The effect of the multiple arterial grafts compared with single arterial graft for coronary artery bypass grafting on sternal wound complications: A meta-analysis.

A meta-analysis investigation was executed to measure the influence of multiple arterial grafts (MAGs) compared with single arterial graft (SAG) for coronary artery bypass grafting (CABG) on sternal wound complications (SWCs). A comprehensive literature inspection till February 2023 was applied and 1048 interrelated investigations were reviewed. The seven chosen investigations enclosed 11 201 individuals with CABG in the chosen investigations' starting point, 4870 of them were using MAGs, and 6331 were using SAG. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of the MAGs compared with SAG for CABG on SWCs by the dichotomous approaches and a fixed or random model. MAGs had significantly higher SWC (OR, 1.38; 95% CI, 1.10-1.73, P = .005) compared with those with SAG in CABG. MAGs had significantly higher SWC compared with those with SAG in CABG. However, care must be exercised when dealing with its values because of the low number of selected investigations for the meta-analysis.

Twenty-year experience with skeletonized bilateral internal thoracic arteries for surgical myocardial revascularization. A single center experience.

BACKGROUND AND AIM OF THE STUDY: The mammary artery shows excellent long-term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We analyzed the long-term outcome of patients operated for myocardial revascularization with BITA in a single center. MATERIALS AND METHODS: Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long-term follow-up of the study group is provided. RESULTS: From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple-vessel disease were 81%, 15.3% of all procedures were performed off-pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios [OR]: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow-up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all-cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years). CONCLUSIONS: Use of skeletonized bilateral thoracic arteries shows low-rate of wound infection and good long-term outcome with low risk of repeated revascularizations, regardless of patients' age.

Intraoperative transit time flow measurements during off-pump coronary artery bypass surgery: The impact of coronary stenosis on competitive flow.

BACKGROUND: Combining preoperative angiography findings with intraoperative transit time flow measurements (TTFM) may improve patency of coronary artery bypass grafts. Nevertheless, graft flow might be impaired by native coronary flow based on the severity of stenoses, with inferior long-term outcomes. This study investigates the impact of left anterior descending artery (LAD) stenosis on competitive flow measured in left internal mammary artery (LIMA) grafts during off-pump coronary artery bypass grafting. METHODS: Fifty patients were included in this prospective single-center cohort study. LAD stenosis was assessed with quantitative coronary analysis (QCA) and stratified into three groups based on its severity. TTFM of LIMA grafts were performed with LAD open and temporarily occluded. Change in mean graft flow after LAD snaring was the primary endpoint. Secondary endpoints included further TTFM parameters, clinical outcomes, and competitive flow index (CFI), defined as the ratio of mean graft flow with open or closed LAD. RESULTS: Mean LAD stenosis as objectified with QCA was 58 ± 15%. Mean LIMA graft flow increased from 20 ml/min with open LAD to 30 ml/min with snared LAD (p < .001). TTFM cut-off values for graft patency improved in 26%-42% of patients after LAD occlusion. Median CFI was 0.66 (IQR: 0.56-0.82). Postoperative myocardial infarction occurred in 2.0% of patients, 120-day mortality was 0%, and 2-year mortality was 6.0%. CONCLUSIONS: Routine snaring of the LAD with CFI calculation during coronary artery bypass grafting is useful to detect significant competitive flow in LIMA grafts, potentially preventing unnecessary intraoperative graft revisions.

Bilateral Internal Thoracic Artery Grafting Concomitant With Other Cardiac Operations　- Insights From a European Multicenter Retrospective Study on 1,123 Consecutive Patients.

BACKGROUND: The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III-IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively. CONCLUSIONS: BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.

Double versus single source left-sided coronary revascularization using bilateral internal thoracic artery graft alone.

