Abstract
Background
Graft flow in coronary artery bypass grafting (CABG) is linked with blood distribution of the target vessel. In this study, we aimed to develop a novel quantitative measurement of target coronary artery quality using coronary computed tomography angiography (CCTA) and investigate its correlation with intraoperative transit time flow measurement (TTFM).
Methods
We enrolled 68 patients with CABG who underwent preoperative CCTA. Target coronary artery volume index (TCAVI) was calculated from CCTA images and measurements in 65 arterial and 94 venous bypass grafts. CCTA-TCAVI, representing total volume (mm3) of arterial vasculature per individual target artery, was statistically analyzed for correlation with TTFM.
Results
CCTA-TCAVI demonstrated a positive correlation with mean graft flow (MGF =0.222, P=0.005). TCAVI was linked with abnormal internal mammary artery (IMA) grafts [intraoperative MGF <20 mL/min and pulsatility index (PI) 5] and saphenous vein grafts (SVGs, <40 mL/min) and PI (5) odds ratio (OR =0.99, <1, P=0.004). Interquartile range (IQR) analysis revealed a significant correlation between abnormal SVG and TCAVI (P<0.001), but no correlation between abnormal IMA and TCAVI (P=0.91). Compared with previous predictive measurements, TCAVI correlated with graft flow(MGF =0.222, P=0.005). The cutoff value for CCTA-TCAVI was 200 mm3. Compared with coronary stenosis percentage, TCAVI prediction accuracy was 13% higher.
Conclusions
TCAVI as a novel measurement may be useful to appropriately select the optimal target arteries at the time of CABG. It may have clinical potential to predict intraoperative abnormal venous grafts with high accuracy.
Keywords: Intraoperative target graft flow, cardiac computed tomography (cardiac CT), coronary artery bypass grafting (CABG), bypass graft volume
Highlight box.
Key findings
• The present study focused on establishing a novel quantitative predictive factor [target coronary artery volume index (TCAVI)] of potential target vessels using coronary computed tomography angiography (CCTA) and investigated its correlation with intraoperative graft flow by transit time flow measurement.
What is known and what is new?
• Several methods guide cardiac surgeons for target coronary artery in CCTA: (I) target vessel internal diameter >1.0 mm; (II) ≥70% proximal vessel stenosis with adequate distal run-off; (III) surgically accessible epicardial artery; and (IV) artery perfusing relatively large viable myocardium.
• We defined a quantitative volume index for target coronary arteries and observed that TCAVI might be linked with intraoperative mean graft flow. It might be useful for finding intraoperative abnormal bypass graft flow. It may have potential utility to optimally select coronary artery bypass grafting (CABG) target arteries. Moreover, the accuracy of TCAVI prediction value rivals that of previous indicators such as coronary stenosis percentage in our study, which may have clinical potential.
What is the implication, and what should change now?
• This novel predictive factor may be useful to select the optimal target arteries at the time of CABG.
Introduction
Myocardial revascularization effectively treats coronary artery disease and prolongs lifespan(1). Although percutaneous coronary intervention is a more common, less-invasive therapy, surgical revascularization through coronary artery bypass grafting (CABG) offers irreplaceable advantages for treating left main coronary artery disease, diabetes, and multi-vessel lesions according to the American Heart Association and American College of Cardiologyguidelines (2). Selecting appropriate target coronary arteries for CABG critically influences clinical outcomes. However, unlike myocardial revascularization strategy selection (percutaneous coronary intervention versus CABG) guided by Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, few methods exist to analyze the optimal selection of CABG target vessels. Bypass graft anastomosis targets are typically decided based on cardiac surgeons’ interpretation of fluoroscopy-based coronary angiogram and computed tomography angiography (CTA) studies.
