Current trends in bilateral internal thoracic artery use for coronary revascularization: Extending benefit to high-risk patients.

BACKGROUND: We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists among perceived "high-risk" patients, compared with the use of left internal thoracic artery alone. METHODS: A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in "high-risk" patients (ejection fraction <40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated. RESULTS: A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the "high-risk" subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival. CONCLUSIONS: Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique.

Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting.

OBJECTIVE: Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used. METHODS: In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts. RESULTS: From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years. CONCLUSIONS: Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.

Pseudoaneurisma de la arteria mamaria interna como complicación de una biopsia selectiva de ganglio centinela / Internal mammary artery pseudoaneurysm as a complication of sentinel node biopsy

No disponible

Using skeletonised grafts for coronary artery bypass grafting.

Coronary artery bypass graft surgery relieves angina symptoms and reduces mortality among ischaemic heart disease patients. It remains the gold standard for the treatment of multi-vessel and left main coronary artery disease. It is a well-known fact that internal mammary artery conduits have excellent and long-lasting patency when used for coronary artery bypass grafting. Its supremacy is largely because it prevents atherosclerosis. The old-style internal mammary artery bypass grafting, classically known as pedicle grafting, includes a circular rim of tissue around the graft. Bilateral pedicled internal mammary arteries, especially among diabetic patients, have been reported to cause complications in the sternum like sternal osteomyelitis. In many studies it has been reported that dissection of pedicled internal mammary artery can lead to sternal devascularisation which can lead to higher incidence of infections. Considering the higher incidence of deep sternal infections in patients with double pedicled arterial grafts, dissection of internal mammary artery in skeletonised manner was proposed. In this review, we outline the advantages of skeletonised grafting with respect to incidence of sternal infection, patency rates, blood flow, post-coronary artery bypass graft pain and the length of the graft.

Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach.

BACKGROUND: Although the potential survival benefit of bilateral internal mammary artery (BIMA) grafting in comparison with single internal mammary artery (SIMA) grafting has been emphasized by many investigators, the use of BIMA is still low in clinical practice in the absence of randomized trials and long-term results. In the current study, we aimed to assess if there is a long-term survival benefit of BIMA up to 10 years after coronary bypass surgery. METHODS AND RESULTS: We selected published articles comparing survival between SIMA and BIMA patients with follow-up duration of more than a mean of 9 years. We evaluated the log hazard ratio with 95% confidence interval for included studies by using a random-effects meta-analysis. Nine eligible observational studies provided 15 583 patients (8270 SIMA and 7313 BIMA) for meta-analysis. Five studies used propensity score methods for statistical adjustment, 2 with a propensity score-based patient-matching method and 3 with quintile-based stratification. A significant reduction in mortality by using BIMA was observed (hazard ratio, 0.79; 95% confidence interval, 0.75-0.84); no study showed any significantly harmful effect of BIMA on survival. Subgroups of studies using different statistical approaches-unmatched, quintile-based propensity score analysis, and propensity score-based exact patient matching-all showed the survival benefit of BIMA grafting. CONCLUSIONS: BIMA grafting appears to have better survival with up to 10 years follow-up in comparison with SIMA grafting. Long-term survival benefit of BIMA seems to continue in the second decade after surgery. An ongoing randomized trial comparing SIMA and BIMA groups will add evidence on this issue.

Hybrid coronary revascularization for multivessel coronary artery disease.

Hybrid coronary revascularization intends to combine the durability and survival advantage of the left internal mammary artery to left anterior descending coronary artery graft by a minimally invasive surgical procedure and the interventional therapy for non-left anterior descending coronary artery vessels to achieve complete revascularization. It provides a feasible and attractive alternative to conventional coronary artery bypass grafting and percutaneous coronary intervention to target multivessel coronary artery disease, and advances the individualized, patient-oriented treatment for heart disease. In initial experiences, this new approach has yielded favorable early or midterm results in selected patients with multivessel coronary artery disease. However, available data related to these outcomes following hybrid revascularization are limited to retrospective studies with relatively small sample sizes. In this review, we aim to provide an overview of hybrid revascularization, and discuss appropriate patient selection, procedure techniques, and the main literature pertaining to the hybrid revascularization.

Is bilateral internal thoracic artery use safe in the elderly?

