Comparison of the rheologic parameters in left internal thoracic artery grafts with those in saphenous vein grafts.

BACKGROUND: Left internal thoracic artery (LITA) grafts have superior patency to saphenous vein grafts (SVG). Because shear stress augments the release of nitric oxide throughout the LITA endothelium, shear stress and shear rate in coronary artery bypass grafts (CABG) may play an important role in the higher patency, so the aim of the present study was to evaluate and compare the rheologic parameters in CABG using LITA and SVG. METHODS AND RESULTS: Rheologic examinations were done in 197 patients using a vacuum-suction glass tube viscometer after CABG surgery was completed. Shear stress and shear rate were calculated from the geometry of the graft, blood flow in the graft and blood viscosity. Of 197 patients, 177 underwent LITA grafting to the left anterior descending artery (LAD) and 160 had SVG anastomosis to coronary arteries. Mean wall shear stress in the LITA grafts to the LAD (13.8+/-1.0 dyne/cm2) was nearly 4-6-fold larger than that in the SVG grafts. Mean shear rate (559.1+/-57.0 s(-1)) of LITA-LAD grafts was approximately 2-3-fold higher than that of SVG. CONCLUSION: These results suggest that high wall shear stress and shear rate play an important role in the higher patency rate of LITA grafts.     

Strategy for post coronary artery bypass grafting in patients with bypass graft stenosis: comparison of percutaneous transluminal coronary angioplasty for the native coronary artery, internal mammary artery and saphenous vein graft]

OBJECTIVES: The strategy for post coronary artery bypass grafting (CABG) was investigated in patients with graft stenosis. METHODS: The study included 123 post-CABG patients with graft stenosis. The patients were divided into three groups according to target vessels; saphenous vein graft (SVG; n = 72), internal mammary artery (IMA; n = 21) and native coronary artery (n = 30). Furthermore, SVG lesions were divided into proximal anastomosis (n = 23), body (n = 40) and distal anastomosis (n = 9). The procedural success rate and late patency rate were compared between the three groups. Furthermore, the relationships between pre percutaneous transluminal coronary angioplasty (PTCA) percentage diameter stenosis, procedural success rate and late patency rate were evaluated. RESULTS: Procedural success rate was similar in the three groups, but late patency rate was higher in the IMA group. Procedural success rate and late patency rate were significantly lower in proximal anastomoses compared to other sites of SVG stenoses, IMA group and native coronary artery group (p < 0.05). Totally occluded native coronary artery lesions had a high procedural success rate compared with occluded IMA and SVG lesions, but the late patency rate was not higher. Procedural success rate showed no significant difference for 75-99% stenotic lesions, but the late patency rate was significantly higher in the IMA group (p < 0.05). Patients in the stenting group had a greater late patency rate compared with the balloon angioplasty group. There was no significant difference in late patency rate between the IMA group and SVG group. CONCLUSIONS: Late patency rate of the IMA is higher than that of the native coronary artery. SVG with proximal anastomosis and severe stenosis shows a significantly lower late patency rate than the native coronary artery. Therefore, PTCA should be considered for the native coronary artery in the absence of chronic total occlusion.     

Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study

OBJECTIVES: This study defined long-term patency of saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts. BACKGROUND: This VA Cooperative Studies Trial defined 10-year SVG patency in 1,074 patients and left IMA patency in 457 patients undergoing coronary artery bypass grafting (CABG). METHODS: Patients underwent cardiac catheterizations at 1 week and 1, 3, 6, and 10 years after CABG. RESULTS: Patency at 10 years was 61% for SVGs compared with 85% for IMA grafts (p < 0.001). If a SVG or IMA graft was patent at 1 week, that graft had a 68% and 88% chance, respectively, of being patent at 10 years. The SVG patency to the left anterior descending artery (LAD) (69%) was better (p < 0.001) than to the right coronary artery (56%), or circumflex (58%). Recipient vessel size was a significant predictor of graft patency, in vessels >2.0 mm in diameter SVG patency was 88% versus 55% in vessels 2.0 mm in diameter.     