Left-sided coronary revascularization with bilateral internal thoracic artery (BITA) graft is performed usually either with an in situ (double source) or Y-graft configuration (single source). Two hundred fifty-three (mean age, 67.1 ± 9.5 years) patients underwent isolated left-sided coronary revascularization with BITA graft alone at the present authors' institution (2000-2015). Skeletonized BITA grafts were used either in an in situ (n = 199) or Y-graft configuration (n = 54). Forty pairs were identified with the propensity score-matching. Outcomes of the two groups were compared both in unmatched and matched series. Cardiopulmonary exercise testing was performed in five pairs of selected, asymptomatic matched patients having patent BITA grafts at coronary computed tomography angiography. BITA in situ patients had lower risk profiles than BITA Y-graft patients (median EuroSCORE II, 1.9 vs. 2.9%, p = 0.051). In-hospital mortality (5.6 vs. 0, p = 0.0093) and the rates of postoperative complications except deep sternal wound infection were higher in BITA Y-graft patients. However, these differences were not confirmed in matched groups. During the follow-up period (mean, 5.9 ± 4.3 years), between BITA in situ and BITA Y-graft matched patients, there were no differences in non-parametric estimates of freedom from cardiac death (p = 0.6), major adverse cardiac and cerebrovascular events (MACCEs, p = 0.65), and repeat coronary revascularization (p = 0.44). Adjusted risk estimates of MACCEs according to BITA configuration confirmed no superiority of the one configuration over the other (p ≥ 0.44). No significant differences were found at the cardiopulmonary exercise testing. Results of left-sided coronary revascularization with BITA graft alone are independent from BITA configuration, even after stress testing.

18F-FDG PET reveals unique features of large vessel inflammation in patients with Takayasu's arteritis.

PURPOSE: The object of this study was to assess whether 18F-fluorodeoxyglucose PET/CT (FDG PET/CT) provides novel information in patients with Takayasu's arteritis (TA) in addition to that provided by current activity assessment, to analyse the effects of possible confounders, such as arterial grafts, and to verify whether PET/CT could be informative in lesions <4 mm thick. METHODS: We studied 30 patients with TA, evaluated from October 2010 to April 2014 by both PET/CT and magnetic resonance imaging (MRI). All arterial lesions were evaluated by PET both qualitatively (positive/negative) and semiquantitatively (maximum standardized uptake value, SUVmax), and the thickness of lesions in the MRI field of view was evaluated. In a per-patient analysis, the relationships between the PET data and acute-phase reactants and NIH criteria for active TA were evaluated. In a per-lesion analysis, the relationships between the PET features of each lesion and MRI morphological data were evaluated. The effects of the presence of arterial grafts were also evaluated. RESULTS: Increased FDG uptake was seen in 16 of 30 patients (53%) and in 46 of 177 vascular lesions (26%). Significant periprosthetic FDG uptake was seen in 6 of 7 patients (86%) with previous vascular surgery and in 10 of 11 of grafts (91%). Graft-associated uptake influenced the PET results in three patients (10%) and the SUVmax values in five patients (17%). Of 39 lesions with significant FDG uptake, 15 (38%) were <4 mm thick. Lesion thickness was correlated with lesion SUVmax in FDG-avid lesions only. FDG arterial uptake was not associated with systemic inflammation or NIH criteria. CONCLUSIONS: PET/CT reveals unique and fundamental features of arterial involvement in TA. PET/CT may be useful in the assessment of local inflammatory and vascular remodelling events independent of systemic inflammation during follow-up, even in lesions in which the arterial wall is <4 mm. The presence of arterial grafts is a potential confounder. Prospective studies are required to correlate PET findings with relevant clinical outcomes.

Short- and long-term results of radial artery and saphenous vein grafts in the right coronary system: a propensity-matched study.

PURPOSE: The selection of optimal grafts for the right coronary artery remains controversial. This study aims to evaluate the short- and long-term results of radial artery (RA) grafts and saphenous vein grafts (SVGs) to the right coronary artery. METHODS: We reviewed, retrospectively, isolated coronary artery bypass grafts, placed between 1997 and 2007, and compared the long-term results of patients who received RA (n = 110) grafts with those of patients who received SVGs (n = 264) using propensity-score matching for risk. The preoperative predictors of graft occlusion were investigated on a per case basis. RESULTS: Superior survival was noted in the unmatched RA group, but late outcomes after propensity-score matching yielded 91 patient pairs that were similar in the two groups. Graft failure was not correlated with mortality, but showed strong correlation with cardiac events in all patients. The predictors of graft occlusion in the RA group were mild proximal stenosis and low indexing glomerular filtration rates for body surface area, whereas those in the SVG were female gender and off-pump coronary artery bypass grafting. CONCLUSIONS: There were no significant differences in long-term outcomes between the RA and SVG groups. Predictors of graft occlusion differed between the groups. Notably, renal dysfunction impaired radial patency, emphasizing the importance of careful graft selection.

