Bilateral Internal Thoracic Artery Research Articles

Is It Safe to Use Arterial Grafts in Patients with Acute Myocardial Infarction? Short-Mid-Term Propensity Analysis.

The use of multiple arterial grafts (MAGs) has an impact on patient survival; however, preference for its use in the acute phase of myocardial infarction (AMI) has not yet been established. This study aimed to compare the short-mid-term clinical results of AMI patients undergoing coronary artery bypass grafting (CABG) with a single arterial graft (SAG) vs. MAGs. This is a cross-sectional cohort study of 4,053 patients from the Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). CABG in the AMI was considered when performed between one and seven days after diagnosis (n=238). Thirty-five patients underwent surgery with ≥ 2 arterial grafts (MAG group), population adjustment in SAG group was performed using the propensity score matching (PSM). Clinical follow-up was performed by telephone to assess need for readmission, new AMI, reoperation, and death. After PSM, 70 patients were evaluated. During hospitalization, a significant statistical difference was observed in the surgery duration: the MAG group had a median of 4.78 hours while the SAG group had 4.11 hours (P=0.040). Within the MAG group, there was a predominance use of bilateral internal thoracic artery (62.86%), followed by radial graft associated with the use of left internal thoracic artery (28.57%) and the combination of the three grafts (8.57%). There were no significant differences between the groups in terms of outcomes up to 30 days after CABG or up to five years after CABG. In REPLICCAR II, usage of MAGs in the AMI was not associated with clinical worsening of patients until the mid-term follow-up.

Improvement of the outcome of the saphenous vein graft when connected to the internal thoracic artery.

Since 2000, we have been grafting the right coronary artery system (RCAs) using the proximal portion of the right internal thoracic artery (RITA) as the inflow of the saphenous vein graft (SVG) to increase the number of patients undergoing beating heart complete myocardial revascularization. From 2000 to 2022, 928 consecutive patients underwent SVG on the RCAs. In 546 patients (58.8%), the inflow was the RITA (I-graft group), and in 382 patients (41.2%), the inflow was the aorta (Ao-graft group). The inclusion criteria were age ≤75 years, ejection fraction >35%, only one SVG per patient, bilateral internal thoracic arteries as a Y-graft on the left system (three-vessel disease, n = 817, 88.0%) or left internal thoracic artery on the left anterior descending artery and RITA + SVG on the RCAs (two-vessel disease, n = 111, 12.0%). Propensity matching identified 306 patients per group. After a median follow-up of 8 (5-10) years, graft patency was assessed by coronary computed tomographic angiography in 132 patients (64 in the I-graft group and 68 in the Ao-graft group). Early results were similar in both groups. The I-graft group had higher 10-year survival and freedom from main adverse cardiac events (90.0 ± 2.0 vs. 80.6 ± 3.8, p = 0.0162, and 81.3 ± 2.7 vs. 64.7 ± 5.6, p = 0.0206, respectively). When RITA was the inflow, SVG had a higher estimated 10-year patency rate (82.8% ± 6.5 vs. 58.8% ± 7.4, p = 0.0026) and a smaller inner lumen diameter (2.7 ± 0.4 vs. 3.4 ± 0.6 mm, p < 0.0001). When the inflow is the RITA, SVG grafted to the RCAs (I-graft) may result in a higher patency rate and better outcome than when the inflow is the ascending aorta (Ao-graft). The continuous supply of nitric oxide by RITA may be the cause of the higher patency rate of the I-graft, which can behave like an arterial conduit.

Long term follow-up of bilateral internal thoracic artery use in young coronary artery bypass grafting patients: 29 year single surgeon experience.