No-touch与EVH获取大隐静脉桥血管的近中期临床结果分析

目的 比较no-touch和内窥镜获取（endoscopic vein harvesting, EVH）两种不同的大隐静脉移植物获取方式对冠状动脉旁路移植术（coronary artery bypass grafting, CABG）术后早期临床效果及近中期移植物通畅率的影响。 方法 回顾性分析西安交通大学第一附属医院心血管外科2018年7月至2019年12月行CABG患者151例,其中no-touch技术组获取大隐静脉56例;EVH组获取大隐静脉95例。所有患者采取胸骨正中切口入路,非体外或体外循环辅助下完成搭桥手术。统计两组间平均桥血管远端吻合口数量、左乳内动脉吻合口数量及静脉桥远端吻合数量的差异;分析比较两组术后死亡及早期并发症发生情况以及术后切口并发症如血肿、脂肪液化等差异。患者出院前及术后1年行冠脉动脉CT血管成像检查（CTA）以评估移植血管桥近中期的通畅情况。 结果 No-touch和EVH两组在年龄、性别构成、危险因素、术前诊断类型等方面均无统计学差异。术中两组左乳内动脉吻合口数量及静脉桥远端吻合数量等差异均无统计学意义。两组均无手术死亡。在术后早期并发症方面无显著性差异;但在下肢切口并发症中水肿、切口处麻木、疼痛在no-touch组中尤为显著（P<0.05）。术后冠脉CTA复查提示,术后早期桥血管总体通畅率、两组间左乳内动脉及大隐静脉桥血管通畅率均无差异。术后1年总体桥血管通畅率no-touch组要优于EVH组（P<0.05）,其中左乳内动脉通畅率无差异,大隐静脉桥血管no-touch组通畅率要明显高于EVH组（P<0.05）。 结论 No-touch技术获取静脉桥血管对于CABG患者的近、中期临床效果满意,且中期桥血管通畅率要优于EVH组。该技术可行、安全、有效,值得在CABG中进一步推广。     

Relationship between plasma homocysteine levels and saphenous vein graft disease after coronary artery bypass grafts.

The long-term efficacy of coronary artery bypass graft (CABG) surgery is limited by saphenous vein graft (SVG) disease. Elevated levels of plasma homocysteine are a known independent risk factor for cardiovascular disease. However, its influence on the patency of SVG is unknown. To determine whether plasma homocysteine levels are related to SVG disease after CABG we measured homocysteine levels in 80 patients who underwent CABG (age: 64+/-8, interval after bypass surgery: 6.4+/-3.1, range: 1-13 years). The patients were divided into a vein graft disease group (more than 50% angiographical stenosis in any vein graft, n=40) and a no-vein graft disease group (<50% stenosis in any vein graft, n=40). The presence of a mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene was also determined by polymerase chain reaction. Homocysteine levels in the vein graft disease group were significantly higher than in the no-vein graft disease group (11.2 vs. 9.1 micromol/l, p=0.01). Multiple regression analysis showed that the interval after CABG was an independent factor for SVG disease (odds ratio: 1.014, 95% confidence intervals: 1.003-1.025, p=0.013) and elevated levels of homocysteine tended to be an independent factor for SVG disease (odds ratio: 1.098, 95% confidence intervals: 0.994-1.213, p=0.067). There was no significant difference in MTHFR genotypes between the two groups. These findings indicate that elevated levels of plasma homocysteine are related to SVG disease after CABG.     

Aspirin plus ticagrelor or clopidogrel on graft patency one year after coronary bypass grafting: a single-center,randomized, controlled trial

BackgroundDual antiplatelet therapy (DAPT) improves early post-operative graft patency, but the optimal DAPT strategy for the patients after coronary artery bypass grafting (CABG) has not been confirmed. We sought to evaluate the effect of aspirin plus ticagrelor versus aspirin plus clopidogrel on saphenous vein graft (SVG) patency within 1 year after CABG.MethodsBetween October 2017 and December 2018, 147 consecutive patients undergoing elective CABG at Changhai Hospital were randomized into two groups: group AT, receiving aspirin 100 mg/d plus ticagrelor 2×90 mg/d; group AC, receiving aspirin 100 mg/d plus clopidogrel 75 mg/d. Both DAPTs should be administered within 24 h when clinical stability was ensured. 64-multislice computed tomography angiography (MSCTA) was used to assess the graft patency at 12 months after CABG.CYP2C19 gene variants were measured to assess the clopidogrel efficacy on graft patency.ResultsAmong the 147 participants who completed the study, one (0.7%) patient from the AC group died at 5 weeks after surgery due to severe infection. All other patients were treated with DAPT for 12 months and underwent 64-MSCTA according to schedule. There were no significant differences in pre-operative characteristics and intraoperative transit-time flow measurement findings between the two groups. Besides, no significant differences in the incidence of major adverse cardiac events (MACEs) and major bleeding were observed. A 64-MSCTA showed that SVG patency was 91.0% (141 of 155) in the AT group and 89.9% (161 of 179) in the AC group (P=0.751). No significant associations were found between different CYP2C19 genotypes and SVG patency (P>0.05).ConclusionsEither aspirin plus ticagrelor or aspirin plus clopidogrel can maintain a fairly high graft patency rate in the early phase after CABG, regardless of CYP2C19 genotypes.     

