Review
Antispastic Management in Arterial Grafts in Coronary Artery Bypass Grafting Surgery

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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.

Section snippets

Review Criteria

A search for original articles focusing on coronary artery revascularization published between 1950 and 2015 was performed in the MEDLINE and PubMed databases. The search terms used were “arterial grafting antispastic,” “coronary artery bypass grafting,” and “spasm coronary arterial grafting,” alone and in combination. All articles identified were English language, full-text papers. We also searched the reference lists of identified articles for further relevant papers. Owing to the limit on

Papaverine

Early studies reported a traditional topical vasodilator, papaverine, with satisfactory results [2], and it has been used since in internal mammary artery (IMA) [3] and other arterial grafts [4]. Papaverine is an opioid derivative and a nonspecific vasodilator substance that relaxes blood vessels through several mechanisms, including inhibiting phosphodiesterase (PDE) and decreasing calcium influx or inhibiting release of intracellularly stored calcium [2]. However, papaverine is not

Existing Pharmacologic Antispastic Protocols

There are various antispastic protocols available in different units around the world. Pharmacologic methods are the most common antispastic protocols used in clinical practice worldwide. Table 2 gives a summary of the pharmacologic antispastic protocols used in CABG. Some of the protocols were designed based on the pharmacologic studies on arterial grafts, as detailed in Table 1. However, other protocols are rather empirical.

Skeletonization, Denervation, or En Bloc Harvesting?

Skeletonization of grafts was initially used in IMA. It has been suggested that skeletonized arterial graft may denervate the vessel, reduce the risk of spasm, and improve graft patency in GEA 67, 68, 69 and RA [35], and this is often done with the ultrasonic scalpel [69]. Conversely, studies have demonstrated that skeletonization with an ultrasonic scalpel did not result in additional length and was more frequently associated with severe endothelial damage [70], and that en bloc free GEA

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      For example, Ca2+ antagonists are particularly effective against voltage-operated but less effective against receptor-operated Ca2+ channels, as mentioned earlier, and the effect of NTG is the reverse.21 Our previous studies demonstrated that the depressive effect of combined vasodilators, using either Ca2+ antagonists such as verapamil3,9 or phosphodiesterase inhibitors such as milrinone,33 with NTG was more than with either verapamil or milrinone or NTG alone in K+- or U46619-mediated contraction. In this study, the combination of fasudil and NTG not only caused more depression than using either fasudil or NTG alone in the contraction study (Figures 4A, D), but it also caused more rapid and sustained relaxation in the relaxation study (Figure 5).

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      Papaverine, an opioid derivative that causes vasodilation by phosphodiesterase inhibition and reducing intracellular calcium, commonly is delivered as a topical spray or perivascular injection to the left internal mammary artery during harvest to prevent vasospasm.6,7 Nitroglycerin and isosorbide dinitrate are organic nitrates that cause vasodilation by releasing nitric oxide, leading to increased cyclic guanosine monophosphate and reduced intracellular calcium that cause smooth muscle cell relaxation.6 Nitrates generally are better at treating vasospasm than preventing it.

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