BACKGROUND: The strategy of bilateral mammary artery grafting is often not considered for elderly patients due to perceived concerns of increased morbidity and mortality. The objective of this study is to explore the safety of bilateral mammary in elderly patients. METHODS: Out of 7746 patients who underwent coronary artery bypass grafting using at least one internal thoracic artery (ITA), there were 3940 patients aged 65 years or greater, and of those, 3581 patients had a single ITA (SITA) and 359 patients had bilateral ITAs (BITAs). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCEs). Secondary outcomes included re-exploration for bleeding, blood transfusions, sternal wound infections, and intensive care unit and hospital length of stay. RESULTS: The incidence of mortality and MACCE were similar in both groups (mortality BITA 2.6%, SITA 3.6%, p = 0.25, MACCE BITA 8.5%, SITA 6.1%, p = 0.13). Superficial and deep sternal site infections were significantly more prevalent in the BITA group than the SITA group [superficial OR 0.42, 95% CI [0.23-0.75] (p = 0.003) and deep OR 0.29, 95% CI [0.14-0.58 (p = 0.0005)]. CONCLUSION: Use of BITA is safe in the elderly with respect to mortality and early cardiovascular outcome. BITA use in the elderly is associated with an increased risk of sternal wound infection. Our experience in this situation suggests that there is a maximum age (approximately 74 years) beyond which the combined risk of MACCE and wound complications supersedes the benefits in terms of sternal infections.

Current status of coronary artery bypass grafting.

The number of cases of coronary artery bypass grafting (CABG) reached more than 21 000 in Japan in 2002, and the operative mortality decreased to less than 1%, including emergency operations. The annual number of CABGs in Japan declined 17% after 2003 to 18 000 cases in 2005 owing to unrestricted percutaneous coronary intervention (PCI) with drug-eluting stents. However, CABG is the best treatment for multivessel coronary artery disease based on the comparative data of PCI versus CABG. There have been two trends in CABG during the last decade. One is the widespread use of off-pump (OP) CABG, and the other is multiple coronary artery revascularization. In 2004 and 2005, approximately 60% of all isolated CABG procedures in Japan were performed without cardiopulmonary bypass. In a study of long-term outcomes comparing PCI with drug-eluting stents versus CABG with only arterial grafts, the latter was carried out in 52% of total cases and in 66% of OPCAB cases. OPCAB with multiple arterial grafts has become the standard CABG in Japan.

Revascularização da artéria marginal com uso da artéria torácica interna direita pediculada retroaórtica sem circulação extracorpórea / Off-pump grafting of the circunflex artery with pedicled retro-artic right internal thoracic artery graft

Objetivo: a revascularização miocárdica(RM) sem circulação extracorpórea(CEC) tem demonstrado proporcionar redução da mortalidade e da morbidade. Também o uso bilateral das artérias torácicas internas(ATis) pode oferecer benefício adiocinal, conferindo maior sobrevida. Apresentamos técnica de revascularização miocárdica utilizando ambas ATis pediculadas, com a ATI direita(ATID), passada retroaórtica, para revascularizar os ramos da artéria circunflexa(ACx), sem CEC.Método: Foram estudados 26 pacientes submetidos à RM sem CEC, com enxertos bilaterais de ATis, sendo a ATI esquerda(ATIE) dirigida para a artéria descendente anterior(ADA) e a ATID, pediculada através do seio transverso, anastomosada aos ramos da ACx. Foram analisados 21 pacientes do sexo masculino e cinco do feminino, a idade variou de 42 e 74 anos. As co-morbidades associadas foram infarte do miocárdio prévio em 18(69 por cento) pacientes, diabetes mellitus em 10(38 por cento), insuficiência renal em quatro(7,7 por cento) e AIDS em um(3,8 por cento) doente.Resultados: Nenhum paciente apresentou alteração de ECG ou elevação enzimática no pós-operatório. As pontes por paciente variaram de 2 a 4(média de 3,0 pontes/paciente). Não houve infecção ou deiscência esternal. Um paciente apresentou AVC no 4ºPO e faleceu. A permanência hospitalar pós-operatória variou entre 3 e 12 dias(média 5,8 dias). A duração do seguimento tardio foi de 2 a 38 meses. Não houve eventos cardiovasculares ou óbitos tardios.Conclusões: Esta técnica, possibilitando a revasculrização dos ramos da artéria circunflexa com enxerto de ATI direita pediculada, sem uso de CEC, potencialmente amplia os benefícios da cirurgia de revascularização miocárdica

Robotic coronary artery surgery--the evolution of a new minimally invasive approach in coronary artery surgery.