String-sign in left internal thoracic artery is associated with regression in left main trunk stenosis after coronary artery bypass

The left internal thoracic artery (LITA) is the conduit of choice for coronary artery bypass (CABG) due to favorable long-term patency. Uncommonly, diffuse narrowing like a string without significant stenosis of an anastomosis is observed in the LITA graft (called "string sign"). Isolated left main trunk (LMT) diseases were reported to regress in some cases. However, the relationship between "string sign" and the regression of solitary LMT disease remains unknown.We retrospectively studied 40 consecutive patients with isolated LMT stenosis who underwent CABG using LITA and who underwent angiography before and after operation (31 males, 9 females, mean age, 65.0 years). The patients were divided into 2 groups according to the postoperative angiographic outcomes of the LITA graft: one group included patients with "string sign" (6 patients), the other group consisted of patients with a patent LITA graft (34 patients).There were no significant differences in clinical backgrounds between the two groups. The 2 groups showed similar quantitative % coronary artery stenosis of the LMT before operation (77.5% versus 76.8%) and the observation period was similar in both groups. Coronary angiography after CABG revealed that % stenosis of the LMT in patients with "string sign" was significantly less than that in patients with a patent LITA graft (41.7 ± 26% versus 82.5 ± 11%, P < 0.001). Regression in LMT was significantly more frequently observed in the "string sign group". Furthermore, ostial stenosis was more frequent in patients with "string sign". "String phenomenon" of the LITA graft is one of the signs related to the regression of LMT stenosis, and especially in ostial stenosis of the LMT.     

Outcome of off-pump coronary artery bypass in renal dialysis patients

BACKGROUND: Renal dialysis patients are a subgroup at major operative risk when undergoing coronary artery bypass grafting (CABG). Even though CABG without cardiopulmonary bypass (CPB) has decreased the surgical risk and provided good short-term results, the long-term survival seems uncertain. We report here on the long-term outcome of CABG without CPB in renal dialysis patients. METHODS: From 1998 to 2002, 44 renal dialysis patients underwent elective CABG without CPB, including 17 minimally invasive direct coronary artery bypass (MIDCAB) and 27 off-pump CABG (OPCAB) procedures. There were 5 one-vessel, 12 two-vessel and 27 multi-vessel coronary artery disease patients, who mainly had left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) grafting with an additional saphenous vein graft to non-LAD coronaries. RESULTS: All 44 patients were followed up for 44.4 +/- 31.2 months. Three (6.8 %) surgical deaths within 30 days occurred and 25 late mortalities happened over a period of 2 - 79 months. The 5-year cumulative rate of total survival is 38.2 % and the freedom from cardiac death is 70.9 %. Using hazard analysis, old age (> 60 years) and incomplete coronary revascularization was found to significantly affect the total survival. CONCLUSIONS: CABG without CPB provided an acceptable surgical mortality and morbidity. The high incidence of non-cardiac death associated with dialysis complications had an adverse impact on the overall outcome. The LITA bypass operation method combined with intensive care for dialysis complications would hopefully fulfill the goal to improve the short- and long-term results in this subgroup.     

Initial results and long-term outcome of percutaneous coronary intervention in patients with previous coronary artery bypass grafting