Several methods guide cardiac surgeons for selecting the target coronary artery: (I) target vessel internal diameter >1.0 mm; (II) ≥70% proximal vessel stenosis with adequate distal run-off; (III) surgically accessible epicardial artery; and (IV) artery perfusing relatively large viable myocardium(3). However, these criteria may still result in graft failure, causing inadequate graft flow and early failure, for instance, target vessel selection solely based on anatomical stenosis severity determined by coronary angiography may fail to identify functionally non-significant stenoses, which may induce competitive native coronary flow, insufficient graft perfusion pressure and early graft occlusion following bypass surgery, ultimately resulting in graft failure (4,5). Moreover, if target vessel stenosis is not hemodynamically significant, the native coronary artery maintains substantial forward flow, creating competitive perfusion against the graft. This also reduces effective graft perfusion and raises the risk of early graft failure (6). Therefore, predicting target coronary artery conditions preoperatively is essential to prevent graft failure.
Selecting target coronary arteries through visual inspection of an isolated coronary angiogram is challenging, primarily because angiography generates two-dimensional projections of three-dimensional vascular anatomy. This imaging modality is susceptible to multiple confounding factors, including projection angles, vessel branch overlap, tortuous vascular courses, and heterogeneous contrast opacification. Hence, assessments of stenosis severity carry substantial subjectively and poor reproducibility. Particularly for intermediate stenosis (40–70%), the accuracy of judging their functional significance declines markedly (7-9). CTA, a noninvasive vascular imaging approach, offers unique advantages over coronary angiogram, including multi-planar reconstruction, maximum intensity projection, and cinematic volume rendering. We hypothesized a novel predictive indicator: CTA-target coronary artery volume index (TCAVI). TCAVI represents a validated index derived from CTA measurements which is standardized via an analytical algorithm. It is based on cumulative values of diameters and lengths encompassing both the potential main target coronary artery and its branch vessels. In this study, we aimed to investigate relationships between intraoperative graft flow and TCAVI, proposing a novel predictor for optimal target coronary artery selection to prevent graft failure. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1523/rc).
Methods
Study population
The surgical database included 68 patients who underwent on-pump CABG at the Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College from April 2022 to March 2025. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical college (IRB No. 2025-2907). Written informed consent from patients was obtained. All patients underwent preoperative cardiac CTA 3.2 [standard deviation (SD) 6.0] days before surgery. Data collection was conducted and analyses were performed following CABG surgery. Preoperative patient characteristics are presented in Table S1.
Standard surgical care for patients undergoing CABG
Surgical approach was discussed and determined in weekly cardiac team meetings based on fluoroscopy-based coronary angiography and coronary computed tomography angiography (CCTA). All CABG procedures through full median sternotomy were performed via cardiopulmonary bypass and cardioplegia under general anesthesia with right heart catheter monitoring. Left internal mammary artery (LIMA) was the sole arterial conduit; saphenous vein served as venous graft. LIMA was grafted to the left anterior descending artery. The saphenous vein graft (SVG) was used for other left and right cardiac territories, including left circumflex (LCX), obtuse marginal (OM) branch, diagonal branches, right coronary artery (RCA), posterolateral artery (PLA), and posterior descending artery (PDA). In total, 159 individual bypass grafts, including 65 LIMAs and 94 SVGs, were analyzed in 68 patients. Patients with composite grafts or sequential anastomosis were excluded. LIMA and SVG were harvested using the traditional standard open technique. Graft anastomosis utilized 7-0 polypropylene suture.
Intraoperative transit time flow measurement (TTFM) measurement
The TTFM device was equipped with 2- or 4-mm probes, depending on graft size. (VeriQ; Medi-Stim, Inc., Oslo, Norway) The TTFM technique measurement was described by Gaudino et al. in a detailed review (10). Graft flow was measured intraoperatively by TTFM before protamine administration under stable hemodynamic conditions without mechanical support devices such as cardiopulmonary bypass or intra-aortic balloon pump. MGF and pulsatility index (PI) [calculated as (maximum flow volume – minimum flow volume)/mean flow volume] were recorded. Abnormal grafts were defined as bypass grafts with PI >5.0 and MGF <20 mL/min for IMA or MGF <40 mL/min for SVG, according to the 2010 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines.