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly.

Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.

Composite Y-Grafting Using the Left Internal Thoracic Artery: Survival and Angiography in 198 Cases.

BACKGROUND: Extended left internal thoracic artery (LITA) harvesting allows maximal grafting to the anterior and lateral walls with a single ITA conduit. This study evaluates outcomes following the use of a LITA Y graft as the primary grafting strategy. METHODS: Patients who underwent LITA composite Y-grafting (n=198) between 1995 and 2009 were identified from a cardiac surgical database. Follow-up (mean 13.1 years) was obtained by cross-reference with the state death registry and local cardiology databases. RESULTS: Operative mortality was zero in the 168 patients who underwent isolated CABG and was 3.5% overall. There were no episodes of perioperative myocardial infarction. Kaplan-Meier 10-year survival was 75.9%. Independent predictors of worse late survival were age, diabetes, chronic obstructive pulmonary disease and pre-existing left ventricular dysfunction. There were 53 episodes of post-discharge angiography at an average of 5.8 years post LITA Y grafting. Twenty cases of LITA Y graft failure were identified, predominantly affecting the free limb (n=15). The ratio of symptom driven angiography to Y graft failure increased over time. Eighteen patients required revascularisation, percutaneous intervention in 15 and reoperative coronary bypass in three. CONCLUSIONS: Left Internal Thoracic Artery Y grafting is a feasible revascularisation strategy with satisfactory outcomes. These are comparable to other arterial composite graft configurations. A LITA Y allows efficient conduit use without compromising the in situ LITA graft.

A lateral costal artery complicating video-assisted thorascopic surgery (VATS) pleurectomy.

The lateral costal artery is a rare variant arising from the internal thoracic artery (ITA). It has been associated with steel syndrome after coronary artery bypass using the ITA as a conduit. Clinically, it is under-reported in the literature. We report the presence of a prominent lateral costal artery, coursing below the diaphragm, discovered during video-assisted thorascopic surgery pneumothorax surgery and preventing parietal pleurectomy.

Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8 ± 7.7 vs. 7.6 ± 6.1 %, p = 0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2 %, p = 0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2 %, p = 0.022). The mean follow-up was 4.7 ± 3.3 years. There were no differences between the two groups in overall survival (p = 0.79), freedom from cardiac and cerebrovascular deaths (p = 0.73), major adverse cardiac and cerebrovascular events (p = 0.63) and heart failure hospital readmission (p = 0.64). Predictors of decreased late survival were diabetes (p = 0.0062) and congestive heart failure (p = 0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.

The Impact of Diabetes on Early Outcomes after Routine Bilateral Internal Thoracic Artery Grafting.

BACKGROUND: Increased risk of postoperative complications limits use of bilateral internal thoracic artery (BITA) grafting in diabetic patients. The authors' experience in routine BITA grafting was reviewed to investigate the impact of diabetes on early outcomes. METHODS: Among the 4508 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery from January 1999 throughout August 2015, skeletonised BITA grafts were used in 3228 (71.6%) patients, 972 diabetic and 2256 non-diabetic. After one-to-one propensity score (PS)-matched analysis, 819 pairs of diabetic/non-diabetic patients were compared for postoperative outcomes. The operative risk was calculated for each patient according to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II). RESULTS: Although diabetic had higher risk profiles than non-diabetic patients both in unmatched (EuroSCORE II: 5.3±7.3% vs. 3±4.2%, p<0.0001) and PS-matched series (EuroSCORE II: 5.1±7.1% vs. 3.6±4.3%, p<0.0001), there were no differences in hospital mortality (2.2% vs. 1.8%, p=0.52 and 2.1% vs. 2.3%, p=0.74, respectively). In PS-matched pairs, the use of adrenergic agonists (p=0.03), postoperative bleeding (p=0.0055) and deep incisional sternal wound infection (p=0.0018) were more frequent in diabetic patients who had a mean of longer hospital stays (p=0.023). CONCLUSIONS: Bilateral internal thoracic artery grafting may be routinely performed even in diabetic patients despite higher risk profiles. Increased postoperative complications prolong hospital stay but do not impact on early mortality.