OBJECTIVES: The incidence of percutaneous coronary intervention following bypass surgery(coronary artery bypass grafting: CABG) is not low, but the outcomes of patients requiring percutaneous coronary intervention after CABG are not well known. METHODS: From June 1970 to June 2000, 2,981 patients underwent CABG at our institute using 6,747 grafts including 2,875 saphenous vein graft(SVG), 3,042 internal thoracic artery(ITA), 706 gastro-epiploic artery(GEA), 122 radial artery(RA), and 2 others. Three hundred twenty-seven patients underwent subsequent percutaneous coronary intervention in 520 lesions(104 SVG, 97 ITA, 12 GEA, 8 RA, 299 native artery). The initial results and long-term outcome following percutaneous coronary intervention in these 520 consecutive procedures were evaluated retrospectively. RESULTS: Percutaneous coronary intervention to arterial grafts were performed mainly within the early post-operative period, whereas percutaneous coronary intervention to vein grafts had two periodic peaks in the early post-operative period and at 7 years after CABG. Procedural success rate of percutaneous coronary intervention was 90% for SVG, 81% for ITA, 58% for GEA, 88% for RA, and 87% for native arteries. Restenosis rate was 56% for SVG, 30% for ITA, 83% for GEA, 83% for RA, and 49% for native arteries. Cardiac events after percutaneous coronary intervention with previous CABG were greater in cases of ITA, followed by native arteries, SVG, GEA and RA(p = 0.0046). In the early post-operative period, there was no significant difference between ITA and SVG. In the chronic stage, the prognosis of cardiac events after PCI for SVG was worse than for ITA. CONCLUSIONS: Percutaneous coronary intervention after CABG requires strategic consideration based on target-specific initial results and long-term outcome.     

Prevalence and prognostic significance of exercise-induced ventricular arrhythmias after coronary artery bypass grafting

Exercise-induced ventricular arrhythmias occur often after coronary artery bypass grafting (CABG), but their prognostic significance is unknown. Two hundred patients examined by exercise electrocardiography and cardiac catheterization (including left ventriculography, bypass graft and native coronary artery angiography) before and 3 months after CABG were prospectively followed up. Exercise-induced ventricular arrhythmias occurred more often after (49 of 200 patients, 24.5%) than before (32 of 200 patients, 16.0%) CABG (p less than 0.05). There were no differences between the patients with and without ventricular arrhythmias in the prevalence of graft patency (79 vs 80%) or the postoperative ejection fraction (57 +/- 9 vs 57 +/- 12%). Ten cardiac deaths occurred during the mean follow-up time of 61 +/- 19 months, 8 of which were witnessed sudden cardiac deaths. All cardiac deaths occurred in patients who did not have exercise-induced ventricular arrhythmias after CABG. The postoperative ejection fraction was lower in the cardiac death patients (42 +/- 16%) than in the survivors (58 +/- 10%) (p less than 0.01). No other clinical or angiographic variable predicted the occurrence of cardiac death. Thus, the prevalence of exercise-induced ventricular arrhythmias increases after CABG, but the occurrence of ventricular arrhythmias does not indicate an increased risk of cardiac death.     

Long-term survival in coronary artery bypass grafting surgery depending on the second conduit used

There is still debate whether radial artery (RA) conduits are better grafts then saphenous vein grafts (SVG) as a second conduit in coronary artery bypass grafting (CABG) surgery. Although it has been confirmed that RA grafts have significantly better patency over years, only some observational studies have associated RA use with reduced all-cause mortality. So far, no randomized controlled trial (CRT) has confirmed significantly better survival for RA graft recipients versus SVG recipients. Therefore, we have to wait for the results of the ongoing ROMA (CRT) study, to draw relevant conclusions about the impact of the second graft on long-term survival in patients undergoing CABG surgery.     

Hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with internal mammary arteries in children with Kawasaki disease

BACKGROUND. Saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts have been used for coronary artery bypass grafting. In adult patients with bypass grafting for atherosclerotic coronary artery disease, IMA grafts have been reported to have long-term patency; however, results are conflicting on whether the graft is sufficient to meet increased myocardial oxygen demand during exercise. There have been no studies on hemodynamics and blood flow during exercise after bypass grafting with IMA in pediatric patients with Kawasaki disease. METHODS AND RESULTS. We studied 17 pediatric patients with Kawasaki disease (average age, 7.5 +/- 3.1 years), who underwent coronary artery bypass grafting with the IMA. The average number of coronary artery bypass grafts was 2.1 +/- 0.7/patient. For all patients, the left IMA was anastomosed to the left anterior descending coronary artery; for eight patients, the right IMA was also anastomosed to the right coronary artery. In addition, 11 SVGs were used. The postoperative patency rates after 1 month were 100% with the IMA graft and 91% with SVG. One year after the operation, the patency rates were 100% with IMA and 50% with SVG. Hemodynamics during exercise were measured with a bicycle ergometer, and coronary sinus blood flow was measured by the continuous thermodilution method in six patients. The relation between delta LVEDP (the difference between left ventricular end-diastolic pressure at rest and during exercise) and delta SVI (the difference between the stroke volume index at rest and during exercise) was analyzed. Four of six patients had reduced cardiac function before operation (delta LVEDP, positive; delta SVI, negative). However, after the operation, all patients demonstrated improvements in cardiac function during exercise (delta LVEDP, positive; delta SVI, positive). Coronary sinus flow per left ventricular mass increased after operation from 70 +/- 46 to 87 +/- 56 ml/min at rest (p less than 0.05) and from 139 +/- 118 to 183 +/- 150 ml/min during exercise (p less than 0.05). CONCLUSIONS. In conclusion, this study reveals improvements in both hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with IMA grafts in pediatric patients with Kawasaki disease.     