CCTA-TCAVI study
For CTA-TCAVI analysis after CABG surgery, images were acquired using computed tomography (CT) scanner (Discovery CT750HD, GE Healthcare, Waukesha, USA) with 0.625-mm (GE) slice thickness and 0.5-mm section intervals. 2-dimentional CCTA images were systematically analyzed using Cardiac Function software (Frontier, Siemens Healthineers, Germany) (11). CCTA measurements (diameter, length of the main vessel and branches) were measured during the diastolic phase of cardiac cycle, three observers in the room of CT data analysis, first observe is a cardiac surgeon, the second a CT technologist, and the third a radiologist, after completing independent analyses, the three observes presented their assessments simultaneously. Consensus was reached through group discussion to ensure accuracy and reproducibility and TCAVI was measured for each target vessel individually. Currently, there is a lack of documentation detailing the methodology of TCAVI. Hence, we hypothesized that the coronary vessel flow volume relates to anatomical characteristics, the shape of each coronary artery is similar to a cone, and the formula for the volume of the cone = 1/3 π r2h. Therefore, based on this hypothesis, TCAVI was theoretically simplified to the mathematical product of diameter squared and length (r2h). As we know, each coronary artery has numerous branches. For better clinical application, the TCAVI was indexed based on cumulative values of diameters and lengths encompassing both the potential main target coronary artery and its branch vessels. Since SYNTAX score only estimated internal diameter >1.5 mm(12,13), TCAVI was designed to include only the main coronary artery and branch diameters >1 mm. The CCTA-TCAVI algorithm was constructed as follows:
TCAVI (mm3) = diametermain artery2 (mm2) × the lengthmain artery (mm) + diameterbranch artery 12 (mm2) × the lengthbranch artery 1 (mm) + diameterbranch artery 22 (mm2) × the lengthbranch artery 2 (mm) + ... + diameterbranch artery n2 (mm2) × the lengthbranch artery n (mm).
Statistical analysis
Continuous variables were presented as mean (SD), categorical variables as percentages. Differences in interquartile range (IQR) among groups were determined by Kruskal-Wallis H test, followed by Mann-Whitney U pairwise comparisons with Bonferroni correction for multiple comparison. Logistic regression was adopted for outcome with dichotomous data. Variables with P<0.20 in univariate analysis were included in the multivariate logistic regression model, including sex, age, arterial and venous bypass graft. Odds ratio (OR) and the corresponding 95% confidence interval (CI) were calculated. Correlation between continuous values was evaluated by Pearson’s r. Receiver operating characteristic analysis was used in this study. Statistical analyses were performed using the Statistical Package for Social Science (SPSS; SPSS Inc., Chicago, IL, USA). Area under the curve (AUC), sensitivity, specificity, accuracy, and positive and negative predictive values were calculated based on the threshold maximizing the Youden index. DeLong testing compared AUC differences. A P value <0.05 was considered statistically significant.
Results
Correlation between CCTA-TCAVI and TTFM
We investigated the correlation between CCTA-TCAVI and TTFM in 65 arterial and 94 venous bypass grafts. TCAVI demonstrated positive correlation with mean graft flow (MGF) (Table S2, MGF =0.222, P=0.005), but no relationship with PI (PI =−0.104, P=0.19) via Pearson’s correlation analysis. We further explored intraoperative MGF. Intraoperatively abnormal LIMA graft flow <20 mL/min, and PI 5 and abnormal SVG flow <40 mL/min, and PI 5 was recorded. We selected 16 abnormal arterial grafts and 39 abnormal venous grafts and analyzed their CCTA-TCAVI via logistic regression analysis. Notably, the TCAVI was associated with abnormal IMA and SVG grafts (Table S3, OR =0.99, 95% CI: 0.98–1.00, P=0.004).
