In situ skeletonized bilateral thoracic artery for left coronary circulation: a 20-year experience

Abstract

OBJECTIVES Our goal was to analyse the outcomes in a patient population using a standardized technique for coronary artery bypass grafting (CABG) consisting of total arterial myocardial revascularization utilizing the in situ skeletonized bilateral thoracic artery for left coronary circulation. We also explored potential predictors of long-time unfavourable outcomes. METHODS Patients undergoing total arterial myocardial revascularization using in situ skeletonized bilateral thoracic artery for left coronary circulation between January 1997 and May 2017 were included prospectively in this study. The median follow-up (100% complete) was 103 months (interquartile range 61–189 months) and ranged from 1 to 245 months. RESULTS A total of 1325 consecutive patients were recruited. During the follow-up period, there were 131 deaths (9.8%), 146 repeat revascularizations (11.0%) and 229 major adverse cardiac events (17.2%). The 18-year freedom from major adverse cardiac events was 62.6 ± 9.3%, 62.5 ± 6.3% and 53.9 ± 11.0%, respectively. Multivariable models showed that a left ventricular ejection fraction ≤35%, chronic obstructive pulmonary disease, peripheral vascular disease (P < 0.001), chronic kidney disease and age ≥80 years (P = 0.002) were independent predictors of diminished long-term survival. Moreover, peripheral vascular disease and off-pump coronary artery bypass (both, P < 0.001) predicted repeat revascularization. Finally, age ≥80 years, peripheral vascular disease, left ventricular ejection fraction ≤35%, off-pump coronary artery bypass and chronic pulmonary obstructive disease were independent predictors of major adverse cardiac events during the long-term follow-up period (all, P < 0.001). CONCLUSIONS Coronary artery bypass using the in situ skeletonized bilateral thoracic artery for left coronary circulation configuration for total arterial myocardial revascularization resulted in satisfactory long-term results with a low incidence of death and late events and may represent a technique of choice in selected patients having CABG. Larger and long-term prospective studies are, however, warranted.

The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

“…The main aim of this study was to analyze the influence of two different CABG techniques involving the use of single or double thoracic arteries on the occurrence of post-operative ALLI in patients with PAD. The importance of PAD as a predictor of reduced long-term survival and increased risk for complications following CABG has been sufficiently documented [4,[20][21][22][23]. Any final conclusion is far from being drawn as to whether a specific technique may help in improving the outcomes and, more specifically, whether the use of the double mammary artery technique is the right choice for these patients when considering its established advantages [9][10][11][12][13].…”

Reply: Can you really turn a vein into an artery?

“…6 In a recent study of 1325 patients who received in situ bilateral internal thoracic artery grafts to left coronary bed as a part of total arterial revascularization, the rate of graft failure after 18 years of follow-up was 1.6% for LITA, 2.9% for right internal mammary artery, and as high as 20.7% for the radial artery, which was used as a free graft to the right coronary bed. 7 Hwang and colleagues 8 reported that the use of SVG as a part of composite graft (SVG off the LITA) confers similar results as the use of multiple arterial grafts. The 10-year patency rates reported by Hwang and colleagues 8 were excellent: 96.6% in the composite SVG group and 91.4% in the multiple arterial group.…”

“… 6 In a recent study of 1325 patients who received in situ bilateral internal thoracic artery grafts to left coronary bed as a part of total arterial revascularization, the rate of graft failure after 18 years of follow-up was 1.6% for LITA, 2.9% for right internal mammary artery, and as high as 20.7% for the radial artery, which was used as a free graft to the right coronary bed. 7 …”

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

“…Long-term outcomes were comparable with those of other similar studies in the literature, 28-38 but, as expected, poorer than those for isolated BITA grafting. [5][6][7][8][9][10][11][12][13]15,17,27,39,40 In this series of patients with an average age of more than 70 years, approximately 50% of subjects were alive or free from MACCE at 10 years after surgery; approximately 85% of patients were free from cardiac or cerebrovascular death or from hospital readmission for CHF; approximately 97% of patients were free from PCI or cardiac reoperation; finally, approximately 95% of patients were free from cerebrovascular accident after hospital discharge. Although female sex, extracardiac arteriopathy, chronic dialysis, and poor systolic function before surgery were risk factors for both cardiac or cerebrovascular death and MACCE, active infective endocarditis and prolonged myocardial ischemia during surgery were the sole predictors of repeat operation or PCI.…”