948, Beck and colleagues first carried out blobally retroperfusion by CVBG through coronary sinus[8]. These

(Figure 3)

278 Artery Bypass

**Figure 1.** Diffuse CAD of the right coronary artery

**3. History**

**Figure 3.** Diffuse coronary artery with immature plaque

findings led them to state that there are communications between the venous and arterial sides of the circulation which, in the dead specimen, allowed blood flow in a retrograde direction. The Beck II procedure afterwards consisted of a free vein graft from the aorta to the coronary sinus, with a second operation 2 to 3 weeks later to ligate the coronary sinus, which reported remarkable success in attempts to revascularize the heart. The effectiveness of reversing flow in the coronary venous system had been debated and this operation was gradually abandoned because of related mortality of 26.1% and development of CABG. However, CABG was soon discovered to have its own limitations, particularly in patients with diffuse atherosclerotic lesion and tiny coronary arteries. Arterialization of coronary veins therefore regained its appeal. Arealis and colleagues brought forth selective CVBG in 1973 which was made only for part of ischemic myocardium, while normal reflux was kept for the rest myocardial veins. Great cardiac vein parallel to LAD and middle cardiac vein parallel to PDA were selected as goal vessels. Eventually an ample report of CVBG animal trial was published by Dr. Hochberg in 1979which indicated CVBG's advantages, such as perfusion all layers of the myocardium, especially the subendocardium – the crucial layer of myocardial muscle[2]. However, this mechanism had been studied at the experimental level because its relatively high clinical mortality and was only theoretic until CVBG technique developed in the recent years.

patients who are not amenable to these traditional treatment strategies. Many patients being referred for CABG nowadays have far advanced CAD, which is often diffuse and exhibits poor vessel runoff. The idea of myocardial revascularization by means of grafting the coronary venous system is more than a century old; in cases of diffuse coronary artery disease, this may

Surgical Treatment for Diffuse Coronary Artery Diseases

http://dx.doi.org/10.5772/54416

281

The lack of suitable targets vessels remains a challenge for aortocoronary bypass grafting in diffuse coronary heart disease. Although this figure approximates 20% to 50% frequency reported in many series [17], our study represents a highly selective group with diffuse coronary disease in which CABG was not feasible with or without an endarterectomy.

From March 2004 to August 2010, patients with diffuse right coronary lesions were studied retrospectively and divided into two groups (Table1). Informed consent and ethical review committee approval were obtained. Group 1 included seventeen patients who underwent selective CVBG during OPCAB while group 2 included twenty-one patients without right coronary artery surgical therapy. Group 1 included eleven male cases (64.7%), the mean age was (46.1±6.2) years, seven hypertension cases (41.2%) and ten diabetes mellitus (58.8%) cases were involved. The case number of cardiac function from II–IV grade was eight, eight, and one respectively. Left ventricular ejection fraction (LVEF) was 0.52±0.09 and left ventricular end diastolic diameter (LVEDD) was (52.7±5.1) mm. Group 2 included fourteen male cases (66.7%), the mean age was (45.9±5.7) years, nine hypertension cases (42.9%) and eleven diabetes mellitus (52.4%) cases were involved. The case number of cardiac function from II–IV level was twelve, seven, two respectively. LVEF was 0.52±0.11 and LVEDD was (51.9±5.2) mm. There was no significant difference between the two groups (*P* >0.05). All the patients had angina pectoris symptom before operation. It was indicated by electrocardiogram that all the cases with old myocardial infarction had obvious ST-T changes. Coronary angiography showed that seven cases had double-vessel lesions and ten cases had triple-vessel lesions in group 1; nine cases had double-vessel lesions and twelve cases had triple-vessel lesions in group 2. Right coronary artery of all the patients took on diffuse lesions with vascular diameter <1 mm and length >20 mm. It was shown by vascular ultrasound examination that blood flow in bilateral mammary artery was smooth and vascular diameter >2 mm; and left subclavian artery was

OPCAB was performed with an average of 3.6 grafts per patient, group 1 being (3.3±1.1) grafts and group 2 being (2.2±1.6) grafts respectively. These patients discharged eight to fourteen days after the operation. Determination of blood flow was made for eleven cases in group 1 and thirteen cases in group 2 which were (81.47±32.65) ml/min and (76.82±28.36) ml/min in trunk of IMA, (32.52±18.82) ml/min and (28.12±16.71) ml/min in trunk of left IMA, (39.63 ±19.02) ml/min and (35.92±18.34) ml/min in trunk of right IMA. The both groups had no death. Tracheal cannula was pulled out on the date of operation or one day after operation. Low-dose positive inotropic drugs were used as assistance for four cases postoperatively. All the patients

had no brain complication and no infection of sternum and mediastinum.

represent a valid therapeutic option [16].

**5.1. Data analysis**

not narrow.