Improved long term survival has demonstrated by grafting left internal thoracic artery (LITA) to the left anterior descending artery (LAD). This study investigated the prognostic benefits of BITA versus single LITA with common anastomotic configurations of BITA. Elective patients age below 60years, undertaken by a single surgeon, between 1992 and 2014 were explored. Cox regression models were fitted to investigate prognostic benefits of BITA. Specific comparisons were made with BITA subgroups who received LITA to LAD or RITA to LAD to establish long-term prognostic difference with the use of the RITA to LAD as compared to the LITA to LAD anastomosis. Comparisons were made with other BITA configurations to establish long-term difference in survival as a result of the actual targets bypassed with BITA grafts. Both groups had similar baseline patient characteristics. Following risk adjustment, the use of a second ITA conferred a significant 48% reduction in long-term mortality to BITA group [HR 0.52 (95%CI: 0.36-0.74) p < .001]. The use of the RITA to LAD, instead of LITA, resulted in no difference in the long-term prognostic benefit. The targets grafted with second ITA conferred a significant prognostic benefit for common configurations it was used in for bypass surgery. The use of BITA confers long term prognostic benefit to patients. Grafting RITA to LAD instead of more common LITA to LAD made no difference in long term prognosis when compared to CABG patients with single ITA. The use of a second ITA conduit in common configurations for CABG confers prognostic benefits irrespective of distal target grafted.

How to Use a Right Internal Thoracic Artery Graft in On- and Off-Pump Coronary Artery Bypass Grafting

In coronary artery bypass grafting, internal thoracic artery grafts and other arterial grafts have shown superior results compared with saphenous vein grafts. The right internal thoracic artery (RITA) has been reported as one of these various arterial graft options. However, there are some limitations and concerns associated with using the RITA. This review presents the current topics and scientific evidence on the use of RITA grafts in coronary artery bypass grafting. The reviewed papers mainly focus on the operative results of using the RITA, graft configurations and target vessels, and the comparison between on- or off-pump coronary artery bypass procedure. The results of these studies suggest the followings. The method of using the RITA (either in situ or as a free graft) should be selected based on the need to reach crucial targets and the number of required target vessels. A free RITA graft anastomosed to the aorta with modified proximal anastomosis allows for the revascularization of multiple vessels with acceptable flow characteristics. For revascularization of the right coronary artery system with low-grade proximal stenosis, the RITA should not be used. The decision to use cardiopulmonary bypass depends on the patient's condition, target vessels, as well as the experience of institution. Skeletonized harvesting is more effective in preventing sternal wound infections in coronary artery bypass grafting using bilateral internal thoracic arteries compared with using a single internal thoracic artery.

Horner’s syndrome caused by the first rib fracture sustained during coronary artery bypass grafting: a case report and literature review

BackgroundHorner’s syndrome is a rare complication of cardiovascular surgery. A bone fragment and hematoma due to rib fracture after cardiac surgery may cause injury to the brachial nerve plexus and sympathetic nerve trunk, leading to neurologic disorders and Horner’s syndrome. However, few reports have revealed the etiology of Horner’s syndrome after cardiovascular surgery based on imaging. Herein we present a case in which a plain CT scan confirmed the etiology of Horner’s syndrome after coronary artery bypass grafting (CABG), reviewing 139 CABG cases retrospectively in our hospital and 6 case reports of Horner’s syndrome associated with cardiovascular surgery.Case presentationA 69-year-old woman with a history of percutaneous coronary intervention and total abdominal hysterectomy with bilateral salpingo-oophorectomy had chest pain on exertion. Coronary angiography showed severe triple vessel disease. She underwent off-pump coronary artery bypass grafting (CABG). A median sternotomy was performed, and the split sternums were widened using a sternal retractor. The bilateral internal thoracic arteries were harvested. A triple CABG was performed. She had left shoulder pain after surgery. She complained of anhidrosis involving the left face and hyperhidrosis involving the right face from postoperative day (POD) 6. Left ptosis and blurry vision appeared after discharge from the hospital, for which she saw a neurologist in our hospital on POD 48. Miosis could not be clearly confirmed. She was diagnosed with Horner’s syndrome. A plain CT scan revealed displaced fractures of the bilateral first ribs and left second rib. The bone fragment of the left first rib head was displaced 3 mm anteriorly compared to the left first rib head before surgery, which suggested that the fragment affected the stellate ganglion in the sympathetic trunk. The patient had regular follow-up evaluations. The anhidrosis persisted, but the ptosis improved, and the miosis was not confirmed at the 6-month follow-up evaluation.ConclusionsWe should recognize that Horner’s syndrome is one of the complications of cardiovascular surgery, especially CABG. Fracture of the first rib head with a displaced bone fracture was shown to be a contributor to ipsilateral Horner’s syndrome. When symptoms of Horner’s syndrome and other neurologic symptoms are noted after open heart surgery, a plain CT examination should be obtained.

