The propriety of bilateral internal thoracic artery grafting in women

In our institusion, the exclusion criteria of the bilateral internal thoracic artery (BITA) grafting include age over 70 years old, obesity, severe diabetus, renal dysfunction and poor preoperative physical activity. The objective of this study is to evaluate propriety of the use of bilateral internal thoracic artery for coronary artery bypass grafting (CABG) in women. Clinical outcome of female patients who underwent BITA grafting (group B-F; n=50) was compared with that of female patients who underwent single internal thoracic artery grafting (group S; n=50). In addition, clinical outcome of the male patients who underwent BITA grafting (group B-M; n=50) was compared with that of group B-F. Between group B-F and S, the age, prevalence of obesity and that of renal dysfunction were significantly different, which was predictable because of the group selection according to the criteria. However, the prevalence of previous myocardial infarction and that of left ventricular dysfunction and the extent of coronary artery disease were not significantly different. Whereas, between group B-F and B-M, preoperative factors were not significantly different except the body size. Intraoperative technical factors, such no of grafts, aortic cross clamp time, cardiopulmonary bypass time, rate of complete revascularization, were not significantly different. In comparison of group B-F with group B-M, the site of anastomosis with arterial grafts were not significantly different. Patency rate of arterial and venous grafts two week after operation was not significantly different. Either postoperative complications, such as reoperation for bleeding, wound complication, low output symdrome, renal dysfunction etc, were not significantly different. One patient (2%) in group B-F and 1 patient (2%) in group B-M died in the hospital (p>0.05). In summary, BITA can be a viable conduit of choice for CABG in female patients as well as that in male patients. Criteria of the use of BITA is recommended to exclude preoperative risk factors abovementioned.     

Arterial switch operation: successful bilateral internal thoracic artery grafting

Internal thoracic artery grafting in arterial switch operations for transposition of great arteries has been reported for salvage of myocardial ischemia after initial coronary transfer. We report a situation where we opted for primary coronary bypass grafting to avoid an obviously difficult coronary transfer, with successful outcome.     

Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting.

The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.     

Internal thoracic artery malperfusion syndrome after bilateral internal thoracic artery grafting: Report of a case

(Received for publication on Sept. 17, 1996; accepted on May 12, 1997)     

Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting

Background

Aortic valve replacement (AVR) after coronary artery bypass using bilateral internal thoracic arteries (ITAs) is a challenge. Management of these patent grafts and myocardial protection are important issues. Moreover the risk and outcome of these complex operations have not been clearly defined.

Methods

Eighteen consecutive patients (all male) who exhibited previous bilateral ITA grafts underwent subsequent AVR surgery from 1990-2001 at the Cleveland Clinic Foundation. Their medical records were retrospectively analyzed.

Results

At the time of reoperation, the mean age of the patients was 67 ± 6.4 years and 33 out of 36 (92%) ITAs were patent. The interval between previous coronary bypass and aortic valve surgery was 10.3 ± 5.3 years. All patients underwent redo-median sternotomy with aortic cannulation in 12 patients (67%) and femoral or axillary artery cannulation in 6 patients (33%). The patent ITAs were clamped during aortic cross-clamping in 15 patients. In 3 patients the ITAs were not dissected. These 3 patients underwent deep hypothermic arrest for myocardial protection. Concomitant coronary revascularization was performed in 8 patients (44%). There were no hospital deaths. One stroke occurred but there were no other major complications. Average intubation time was 23.1 ± 27.1 hours, intensive care unit stay was 2.3 ± 3.1 days, and postoperative hospital stay was 10.3 ± 7.6 days.

Conclusions

Reoperative aortic valve surgery in the patients with patent bilateral ITA grafts can be performed safely.     