Minimally Invasive Coronary Artery Bypass Grafting is the Future: Pro.

Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.

Comparison of Intercostal and Subxiphoid Left Pleural Drain After Coronary Artery Bypass Grafting (CABG) Surgery: A Systematic Review and Meta-Analysis.

Coronary artery bypass grafting (CABG), a prevalent surgery for coronary artery disease, often involves left internal mammary artery harvesting, necessitating left pleural drain insertion. This can lead to pain, discomfort, and respiratory issues. This analysis compares outcomes between subxiphoid and intercostal left pleural drain insertion. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis involved searches in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected based on primary outcomes (postoperative ventilator support duration and pain score) and secondary outcomes (percentage predicted vital capacity (VC), forced VC (FVC), and partial pressure of oxygen (PO2) in arterial blood gas (ABG) analysis). Statistical analysis used a random effect model, pooled risk ratio, and I2 heterogeneity. Nine studies (seven randomized and two nonrandomized) with 412 patients met the inclusion criteria. Pooled analysis indicated reduced ventilation time and postoperative pain with the subxiphoid drain compared to the intercostal drain. Spirometry parameters showed improved VC, FVC, and PO2 in ABG analysis. This meta-analysis suggests that subxiphoid pleural drain insertion in CABG patients is associated with shorter ventilation times, lower pain scores, and improved pulmonary function compared to intercostal drain placement.

Impact of High Lipoprotein(a) on Long-Term Survival Following Coronary Artery Bypass Grafting.

BACKGROUND: Lipoprotein(a) is a possible causal risk factor for atherosclerosis and related complications. The distribution and prognostic implication of lipoprotein(a) in patients undergoing coronary artery bypass grafting remain unknown. This study aimed to assess the impact of high lipoprotein(a) on the long-term prognosis of patients undergoing coronary artery bypass grafting. METHODS AND RESULTS: Consecutive patients with stable coronary artery disease who underwent isolated coronary artery bypass grafting from January 2013 to December 2018 from a single-center cohort were included. The primary outcome was all-cause death. The secondary outcome was a composite of major adverse cardiovascular and cerebrovascular events. Of the 18 544 patients, 4072 (22.0%) were identified as the high-lipoprotein(a) group (≥50 mg/dL). During a median follow-up of 3.2 years, primary outcomes occurred in 587 patients. High lipoprotein(a) was associated with increased risk of all-cause death (high lipoprotein(a) versus low lipoprotein(a): adjusted hazard ratio [aHR], 1.31 [95% CI, 1.09-1.59]; P=0.005; lipoprotein(a) per 1-mg/dL increase: aHR, 1.003 [95% CI, 1.001-1.006]; P=0.011) and major adverse cardiovascular and cerebrovascular events (high lipoprotein(a) versus low lipoprotein(a): aHR, 1.18 [95% CI, 1.06-1.33]; P=0.004; lipoprotein(a) per 1-mg/dL increase: aHR, 1.002 [95% CI, 1.001-1.004]; P=0.002). The lipoprotein(a)-related risk was greater in patients with European System for Cardiac Operative Risk Evaluation <3, and tended to attenuate in patients receiving arterial grafts. CONCLUSIONS: More than 1 in 5 patients with stable coronary artery disease who underwent coronary artery bypass grafting were exposed to high lipoprotein(a), which is associated with higher risks of death and major adverse cardiovascular and cerebrovascular events. The adverse effects of lipoprotein(a) were more pronounced in patients with clinically low-risk profiles or not receiving arterial grafts.

Continuous Glucose Monitoring System After Coronary Artery Bypass Graft Surgery: A Feasibility Study.

BACKGROUND: Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device. METHODS: We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated. RESULTS: From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84-0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74-0.82) and ward agreement was 0.91 (95%C.I.: 0.89-0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85-0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29-0.33). CONCLUSIONS: Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.

Left Internal Thoracic Artery versus Saphenous Vein Grafts to Left Anterior Descending Artery after Isolated Coronary Artery Bypass Surgery.

BACKGROUND: This study compared perioperative outcomes and long-term survival of saphenous vein grafts (SVGs) versus left internal thoracic artery (LITA) to left anterior descending artery (LAD) in isolated coronary artery bypass graft surgery (CABG). METHODS: In this retrospective, single-centre study, we included patients with primary isolated CABG from January 2001 to July 2022. Baseline demographics were compared between SVG-LAD and LITA-LAD. Univariable and multivariable regressions were performed for predictors of in-hospital death. Propensity score matching was performed for LITA-LAD vs. SVG-LAD. Kaplan-Meier survival curves were generated for comparison of survival. Cox proportional hazards model was used for predictors of survival. RESULTS: A total of 8237 patients (1602 SVG-LAD/6725 LITA-LAD) were included. Median age was 67.9 years (LITA-LAD; 67.1 years vs. SVG-LAD; 71.7 years, p < 0.01). A total of 1270 pairs of SVG-LAD were propensity-matched to LITA-LAD. In matched cohorts, in-hospital mortality (0.8% vs. 1.6%, LITA-LAD and SVG-LAD respectively; p = 0.07), deep sternal wound infection, new cerebrovascular events, renal replacement therapy and hospital stay >30 days were similar. SVG-LAD did not adversely affect in-hospital mortality (OR; 2.03, CI; 0.91, 4.54, p = 0.08). Median long-term survival was similar between the groups (13.7 years vs. 13.1 years for LITA-LAD and SVG-LAD respectively, log rank p < 0.31). SVG-LAD was not a predictor of adverse long-term survival. (HR; 1.06, 95% CI; 0.92, 1.22, p < 0.40). Long-term survival was better with LITA-LAD for LVEF <30% (log rank p < 0.03). CONCLUSIONS: There was no difference in the propensity-matched cohorts for use of SVG vs. LITA to the LAD. Further contemporary long-term studies are needed for substantiation.

The choice of conduits in coronary artery bypass surgery.

Choosing appropriate bypass conduits is important in the consideration of long-term outcomes after surgical revascularization. When deciding on a grafting strategy, attention should be given to technical, anatomic, and angiographic determinants of conduit properties, as well as the clinical characteristics of the patient. The aim of the study was to present a current review of available choices of conduits in coronary artery bypass surgery. To date, only 4 conduits have proven to be effective: the saphenous vein (SVG), the internal mammary arteries (IMAs), the radial artery (RA), and the right gastroepiploic artery (RGEA). The IMA has unique biological properties that confer protection to intimal growth and atherosclerotic plaque formation, making it the conduit of choice for coronary artery bypass grafting. SVG exhibits a lower patency rate than those of IMAs. The RGEA allows revascularization of the inferior wall but is less commonly used, given that it is more prone to spasms.

Is the COMPASS pointing towards clinical equipoise for the right internal mammary artery?

The right internal mammary artery (RIMA) has been considered the second-best graft after the left internal mammary artery by many. Recent guidelines have awarded class IIa recommendation for using the RIMA. The findings of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS)-coronary artery bypass grafting (CABG) sub-study showed a high graft failure rate for the RIMA. The findings of the study should initiate further scientific scrutiny of the RIMA and studies need to be carried out for further evaluation of the RIMA as a conduit.

Up-to-Date, Skeletonized or Pedicle Bilateral Internal Mammary Artery; Does It Matter?

PURPOSE: In this article, we reported on the up-to-date literature regarding skeletonized bilateral internal mammary artery (BIMA) flow and the effect on sternal perfusion. We also reviewed the pros and cons of the skeletonization technique versus the conventional pedicle technique for harvesting the BIMA. METHODS: We performed an up-to-date review using the PubMed database, with a specific focus on the contemporary published literature. RESULTS: BIMA skeletonization can preserve the sternal microcirculation, minimize tissue damage, and maintain blood supply to the chest wall at the tissue level. This effect is also apparent in diabetics. Deep sternal wound infection (DSWI) rates are significantly less with skeletonization versus the conventional pedicle technique and are comparable to single internal mammary artery harvesting. CONCLUSIONS: Contemporary large-scale studies demonstrate that skeletonization of the BIMA increases conduit length, provides superior flow, reduces the incidence of DSWIs, and improves late survival. Hopefully, this review will increase awareness of the compelling evidence in favor of using skeletonized internal mammary arteries and stimulate increased uptake of BIMA revascularization surgery.