Influence of intracoronary shunt size on coronary endothelial function during off-pump coronary artery bypass.

OBJECTIVE The insertion of intracoronary shunts during off-pump coronary artery bypass surgery may induce severe endothelial dysfunction in the target arteries. The purpose of this study was to determine the role of the ratio of the shunt diameter to the target artery diameter in the development of endothelial dysfunction and to develop guidelines for selecting the most appropriate shunt size. METHODS Nine swine (25 +/- 4 kg) were used for this study. Three ClearView shunts 3 mm, 2 mm, and 1.25 mm in diameter were inserted proximally to distally via 3 arteriotomies into the right coronary artery to obtain oversizing with the 3-mm shunt, undersizing with the 1.25-mm shunt, and a satisfying congruence with the 2-mm shunt. The shunts were left in place for 15 minutes, and the levels of bleeding were quantified. Coronary rings upstream and downstream from the arteriotomies were then harvested and placed in organ chambers to study endothelium-dependent relaxations to serotonin and bradykinin. Noninstrumented coronary arteries served as controls. RESULTS A decrease of endothelium-dependent relaxation occurred with the 3-mm shunts (P <.005), which were associated with an adequate hemostasis. A decrease of endotheliumdependent relaxation occurred with the 2-mm shunts (P <.05), which were associated with intermittent bleeding, and no significant decrease of endothelium-dependent relaxation occurred with 1.25-mm shunts (P >.05), which were associated with continuous bleeding. CONCLUSIONS Intracoronary shunts are associated with different disadvantages, depending on the mismatch to the target coronary artery, and whatever their size, shunts are not the ideal device for safely obtaining a satisfactory hemostasis. These results support our clinical attitude of the selective use of intracoronary shunts.