BACKGROUND: With the introduction of a wrist-enhanced robotic surgical system into minimally invasive cardiac surgery, the outlook of performing closed chest coronary artery bypass operations became a reality. METHODS: Since May, 1999, this new wrist-enhanced instrumentation has been used in 109 (79 male, 30 female, median age 63 +/- 9.9 years) patients. Seven suffering from single vessel coronary artery disease (SVD) and double vessel disease (DVD) were treated as totally endoscopic coronary artery bypass (TECAB). 60 with SVD underwent a wrist-enhanced, minimally invasive direct coronary artery bypass procedure. 25 with DVD were treated using the robotically enhanced Dresden Technique coronary artery bypass. RESULTS: Survival was 100%. In all patients the IMAs were safely harvested totally endoscopically. In the TECAB group, all patients were operated via a three-point stab incision. Data were observed during and after the operation. CONCLUSIONS: Our preliminary experiences with this new surgical technique for the robotically enhanced, minimally invasive treatment of coronary artery disease promote an optimistic way of thinking about the further development of these procedures.

Perspectives of operative myocardial revascularization--minimally invasive coronary bypass--an alternative?

Minimally invasive direct coronary artery bypass surgery has evolved as a reliable method to perform left internal mammary artery (LIMA) bypass surgery to the LAD. This novel technique represents a synthesis of known approaches to coronary surgery using sternotomy without extracorporeal circulation and limited access techniques in general thoracic surgery. Applying specially designed tools for both harvesting the internal mammary artery and mechanically stabilizing the anterior surface of the heart during anastomosis, this approach is gaining widespread acceptance. A steadily growing number of patients with proximal LAD lesions are submitted to cardiac surgery and the procedure is performed with increasing success rates, now approaching 98% short term patency. Improved cosmetic results, less surgical trauma, decreased length of stay in the hospital, and comparable longterm results to open LIMA bypass to LAD are the key characteristics of this new approach to single vessel coronary disease.

Resultados preliminares de una nueva técnica de revascularización miocárdica mínimamente invasiva / Preliminaries results about new technique of minimally invasive direct coronary artery bypass grafting

Antecedentes: La cirugía coronaria mínimamente invasiva (CRMMI) intenta disminuir la invasividad de la cirugía convencional (CRM). Objetivo: Presentar los resultados iniciales de una técnica de CRMMI y compararla con los de la CRM. Diseño: Estudio observacional prospectivo (grupo experimental), observacional histórico (grupo control). Población: 20 pacientes operados con CRMMI (experimental) y 36 con CRM (control), todos con lesión única de descendente anterior (DA). Método: Descripción de técnica quirúrgica y análisis de morbimortalidad comparativo entre CRMMI y CRM. Resultados: En el grupo con CRMMI el 60 por ciento (12/20) presentaba algún factor de riesgo importante. No surgieron durante las operaciones situaciones que no pudieron ser resueltas por el mismo abordaje, excepto 2 casos de conversión (10 por ciento). El dolor torácico en el posoperatorio alejado fue importante en el 15,8 por ciento (3/19). Los resultados comparativos CRMMI vs CRM fueron: antecedentes CRM previa 20 por ciento (4/20) vs 2,7 por ciento (1/36) p < .04, infarto posoperatorio 5 por ciento (1/20) vs 2,7 por ciento (1/36) p = NS, mortalidad operatoria 0 por ciento (0/20) vs 2,7 por ciento (1/36) p = NS y mortalidad a 6 meses 5 por ciento (1/20) vs 5,7 por ciento (2/35) p = NS. Conclusión: La CRMMI se presenta como una alternativa válida para tratar las estenosis proximales únicas de DA

Resultados preliminares de una nueva técnica de revascularización miocárdica mínimamente invasiva / Preliminaries results about new technique of minimally invasive direct coronary artery bypass grafting

