Intraoperative assessment of coronary grafts with fluorescent angiography

A 71-year- old man with triple vessel disease was treated with off-pump coronary artery bypass grafting (CABG). The following arteries were grafted: (a) left internal thoracic artery (LITA) to first diagonal branch (D1) and left anterior descending artery (LAD) sequentially (panel A); (b) free-radial artery to right ventricular branch and distal right coronary artery; and (c) saphenous vein to middle left circumflex artery. Immediately after all grafts were anastomosed, graft patency was assessed using a new intraoperative fluorescent imaging (IFI) system (SPY) using indocyanine green injected from a central venous line. The IFI system demonstrated rapid filling and emptying of the entire graft with indocyanine green. These results were confirmed by coronary angiography 10 days after surgery. Panels A and B (supplementary movies 1 and 2, respectively, available online) show representative IFI and angiography of LITA to D1 and LAD.

Compared with on-pump CABG, off-pump surgery potentially decreases the incidence of myocardial injury, renal damage and central nervous system complications. However, these clinical benefits of off-pump CABG are partly offset by a relatively higher rate of early graft failure. The IFI system may help to reduce procedure-related, early graft failures by enabling interactive evaluation of graft patency with images similar to conventional angiography but directly in the operating room before the chest closure.