IQR analysis between CCTA-TCAVI and TTFM
The correlation of the CCTA-TCAVI and TTFM was continuously investigated. In our study, TCAVI IQR values of MGF were separated into Q1 [Figure 1, Q<186; MGF =29.2 (SD 2.4) mL/min] through Q4. Notably, intraoperative bypass graft flow in Q3 [408≤Q≤790; MGF =47.6 (SD 3.8) mL/min, P<0.001] and Q4 [Q>790; MGF =48 (SD 4.3) mL/min, P<0.001] were significantly higher than Q1, but PI showed no similar significance across groups.
Figure 1.
Box-and-whiskers plots illustrating intraoperative MGF into quartile (Q1–Q4) of TCAVI. The box depicts the interquartile range (IQR, 25th–75th percentile), with the horizontal line inside the box marking the median The lower and upper whiskers represent the minimum and maximum values of non-outliers. Extra dots represent outliers. Q1<186 mm3; 186≤Q2≤408 mm3; 408≤Q3≤790 mm3; Q4>790 mm3. P value <0.05 is significant. IQR, interquartile range; MGF, mean graft flow of bypass grafts; TCAVI, target coronary artery volume index.
Continuous variable dose-response relationship between CCTA-TCAVI and intraoperative abnormal MGF
Due to vessel structure, spasm, intimal hyperplasia, and thromboses, SVG longevity and long-term postoperative patency are typically inferior to those of the IMA (14). Unexpectedly, abnormal venous grafts significantly correlated with CCTA-TCAVI across different phases (Figure 2, P<0.001). However, the same phenomenon did not occur with arterial grafts across phases; no correlations existed in our detection between arterial conduits and TCAVI (P=0.91).
Figure 2.
Interquartile range analysis between CTA-TCAVI value and intraoperative abnormal MGF of arterial bypass grafts (<20 mL/min) and venous bypass grafts (<40 mL/min). Q1<186 mm3; 186≤Q2≤408 mm3; 408≤Q3≤790 mm3; Q4>790 mm3. A, arterial bypass graft; CTA-TCAVI, computed tomography angiography-target coronary artery volume index; MGF, mean graft flow; V, venous bypass graft.
Correlation analysis of CCTA-TCAVI and venous graft flow in left-sided and right-sided cardiac systems
The clear correlation between venous grafts and CCTA-TCAVI prompted investigation of whether venous graft flow differs between left-sided coronary system (LCS) and right-sided coronary system (RCS). Therefore, SVG-LCX and SVG-OM grafts in LCS, and SVG-RCA, SVG-PLA, and SVG-PDA grafts in RCS were investigated. Specifically, abnormal venous graft flow showed no association was detected with TCAVI in LCS (Figure 3, P=0.12). However, RCS correlated with TCAVI (Figure 3, P=0.002).
Figure 3.
Interquartile range of CTA-TCAVI value and intraoperative abnormal MGF of venous bypass grafts (<40 mL/min) in left-sided coronary system and right-sided coronary system. Q1<186 mm3; 186≤Q2≤408 mm3; 408≤Q3≤790 mm3; Q4>790 mm3. CTA-TCAVI, computed tomography angiography-target coronary artery volume index; L, left-sided coronary system; MGF, mean graft flow; R, right-sided coronary system.
Correlation between TTFM and three predictive indicators
Several predictive indicators for optimal target graft selection in CABG have been proposed, including coronary artery internal diameter ≥1.0 mm, or ≥70% proximal artery lumen stenosis with adequate distal run-off. Theoretically, smooth, large target coronary lumen correlates with higher blood flow volume. Therefore, we compared the three predictive indicators for correlation with TTFM. Pearson’s analysis showed association between CCTA-TCAVI and arterial and venous MGF (Table 1, MGF =0.222, P=0.005); however, no relationship was observed between coronary stenosis percentage and TTFM (MGF =0.115, P=0.15; PI =−0.017, P=0.83).