Intravascular lithotripsy in saphenous vein grafts and graft stent failure: A case series

The long-term patency of saphenous vein grafts (SVGs) is poor compared to arterial bypass grafts. Re-do coronary artery bypass graft surgery (CABG) is high risk, thus graft failure often requires revascularization with percutaneous coronary intervention (PCI). While PCI to the native vessels is preferable, PCI to SVGs is sometimes necessary despite being associated with a high incidence of stent failure. While early SVG degeneration is associated with friable disease, calcification becomes an increasing problem in older grafts. Intravascular Lithotripsy (IVL) has been demonstrated to be safe and effective in the treatment of calcified native coronary artery disease (CAD). We present the first case series of five patients undergoing PCI to de novo SVG disease or SVG stent failure utilizing IVL for calcium modification.     

Individual Versus Sequential Saphenous Vein Grafts for on-Pump Coronary Artery Bypass Grafting – Does Smaller Coronaries in Indians Affect Graft Choice? – A Mid-Term Patency Comparison Study

PurposeAlthough multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) still accounts for 80% of all CABG conduits (Park et al., 2020) [1]. In India, both the individual and sequential saphenous grafting techniques are used arbitrarily, and there has not been a study that compares the mid-term patency of these two. This is specially relevant in view of smaller coronaries in Indians than the Caucasian counterparts. This study aims to compare the patency for on pump CABG’s.MethodsIn the present study, 323 patients underwent either sequential (group A, N = 151 grafts, each graft having two anastomoses each) or individual (group B, N = 344 grafts) saphenous vein CABG, between February 2014 and June 2017. The SVG anastomoses were created on obtuse marginal (OM1/OM2) and posterior descending artery (PDA). The graft patency of the vein grafts as well as the left internal mammary artery were assessed by serial coronary angiograms.ResultsResults were evaluated at 6 months, 1, 2 and 3 years post operatively. Group A showed a higher graft patency at 3 years at 80.8%, and group B, 67.1% (P = 0.002). Also, anastomoses on sequential conduits had overall better patency rates at three years (77.2% vs 67.2%, P = 0.005). The groups showed similar results at one year post operatively.ConclusionsSequential bypass grafts were associated with superior mid-term patency compared with individual grafts. These findings suggest the more favourable results of sequential bypass grafting to be attributed to the enhanced flow haemodynamics.     

Coronary artery bypass grafting in the elderly

BACKGROUND AND METHODS: The incidence of coronary artery bypass grafting (CABG) in elderly patients has been increasing. We retrospectively analyzed the results of CABG performed at Shin-Tokyo Hospital between January 1, 1991, and December 31, 1998. Preoperative, perioperative, and follow-up data of patients > or = 75 years old (group E, n = 190) were collected, and compared with those of patients < 75 years old (group Y, n = 1,380). RESULTS: Female gender, emergent CABG, preoperative balloon pumping use, cardiogenic shock, hypertension, and preoperative cerebral vascular accident were significantly more frequent in group E (p < 0.05). CABG was completed without any significant differences, except for less frequent use of the bilateral internal mammary artery (p < 0.01), more frequent use of the saphenous vein (p < 0.005), and a greater incidence of blood transfusion in group E (p < 0.0001). The postoperative course required longer intubation, ICU stay, and postoperative hospital stay in group E (p < 0.001), and was more frequently associated with major complication (p < 0.0001) and in-hospital death (p < 0.05). During the mean follow-up of 2.7 years (maximum 6.9 years), the actuarial 5-year survival of groups E and Y were 84.3% and 92.5% (p < 0.01), respectively, excluding in-hospital mortality. The actuarial 5-year cardiac event-free rates were 79.9% in group E and 79.7% in group Y, showing no significant difference. CONCLUSIONS: CABG in the elderly carries certain surgical risks. However, the long-term cardiac event-free rate after CABG in the elderly was almost the same as that of younger patients. Inferior long-term survival in the elderly was most likely due to the biological nature of aging.     