Effect of age on outcome of bilateral skeletonized internal thoracic artery grafting

BACKGROUND: Elderly patients are considered to be at higher risk for coronary artery bypass grafting. Surgical techniques of arterial myocardial revascularization without vein grafts were primarily reserved for the young. This report evaluates the impact of age on the outcome of 634 consecutive patients who underwent double skeletonized internal thoracic artery grafting between April 1996 and December 1997. METHODS: Patients were stratified into five age groups: One hundred ninety-six were less than 60 years of age, 98 between 60 and 65 years, 132 between 65 and 70 years, 116 between 70 and 75 years, and 92 were older than 75 years. The groups did not differ with regard to preoperative risk factors. RESULTS: Hospital mortality was 2.5% (n = 16). Mortality of urgent and elective operations was 1.6%, and that of emergency operations was 9.7% (p < 0.001). There were 7 (1.1%) myocardial infarctions, 9 strokes (1.4%), and 10 deep sternal wound infections (1.6%). Using the Mantel-Haenszel test, there was no relation between age and hospital mortality, myocardial infarctions, strokes, or sternal infections. A correlation was found between advanced age and early unfavorable events (6.7%, 7.2%, 12.9%, 15.5%, and 15.2% in corresponding age groups, p < 0.003), and late mortality (0.6%, 1%, 1.5%, 4.3%, and 9.8%, respectively, p < 0.01). However, early return of angina was lower (2.6%, 1%, 0.8%, 0.9%, and 0%, p < 0.06). CONCLUSIONS: This retrospective, nonrandomized study suggests that older age is not a risk factor for operative mortality in patients undergoing coronary artery bypass grafting with double skeletonized internal thoracic arteries. Apart from avoiding morbidity associated with leg incisions, older patients showed an interesting trend toward lower rates of angina return. Older patients, however, sustained increased perioperative morbidity and late mortality rates.     

Risks and benefits of bilateral internal thoracic artery grafting in diabetic patients

BACKGROUND: There is a tendency to avoid the bilateral internal thoracic artery (ITA) grafting in diabetics. However, we no longer consider diabetes a reason for excluding the bilateral use of ITAs. We compare the early and long-term results in diabetic cases treated by coronary artery bypass grafting (CABG) using unilateral and bilateral ITA grafts. METHODS: A total of 303 consecutive diabetic cases of CABG using ITA grafts between April 1991 and January 2003 were reviewed. Of these, 149 (49%) were being treated with insulin. The cases were divided into two groups: 179 cases in which bilateral ITA grafts had been used and 124 in which a unilateral ITA graft had been used. RESULTS: The mortality for the bilateral ITA group and unilateral ITA group were 1.7% and 1.6%, respectively. The fact that patients were receiving insulin had no effect on the mortality of CABG. A review of morbidity revealed that no differences were found between the two groups. The survival curves, cardiac-death-free curves, and cardiac-event-free curves showed that there was no difference between the use of one or two ITA grafts in diabetics, while bilateral use of ITA grafts was significantly better than unilateral use in a comparable group of nondiabetics operated during the same time period. CONCLUSIONS: There was no significant difference in operative mortality related to single or double ITA grafting in diabetics. There was also no difference between the use of one or two ITA grafts in diabetics in regard to long-term follow-up.     

Clinical results of free (aorta-coronary) internal thoracic artery grafting

In the two year period from 1989 to 1990, 22 patients (18 men, 4 women; age range from 40 to 59 years) underwent coronary artery bypass grafting (CABG) using in situ and free internal thoracic arteries (ITAs). 23 of total 38 ITA grafts were free grafts in the aorta-coronary position, mainly to provide sufficient graft length. All of 34 ITA grafts were patent in 20 patients with coronary arteriography about one month after operation. There were no early and late death, and all patients were free from angina after a 9.4 month mean follow-up. Perioperative complications included reoperation for the bleeding in one case and the elevation of left diaphragm in one case, but there was no other major complication such as perioperative myocardial infarction, cerebral infarction or mediastinitis. These results indicated that the free ITA could be applied as well as the in situ ITA in multiple CABG of the Japanese with good patency rate and low operative risk.     

Long-term results of coronary artery bypass grafting: comparison of angiographic evaluation of internal thoracic artery and saphenous vein grafts

The long term (10 to 15 years) results of coronary artery bypass grafting (CABG) were studied in 20 patients. The duration of follow-up was ranged from 130 to 170 months with mean 146.4 months. Ten out of 20 patients underwent coronary angiography (CAG), which disclosed that the late patency of saphenous vein (SV) grafts was 68.8% (11/16), but 54.5% (6/11) of patent SV grafts showed atherosclerotic changes such as irregularity and localized narrowing. On the other hand, internal thoracic artery (ITA) grafts were all patent without any atherosclerotic luminal changes. We recognized that ITA grafts were superior to SV grafts from an angiographic standpoint of view in the long term in Japan.     