Table 1. Correlation between TTFM and three predictive indicators via Pearson analysis.
| Variable | Pearson R | P value |
|---|---|---|
| CTA-TCAVI | ||
| MGF | 0.222 | 0.005 |
| PI | −0.104 | 0.19 |
| Stenosis percentage | ||
| MGF | 0.115 | 0.15 |
| PI | −0.017 | 0.83 |
| Diameter of lumen | ||
| MGF | 0.305 | <0.001 |
| PI | −0.161 | 0.043 |
CTA-TCAVI, computed tomography angiography-target coronary artery volume index; MGF, mean grafting flow of arterial grafts and venous grafts; PI, pulsatile index; TTFM, transit time flow measurement.
Comparison of AUC area under three predictive measurements curves
We compared AUC for CCTA-TCAVI, stenosis percentage, and lumen diameter in predicting intraoperative MGF. TCAVI AUC (AUCTCAVI =0.69) was not significantly larger than those of stenosis percentage (Figure 4, AUCstenosis =0.57, P=0.59) and lumen diameter (AUCdiameter =0.62, P=0.001). Notably, TCAVI prediction of venous bypasses showed the largest AUC (AUCTCAVI =0.75) compared with stenosis percentage (AUCstenosis =0.54, P=0.02) and lumen diameter (AUCdiameter =0.67, P=0.005), but no obvious difference was observed in arterial TCAVI AUC (AUCTCAVI =0.56), indicating that venous TCAVI is more sensitive in predicting target coronary artery than stenosis percentage and lumen diameter.
Figure 4.
Comparison of AUC area under three predictive indicators curves in arterial graft and venous graft. AUC, area under the curve; CTA-TCAVI, computed tomography angiography-target coronary artery volume index.
Specific predictive value of CCTA-TCAVI successfully identified
To further evaluate CCTA-TCAVI accuracy and reliability, the cutoff value was established as 200 mm3 (Figure 5, sensitivity =86%, specificity =55%) according to Youden analysis. Current guidelines recommend functional assessment of severe coronary stenosis >70%. Therefore, we compared the standard of stenosis ≥70% for abnormal coronary artery with TCAVI ≤200 mm3. Notably, TCAVI prediction accuracy (sensitivity =86%, specificity =55%, predictive value =73%) was 13% higher, and positive predictive value was higher than coronary stenosis percentage (Table 2, sensitivity =81%, specificity =30%, predictive value =60%).
Figure 5.
AUC area under CTA-TCAVI and cutoff value was established. Youden index: sensitivity + specificity − 1. AUC, area under the curve; CT, computed tomography; CTA-TCAVI, computed tomography angiography-target coronary artery volume index; Sen, sensitivity; Spe, specificity.
Table 2. The prediction value comparison between the CTA-TCAVI (≤200 mm3) and lumen stenosis percentage (<70%).
| Variable | CTA-TCAVI | Stenosis |
|---|---|---|
| Sen | 0.86 | 0.81 |
| Spe | 0.55 | 0.30 |
| Accuracy | 0.73 | 0.60 |
| PPV | 0.70 | 0.63 |
| NPV | 0.67 | 0.51 |
CTA-TCAVI, computed tomography angiography-target coronary artery volume index; NPV, negative predictive value; PPV, positive predictive value; Sen, sensitivity; Spe, specificity.
Discussion
The preoperative strategy for patients with coronary artery disease requiring CABG. (I) We defined a quantitative volume index for target coronary arteries and observed that TCAVI might be linked with intraoperative MGF. (II) It might be useful for finding intraoperative abnormal bypass graft flow. (III) It may have potential utility to optimally select CABG target arteries. (IV) Moreover, the accuracy of TCAVI prediction value rivals that of previous indicators such as coronary stenosis percentage in our study, which may have clinical potential.
Coronary angiogram is a traditional technique helping cardiac surgeons assess target coronary arteries for CABG. However, despite adequate coronary angiogram assessment, graft failure often occurs independent of surgical technique. Therefore, comprehensive target coronary artery and bypass graft assessment before CABG is fundamental. Although cardiac surgeons prefer more accurate coronary angiogram for target coronary artery analysis, less-invasive CCTA provides advantageous quantitative information, including fractional flow reserve, internal diameter, calcium score, and three-dimensional anatomical and physiological reconstruction of target coronary arteries(15). Hence, CCTA evaluation is justification for guiding CABG. Recently, increasing numbers of cardiac surgeons emphasize preoperative target coronary artery assessment.