Estimation of left internal thoracic artery flow reserve after coronary artery bypass grafting using Doppler flow wire]

The usefulness of the left internal thoracic artery (LITA) for aortocoronary bypass grafting is now established. Reports of variation in LITA graft function are rare. Graft flow was measured using a Doppler flow wire to estimate graft function in 27 patients (24 males, 3 females) who underwent LITA grafting to the left anterior descending artery. Patients were classified into the following 3 groups: Group A consisted of 9 patients with normal left ventricular function and no native flow; Group B consisted of 11 patients with normal ventricular function and good native flow; Group C consisted of 7 patients with abnormal left ventricular function and no native flow. LITA graft function was also estimated 1 year after operation in 12 of these 27 patients (4 in each group). Diastolic/systolic velocity ratio (DSVR) and flow reserve were determined in the proximal, middle, and distal portions of the LITA graft and native left anterior descending artery before and after papaverine administration (8-10 mg). DSVR was significantly higher in the distal portion than in the proximal portion (p < 0.01), but this value did not change after papaverine administration. After 1 year, DSVR in the proximal portion was significantly higher in Group C than in Groups A or B (p < 0.05 for both). Four weeks after operation, the flow reserve of the distal portion was significantly higher in Group A than in Group C (p < 0.001). After 1 year, this value was significantly higher in Group A than in either Groups B or C (p < 0.01, p < 0.001, respectively). The rate of increase in flow reserve in the distal portion was significantly greater in Group A (23.4%) than in groups B (2.53%) or C (1.94%; p < 0.05 for both). The distal portion of the LITA was the best measurement site, since the flow pattern in the LITA graft varied throughout all portions. Diastolic flow velocity in the LITA graft was dominant in patients with myocardial damage. The results indicate that flow reserve of the LITA graft depends on antegrade native coronary flow and distal myocardial damage.     

Patency of internal thoracic artery compared to vein grafts - postoperative angiographic findings in 1189 symptomatic patients in 12 years

BACKGROUND: The evidence respecting the superior patency of ITA-grafts compared to SVG is conclusive. This study evaluates the angiographic findings in 1,189 symptomatic patients who received either one or both ITA-grafts with or without additional SVG. METHODS: 1,189 patients (975 males, aged 62.4 +/- 9.1 years), operated between 2/93 and 7/05, underwent angiography due to reappearance of angina. Data were compared for patency of single ITA (n = 618), bilateral ITA (n = 416) or SVG (n = 2,218). Re-catherization was performed after 3.8 +/- 2.7 years. Severe bypass stenosis or graft occlusion was related to the target vessels. RESULTS: 3,668 bypasses were performed in 1189 patients. The occlusion rate was 16.5 % for SVG and 7.0 % for all ITAs ( P < 0.001). Severe stenosis was detected in 4.8 % of SVG and in 3.7 % of ITAs ( P < 0.05). Patency was 89.6 % for LITA, 88.7 % for RITA, and 78.7 % for SVG. The occlusion rate for LITA was: to LAD 6.6 %, DIA 8.5 %, obtuse marginal branch/CX 11.5 %. The occlusion rate for RITA was: to LAD 4.6 %, RCA 9.1 %., diag. branch 7.1 %. The occlusion rate for vein grafts was: to LAD 17.3 %, DIA 14.4 %, obtuse marginal branch/CX 15.9 %, to RCA 17.0 %. Patency for all ITAs was 89.3 % vs.78.7 % for all SVG ( P < 0.05). Despite symptoms, bypass patency was found in 711 patients (59.8 %). CONCLUSION: The superior patency of ITA-grafts could be documented angiographically in a negatively selected, symptomatic population. Graft occlusion was at least twofold higher for SVG.     

Postoperative pleural changes after coronary revascularization. Comparison between saphenous vein and internal mammary artery grafting.

Coronary artery bypass grafting (CABG) is commonly performed with a saphenous vein graft (SVG) and/or an internal mammary artery graft (IMA). We hypothesized that there would be a higher incidence of pleural changes after CABG in patients who underwent IMA grafting because pleurotomy is usually performed. In the present study, the pre and the 6th postoperative day chest roentgenograms of 122 patients who received CABG were reviewed. The incidence of effusion in the patients who received only SVG was 43 percent (23/54) and did not differ significantly (p greater than 0.05) from the incidence in the patients who also had IMA 41 percent (28/68). Almost all of the patients (43/51) had unilateral left-sided pleural effusions. Most of the effusions were small and did not require treatment. The incidence of effusion was not higher in patients with enlargement of their cardiac silhouette or atelectasis and was not related to the presence of chest tubes. The incidence of pleural thickening was higher in the IMA group (49 percent) than in the SVG group (31 percent) but the difference did not achieve statistical significance (p greater than 0.05). We conclude that there is a high (approximately 40 percent) incidence of small effusions and thickening after CABG. The incidence of pleural effusion and pleural thickening do not appear to be influenced by the type of surgery (IMA vs SVG). We speculate that the effusions are due to pericardial inflammation.     

Technical aspects of composite arterial grafting with double skeletonized internal thoracic arteries

BACKGROUND: Complete myocardial revascularization with internal thoracic arteries (ITAs) improves long-term survival and decreases the rate of repeat operations, compared to vein grafts. Adequate length of the graft in coronary artery bypass graft (CABG) surgery is essential for providing complete arterial revascularization. Extra length can be obtained by skeletonization of both ITAs. In cases where the right ITA (RITA) is too short to bridge the distance to the target anastomotic site, it is used as a free graft in "composite" arterial grafting, a surgical technique in which free arterial conduits are proximally anastomosed end-to-side to an intact ITA. OBJECTIVES: To describe alternative surgical procedures adapted to accommodate special anatomic requirements. DESIGN: Retrospective study from April 1996 to April 1999. PATIENTS: One thousand fifty patients underwent CABG surgery using bilateral skeletonized ITAs: 650 patients (482 men and 168 women; mean +/- SD age, 69 +/- 7 years) underwent composite arterial grafting. Two hundred sixteen patients (33.2%) were diabetics, 87 patients (13.4%) had severe left ventricular dysfunction (ejection fraction < 35%), and 27 patients (4.2%) underwent emergency operations. INTERVENTIONS: The RITA was used as a free graft connected to the in situ left ITA (LITA) in 618 patients. A free LITA was attached to in situ RITA in 32 patients, and minicomposite grafts (free distal LITA on the LITA or free distal RITA on the RITA) were constructed in 38 patients. The average number of grafts was 3.2 per patient (range, 2 to 6 grafts per patient). MEASUREMENTS AND RESULTS: Operative mortality was 2.9% (n = 19), and there were 11 sternal wound infections (1.7%). Early recatheterization was performed in 41 symptomatic patients. The patency rate was 95%. The mean follow-up was 25 months (range, 14 to 36 months), and the 3-year survival was 92.5%, with 97% of the surviving patients being angina free. CONCLUSIONS: Planning CABG surgery using bilateral skeletonized ITAs as arterial conduits affords greater choice in grafting approaches, especially when a composite technique is feasible.     

Outcomes of left internal mammary artery with saphenous vein composite graft to bypass the left anterior descending artery: a propensity-matched study

BackgroundThis study aimed to evaluate the early and mid-term outcomes of a novel strategy of using the in-situ left internal mammary artery (LIMA) with the great saphenous vein graft (SVG) to bypass the left anterior descending artery (LAD) in coronary artery bypass grafting (CABG).MethodsA total of 979 patients took part in this retrospective observational study; 83 patients were propensity-score matched to the LIMA + SVG group and 83 to the LIMA − LAD group. Early mortality, postoperative complications, mid-term major adverse cardiovascular and cerebrovascular events (MACCE) were compared among the two matched groups after the procedure.ResultsNo significant differences in early mortality and postoperative complications rates were detected between the two matched groups. For mid-term outcomes, the incidence of MACCE was slightly higher in the LIMA + SVG group, but there was no significant statistical difference (14.9% vs. 12.8%, hazard ratio =1.20, 95% CI, 0.24 to 7.95; P=0.70) between the matched groups. Computed tomography coronary artery angiography (CTCA) images showed a LIMA + SVG composite graft patency rate of 94% (32/34) 25 months after the procedure.ConclusionsUsing the in situ LIMA with SVG to revascularize LAD was associated with comparable early and mid-term outcomes. These findings may provide an alternative emergency strategy when in situ LIMA cannot bypass LAD. Further study needs to be conducted to test longer-term outcomes.