Age cut-off for the loss of benefit from bilateral internal thoracic artery grafting

OBJECTIVES: To identify the age-related benefit of single and bilateral internal thoracic artery (ITA) grafting on long-term cardiac-related survival in patients who survived from primary isolated coronary artery bypass grafting (CABG). METHODS: A unicenter study was conducted on 12,231 consecutive survivors from primary isolated CABG who received single (n=9566 patients) or bilateral (n=1388 patients) ITA grafts, or vein grafts only (n=1277 patients) between 1992 and 2005. Data was collected prospectively. The Cox regression model estimates the hazard ratio of each independent variable on cardiac-specific survival over the entire length of follow-up. Age was a significant covariate into the statistical model. The mean follow-up was 5.7+/-3.7 years and 100% complete as of December 2005. The date and cause of death were obtained from the regional statistical institute. RESULTS: After adjustments for different risk factors, the cardiac-related survival benefit in patients undergoing CABG with two ITAs was superior to that of single ITA grafting up to 60 years of age, displaying a constant decrease over time. The use of a single ITA was beneficial on cardiac-related survival in all age groups, including octogenarians, compared to patients receiving only vein grafts. CONCLUSIONS: The use of at least one ITA is associated with increased long-term cardiac-specific survival in all age groups compared to venous-only CABG, even in octogenarians. The additional survival benefit of using a second ITA decreases gradually with age, and is lost after 60 years of age.     

Bilateral pedicled internal thoracic artery grafting

Background: Pedicled bilateral internal thoracic artery grafting (BITA) has been discouraged in historical high-risk groups such as diabetes mellitus (DM), renal failure, old age, and obesity because of reported high incidence of mediastinitis. However, considering the fact that there are abundant short and long-term results including angiography study about the conventional pedicled grafts, it might be worthwhile reassessing the results of pedicled BITA grafting with modern techniques by a disciplined surgical team before abandoning the method. Methods: Between September 1989 and September 1999, 1371 patients underwent isolated coronary artery bypass grafting (CABG) in Kumamoto central hospital. Of these patients, 558 patients who had bilateral ITA strategy (mean age 63.0±9.2 years, 13–79) were studied. The method of harvest of ITAs is consistently the use of conventional pedicled grafts. The use of bone wax and unnecessary electrocautery injury to the periostium or cartilage were avoided as much as possible. The only change in the surgical technique in the study period is the application of the pinpoint hemostasis for the presternal tissues from August 1997 (late period). Results: In late period, there were significantly more patients with sternal sepsis risk factors such as diabetes mellitus (early: late; 19.3% vs. 34.8%, P<0.00003), and renal failure (0.3 vs. 9.7%, P<0.0001) as well as patients who had gastroepiploic artery grafting (16.9 vs 48.5%, P<0.0001) and those who required aortic non-touch technique (2.1 vs. 7.9%, P<0.001). The percentage of the patients receiving BITA grafting among the isolated CABG patients increased in the late period from 31.7% (331/1043) to 69.2% (227/328) (P<0.001), reflecting that a more aggressive approach towards bilateral ITA and arterial grafting has been taken in the late period. Overall operative mortality was 1.1% (n=6). Mediastinitis occurred in seven patients (1.3%). Of these, only one mediastinitis occurred in late period (0.4%). No mediastinitis occurred in 23 chronic renal dialysis patients. Among the 143 DM patients, there were three mediastinitis (2.1%). Of three, only one occurred in late period, yielding 1.3% mediastinitis rate. There was one mediastinitis (0.7%) among 134 elderly patients more than 70 years of age. Univariate analysis identified obesity as a risk factor for mediastinitis. And there was a trend of decreasing mediastinits in late period but did not reached a statistical significance (P<0.2). Multivariate analysis identified obesity and arteriosclerosis obliterates as independent risk factors. Neither diabetes mellitus, dialysis, female gender, nor old age were significant independent predictors of mediastinitis. Despite the significantly high percentage of high-risk patients in late group, there were no significant difference in mortality and morbidity between the two groups. Conclusion: Pedicled BITA grafting is feasible with acceptable morbidity and shouldn't be abandoned even in high-risk patients such as DM, old age, and dialysis, especially combined with pinpoint-hemostasis, avoiding excessive use of bone wax, and strict aseptic technique. These point require a surgical team familiar with these techniques to maintain adequate skills in conduit procurement.