In our study, the correlation between TCAVI and graft flow is modest although statistically significant, several potential contributing factors may account for. The sample size remains relatively small, limiting generalizability of the findings. Additionally, technical CT limitations may lead to alteration of the results by resolution and motion artifacts. CT cannot directly assess whether stenotic lesions cause myocardial ischemia, only provides anatomical and morphological information of the coronary arteries and cannot reflect real-time hemodynamic status. To enable more objective TCAVI evaluation, we have made effort to address limitations by comprehensively analyzing target coronary arteries combined with fluoroscopy-based coronary angiography. Moreover, this study assessed only intraoperative outcomes; long-term clinical outcomes were not evaluated. Future studies with larger patient cohorts are needed to validate TCAVI clinical significance and investigate relationships between postoperative long-term survival rates and TCAVI.
Hiraoka et al. demonstrated CCTA prediction indicators including stenosis percentage, calcium score, and left ventricular mass volume (LVMV). These indicators correlated with intraoperative TTFM, potentially preventing intraoperative graft failure (3). Lukas Stastny et al. proposed a semi-quantitative measurement of target coronary artery flow volume, demonstrating intraoperative IMA flow volume related to target vessel dimensions and stenosis degree under on-pump CABG, but their target vessel volume classification method remained non-objective and crude (16). Therefore, CCTA-TCAVI in this study, offered a novel, objective perspective, reasonably demonstrating positive correlation between TCAVI and intraoperative bypass MGF through TTFM and linked with abnormal bypass grafts during CABG.
We separately explored CCTA-TCAVI relationships with arterial and venous conduits. Results showed no correlation with abnormal arterial MGF but correlation with abnormal venous MGF. The reasons may because that (I) spasm frequently affects arterial graft, abundant and highly sensitive medial smooth muscle in the arterial graft, which responds to vasoconstrictive substances such as catecholamines, histamine. Hence, even mild spasm may significantly impair the graft flow. (II) In addition, the arterial grafting competitive flow probably could not be ignored. The flow volume and pressure of ascending aorta-venous conduits is higher than subclavian artery-arterial conduits. Moreover, when intraoperative venous graft flow is <40 mL/min under identical TCAVI value, surgeons may better carefully evaluate surgical technique, including anastomosis quality and graft twisting. Additionally, we identified TCAVI cutoff value of 200 mm3 by Youden index. Specifically, when intraoperative venous graft flow is <40 mL/min and preoperative TCAVI is >200 mm3, in this circumstance, the reason for low flow volume is likely a technical issue that requires intraoperative graft revision. Furthermore, TCAVI accuracy for predicting abnormal bypass grafts was 13% higher than for lumen stenosis percentage prediction. This finding may be useful for preoperative evaluation of target coronary artery. However, clinical values should be further externally validated.
In cases of diffuse atherosclerotic coronary stenosis and irregular luminal geometry, extending into the distal vessels lie in the absence of reliable anastomotic sites and poor distal runoff. Consequentially, anastomoses tend to be unreliable, raising the risks of grafting failure, ischemic events and graft occlusion, increasing the challenge for TCAVI analysis. For target vessels with extensive diffuse atherosclerotic stenosis, our current surgical strategy is performing coronary endarterectomy to remove multiple stenotic segments, followed by CABG. The coronary lumen exhibits a cone-like morphology after endarterectomy, the TCAVI analysis remains feasible for these reconstructed vessels.
Conclusions
TCAVI as a novel predictive measurement may be useful for identifying the optimal target arteries at the time of CABG. It may have clinical potential to predict intraoperative abnormal venous grafts with high accuracy.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by Ethics Committee of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical college (IRB No. 2025-2907). Written informed consent from patients was obtained.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1523/rc
Funding: This study was supported by National High-Level Hospital Clinical Research Funding (No. 2025-GSP-QN-41).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1523/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1523/dss
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