Antecedentes: La cirugía coronaria mínimamente invasiva (CRMMI) intenta disminuir la invasividad de la cirugía convencional (CRM). Objetivo: Presentar los resultados iniciales de una técnica de CRMMI y compararla con los de la CRM. Diseño: Estudio observacional prospectivo (grupo experimental), observacional histórico (grupo control). Población: 20 pacientes operados con CRMMI (experimental) y 36 con CRM (control), todos con lesión única de descendente anterior (DA). Método: Descripción de técnica quirúrgica y análisis de morbimortalidad comparativo entre CRMMI y CRM. Resultados: En el grupo con CRMMI el 60 por ciento (12/20) presentaba algún factor de riesgo importante. No surgieron durante las operaciones situaciones que no pudieron ser resueltas por el mismo abordaje, excepto 2 casos de conversión (10 por ciento). El dolor torácico en el posoperatorio alejado fue importante en el 15,8 por ciento (3/19). Los resultados comparativos CRMMI vs CRM fueron: antecedentes CRM previa 20 por ciento (4/20) vs 2,7 por ciento (1/36) p < .04, infarto posoperatorio 5 por ciento (1/20) vs 2,7 por ciento (1/36) p = NS, mortalidad operatoria 0 por ciento (0/20) vs 2,7 por ciento (1/36) p = NS y mortalidad a 6 meses 5 por ciento (1/20) vs 5,7 por ciento (2/35) p = NS. Conclusión: La CRMMI se presenta como una alternativa válida para tratar las estenosis proximales únicas de DA (AU)

[20 years of surgical coronary revascularization. The importance of arterial grafts]. / Vent'anni di rivascolarizzazione chirurgica coronarica. Importanza degli innesti arteriosi.

Myocardial revascularization surgery by means of a saphenous aortocoronary by-pass is in its third decennial of employment. Also if it has been proved of value in bettering the survival in various kind of anatomical lesions, and in resolving the anginal symptomatology in a majority of patients, it has been granted of a simple palliative surgical procedure in view of the evolutive characteristic of arteriosclerotic disease and of the progressive degenerations of the internal saphenous vein. The wide use of arterial transplants, internal mammary artery and gastroepiploic artery, gives these patients satisfying results. Due to the more technical complexity of its preparation and anastomosis, internal mammary artery was very late adopted by surgeons. Nevertheless it has acquired a title of noblesse demonstrating its long survival, and in the meantime has given an impulse to the use of the gastroepiploic artery. According to our experience 80% of our patients can obtain a complete revascularization using exclusively simple or sequential arterial transplants. Also if this surgery must rightly be considered a palliative one, for its long term results of survival and quality of life it shows a curative value.

[Current trends in the development of coronary surgery]. / Sovremennye tendentsii razvitiia koronarnoi khirurgii.

The authors conducted a comparative study of various methods of coronary shunting by means of microsurgical techniques in 240 patients who were operated on for ischemic heart disease. Total myocardial revascularization, including arteries measuring less than 1.5 mm in diameter and vessels in the zones of cardiosclerosis, was found to be more effective than the techniques of shunting of only the affected major branches. The advantages of a mammary-coronary shunt over anauto- logous venous shunt in reconstruction of coronary arteries under unfavourable hemodynamic conditions are demonstrated. It is also shown that multiple bi-mammary-coronary shunting of the branches of the left coronary artery is a promising method.

[Coronary heart disease. Surgical development in the last 10 years--status of possibilities in West Germany]. / Koronare Herzkrankheit. Chirurgische Entwicklung über die letzten 10 Jahre--Stand der Möglichkeiten in der Bundesrepublik Deutschland.

This article addresses both the operative facilities for coronary bypass surgery in the Federal Republic of Germany and the surgical progress made in this field during the past 10 years. Like in many other countries, there is a continuing critical discrepancy between the number of patients offered for treatment and those operated upon. The reasons for this lack of facilities is explained. Recent moves by the respective Ministries and the public insurance system, however, have raised the expectation that this problem will be eliminated by the end of the decade. Progress in coronary surgery which is well mirrored by our own experience has undergone substantial changes in regards to patients selection and surgical approaches used. There has been a sharp increase in emergency coronary surgery. The proportion of combined procedures on the coronary arteries and myocardium or peripheral vessels has risen to approximately 10 while the rate of reoperation has not yet exceeded 5%. Resection of left ventricular aneurysms has largely been limited to patients with additional coronary stenoses and/or ventricular tachycardia. Complete revascularization (3.2 peripheral coronary anastomoses per patient) has become the rule and circular sequential vein bypass the preferred method for achieving this aim. On the basis of our experience it may be prognosticated that mammary artery bypass and open endarterectomy also of the left coronary system will play an increasing role in the near future.