Endothelial dysfunction of internal thoracic artery graft in patients with chronic kidney disease Takeshi Kinoshita, PhD, MD, Masashi Tawa, PhD, Tomoaki.

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Endothelial dysfunction of internal thoracic artery graft in patients with chronic kidney disease Takeshi Kinoshita, PhD, MD, Masashi Tawa, PhD, Tomoaki Suzuki, PhD, MD, Yoshinari Aimi, PhD, MD, Tohru Asai, PhD, MD, Tomio Okamura, PhD, MD The Journal of Thoracic and Cardiovascular Surgery Volume 153, Issue 2, Pages 317-324.e1 (February 2017) DOI: 10.1016/j.jtcvs.2016.09.037 Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Typical example of en-face staining of the luminal surface using silver nitrate solution in endothelium-intact (left panel) and -denuded (right panel) internal thoracic artery strip (bar = 50 μm). The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Relaxant responses of ITA strips. Data are expressed as means ± standard error of the mean. Group comparison was performed with the use of an 1-way analysis of covariance and Bonferroni test for post hoc analysis. Precontraction was used as covariate, and the association between the CKD stage (independent variable) and maximal relaxation response to ACh (dependent variable) was evaluated. A, Comparison of ACh-induced relaxations in ITA strips with (+) or without (−) E among patients stratified by CKD stage (GFR >60, 30-60, and <30). *P < .05 versus GFR <30 E(+), †P < .05 versus GFR 30-60 E (+). B, Effect of the NO synthase inhibitor on the ACh-induced relaxations in ITA strips with endothelium among patients stratified by CKD stage (GFR >60, 30-60, and <30). *P < .05 versus GFR >60 + L-NA, †P < .05 versus GFR 30-60 + L-NA. C, Comparison of SNP-induced relaxations in ITA strips with endothelium among patients stratified by CKD stage (GFR >60, 30-60, and <30). GFR, Glomerular filtration rate; E, endothelium; L-NA, NG-nitro-L-arginine; ACh, acetylcholine; SNP, sodium nitroprusside. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Scatter-plots of the relationship between maximal ACh-induced relaxation and GFR (n = 110). The best mathematical curve fit was a cubic (R2 = 0.686). GFR, Glomerular filtration rate. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Scatter-plot graphs showing the relationship between precontraction and maximal ACh-induced relaxation in patients with GFR >60 (A), 30 to 60 (B), and <30 (C) mL/min/1.73 m2. ACh, Acetylcholine; GFR, glomerular filtration rate. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Distribution of glomerular filtration rate. GFR, Glomerular filtration rate. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Endothelial function of internal thoracic artery grafts to release nitric oxide was impaired in patients with chronic kidney disease. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Video 1 Typical example of skeletonized harvesting and off-pump beating coronary artery bypass grafting in our institution. Skeletonization of the left internal thoracic artery (LITA; 00:00-00:32): The LITA was harvested, starting with the endothoracic fascia incised with an electrocautery about 5 to 10 mm medial to the internal thoracic vein. As the fascia was pulled down with forceps, the undersurface of the vein was exposed with an inactive diathermy tip. The cautery tip was used to gently separate the vein and ITA without activation. An ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, Ohio) was used to treat small branches of ITA by applying the activated tip gently for a few seconds. Subsequently, protein coagulation was induced, which sealed the cut surface safely. The LITA was harvested near its origin all the way to the subclavian vein, with all branches divided securely in the same way. Anastomoses (00:33-01:08): The skeletonized LITA was used as a pedicled graft to the distal left anterior descending artery. After positioning of the heart, a coronary stent of 2.0 mm was inserted. Under hemodynamically stable conditions with no arrhythmia, the anastomosis was constructed in an end-to-side fashion with a 7-0 polypropylene running suture. After completion of the anastomosis, the fibrous tissue around the skeletonized LITA was fixed on the heart surface to avoid twisting or kinking. The graft flow was assessed by transit time flowmetry (VeriQc; MediStim, Oslo, Norway) after each anastomosis construction. Video available at: http://www.jtcvsonline.org/article/S0022-5223(16)31155-2/addons. The Journal of Thoracic and Cardiovascular Surgery 2017 153, 317-324.e1DOI: (10.1016/j.jtcvs.2016.09.037) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions