RESUMEN
PURPOSE: To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft. METHODS: Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated. RESULTS: Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes. CONCLUSIONS: When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.
Asunto(s)
Enfermedad de la Arteria Coronaria , Mortalidad Hospitalaria , Anastomosis Interna Mamario-Coronaria , Arterias Mamarias , Arteria Radial , Humanos , Arteria Radial/trasplante , Masculino , Femenino , Anciano , Resultado del Tratamiento , Persona de Mediana Edad , Factores de Tiempo , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Anastomosis Interna Mamario-Coronaria/efectos adversos , Anastomosis Interna Mamario-Coronaria/mortalidad , Arterias Mamarias/trasplante , Arterias Mamarias/cirugía , Análisis Multivariante , Estimación de Kaplan-Meier , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Modelos de Riesgos Proporcionales , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Distribución de Chi-Cuadrado , Puntaje de Propensión , Infección de la Herida Quirúrgica/mortalidad , Infección de la Herida Quirúrgica/etiologíaRESUMEN
Background: Exclusive coronary revascularization with both mammary arteries could result in lower rates of adverse events in the long term. Aim: To describe the five-year evolution of a cohort of patients operated on with this technique. Material and Methods: Follow up analyzing survival of 73 patients aged 59 ± 9 years (82% men) who underwent exclusive coronary surgery with two mammary arteries between December 1,2010 and April 12,2017. We studied their clinical characteristics, surgical results, operative morbidity and mortality and adverse events up to June 30, 2018. Results: Six patients had two-vessel lesions and 67 three-vessel lesions. The operative risk calculated by additive and logistic EuroSCORE was 2.5 and 2.3%, respectively. A mean of 3.75 anastomoses /patient were performed, 116 with left mammary artery (73 to the anterior descending artery, 38 to a diagonal artery and 5 for other objectives) and 158 with right mammary artery (69 to a first marginal artery, 23 to a second marginal artery and 64 to posterior descending artery). There was one case of mediastinitis and one (1.5%) patient died. The mean follow-up was 64.6 ± 23.7 months. The 5-year survival was 90.4%. Conclusions: Coronary revascularization with two exclusive mammary arteries allowed a complete revascularization of the heart with a low rate of complications and adverse effects at five years.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anastomosis Interna Mamario-Coronaria/métodos , Arterias Mamarias/cirugía , Complicaciones Posoperatorias/mortalidad , Factores de Tiempo , Anastomosis Quirúrgica/métodos , Anastomosis Quirúrgica/mortalidad , Reproducibilidad de los Resultados , Factores de Riesgo , Estudios de Seguimiento , Resultado del Tratamiento , Estimación de Kaplan-Meier , Anastomosis Interna Mamario-Coronaria/mortalidadRESUMEN
OBJETIVO: Avaliar a influência da técnica utilizada na dissecção das artérias torácicas na evolução de pacientes diabéticos submetidos a revascularização sem CEC. MÉTODOS: Setenta pacientes diabéticos submetidos a revascularização sem CEC com duas artérias torácicas foram avaliados. No grupo A, as artérias torácicas foram dissecadas de modo convencional, enquanto no grupo B foram esqueletizadas. RESULTADOS: A idade média do grupo A foi de 52,14±7,35 anos contra 55,71±8,1 anos no grupo B (p=0,057). No grupo A, seis (17,1%) pacientes eram diabéticos insulinodependentes contra nove (25,7%) no grupo B (p=0,561). O EUROSCORE foi de 3,97±2,49 para o grupo A contra 4,14±3,06 no grupo B (p=0,879). O número médio de anastomoses distais no grupo A foi de 3±0,77 contra 3,03±0,89 para o grupo B (p=0,981). Três (8,57%) dos pacientes do grupo A apresentaram mediastinite contra nenhum do grupo B (p=0,239). A diabetes insulino-dependente foi o único fator estatisticamente significativo (p=0,008) para mediastinite. Neste grupo, a utilização de artéria torácica interna esqueletizada diminuiu significativamente a incidência de mediastinite (p=0,044). CONCLUSÃO: A incidência de mediastinite foi menor no grupo onde ambas as artérias torácicas foram dissecadas de forma esqueletizada, apesar de, devido ao baixo número de casos, não apresentar diferença estatística. Nos portadores de diabetes insulino-dependente, 50 por cento dos pacientes do grupo em que a artéria torácica foi obtida de forma convencional apresentaram mediastinite, sendo que a utilização de artéria torácica esqueletizada diminuiu significativamente a incidência de mediastinite.
OBJECTIVE: To evaluate the influence of the technique used in the dissection of thoracic arteries in the evolution of diabetic patients submitted to OPCAB. METHODS: Seventy diabetic patients submitted to OPCAB using bilateral thoracic arteries were evaluated. In Group A, thoracic arteries were dissected as a pedicle, while in Group B they were skeletonized. RESULTS: The mean age of patients in Group A was 52.14 ± 7.35 years old versus 55.71 ± 8.1 years for Group B (p=0.057). In Group A, six patients (17.1%) were insulin dependent against nine (25.7%) in Group B (p = 0.561). The EUROSCORE was 3.97 ± 2.49 for Group A opposed to 4.14 ± 3.06 for Group B (p = 0.879). The number of distal anastomoses in Group A was 3 ± 0.77 versus 3.03 ± 0.89 in Group B (p = 0.981). Three patients (8.57%) from Group A presented with mediastinitis. Insulin dependence was the only significant risk factor (p=0.008) for mediastinitis. In this group the use of skeletonized internal thoracic arteries significantly decreased the incidence of mediastinitis (p = 0.044). Conclusion: The incidence of mediastinitis was lower in the group for which mammary arteries were dissected using skeletonization. Among insulin-dependent diabetics, 50 percent of the patients from the group in which the pedicled internal thoracic artery was utilized presented with mediastinitis; the utilization of skeletonized internal thoracic arteries significantly decreases the incidence of mediastinitis.
Asunto(s)
Adulto , Anciano , Humanos , Persona de Mediana Edad , Puente de Arteria Coronaria Off-Pump , Angiopatías Diabéticas/cirugía , Anastomosis Interna Mamario-Coronaria/efectos adversos , Arterias Mamarias/trasplante , Mediastinitis/epidemiología , Recolección de Tejidos y Órganos/métodos , Brasil/epidemiología , Angiopatías Diabéticas/tratamiento farmacológico , Hemostasis Quirúrgica/instrumentación , Hemostasis Quirúrgica/métodos , Hipoglucemiantes/uso terapéutico , Incidencia , Insulina/uso terapéutico , Anastomosis Interna Mamario-Coronaria/métodos , Anastomosis Interna Mamario-Coronaria/mortalidad , Mediastinitis/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
El uso de conductos arteriales, específicamente de la arteria mamaria izquierda, se popularizó a fines de los años 80 e inicio de los 90. pero no ocurrió igual con el uso de las dos mamarias a pesar de existir trabajos favorables a su utilización. Les presentamos nuestra experiencia consecutiva de 50 pacientes coronarios con dos mamarias operados entre enero de 1991 y junio del 2000. El objetivo del trabajo es evaluar la morbimortalidad de este procedimiento a corto plazo y la morbilidad a distancia, al igual que la sobrevida. Los resultados inmediatos mostraron una mortalidad operatoria de 0 por ciento y una morbilidad muy baja. En el seguimiento a 9 años de 42 pacientes (84 por ciento del grupo), la sobrevida fue de 100 por ciento y no existieron complicaciones cardiológicas en el 92.8 por ciento de pacientes evaluados. Basándonos en las múltiples publicaciones recientes favorables al uso de dos mamarias y en nuestros propios resultados creemos que esta modalidad de trabajo debe difundirse dado que ha sido demostrada la disminución de la morbilidad cardiológica a largo plazo, la disminución del riesgo de reoperaciones y finalmente, que aumenta significativamente la sobrevida de los pacientes en comparación de aquellos en los que se usa exclusivamente venas o una sola mamaria.