Competitive flow of bilateral internal thoracic artery Y-graft: Insights from hemodynamics and transit time flow measurement parameters

Recent studies have demonstrated the superior efficacy of bilateral internal thoracic artery (BITA) grafts compared to other graft methods in treating coronary artery disease. Competitive flow (CF) is a primary factor contributing to graft failure in the long term. For the first time, the CF of the BITA-Y graft has undergone rigorous numerical analysis. Through the application of transit time flow measurement (TTFM) and hemodynamic parameters, this study provides a new perspective on graft performance. Simulation results indicate that average flow, TTFM, and hemodynamic parameters fall within the critical range for stenosis severities below 90%. Specifically, at 80% stenosis, the mean graft flow (MGF) and pulsatility index (PI) of the left internal thoracic artery (LITA) were 0.071 cc/s and 27, respectively, while those of the right internal thoracic artery (RITA) were 0.211 cc/s and 11. With increasing stenosis severity, TTFM parameters remained within the clinical permissible limit (MGF &amp;gt; 0.34 cc/s and PI &amp;lt; 5). At 95% stenosis severity, the MGF and PI for LITA were 0.526 cc/s and 1.2, respectively, while those for RITA were 0.790 cc/s and 0.9. The results indicate the presence of competitive flow within the BITA-Y graft for stenosis severities below 90% area reduction, suggesting a potential risk of graft failure in the long term. Additionally, the results indicated that when there are significant differences in stenosis severity between the two native arteries, the BITA-Y graft is not optimal due to CF, characterized by low MGF and high reverse flow.

Clinical and Angiographic Outcomes of Bilateral Internal Thoracic Artery Revascularization: In Situ vs Free Grafts

BackgroundBilateral internal thoracic artery (ITA) grafting is associated with improved long-term outcomes; however, the appropriate graft configuration remains controversial. We compared the long-term outcomes of different graft configurations. MethodsBetween 2009 and 2015, 1171 patients underwent isolated bilateral ITA grafting for left-sided complete revascularization at 4 Japanese cardiac surgery centers: underwent in situ left ITA to the left anterior descending artery plus in situ right ITA to the left circumflex artery (LR group, n = 278), in situ right ITA to the left anterior descending artery plus in situ left ITA to the left circumflex artery (RL group, n = 665), and in situ left ITA to the left anterior descending artery plus free right ITA to the left circumflex artery (free group, n = 228). Major adverse cardiovascular events (MACEs), including mortality, myocardial infarction and revascularization, and ITA patency, were compared. ResultsAmong the 3 groups, the free group showed significantly lower MACEs and overall mortality rates (P < .001). Nonfatal myocardial infarction and revascularization rates showed no marked differences among the groups. A weighted analysis revealed a decreased risk of MACEs and death in the free group. No marked difference was observed in the patency of the ITA anastomosed to the left anterior descending artery. Patency of the ITA grafted to the circumflex artery in the LR group was significantly lower relative to the other groups. Using a free right ITA grafted to the circumflex artery reduced the risk of graft failure. ConclusionsThe free right ITA configuration for left-sided revascularization might have better long-term outcomes and significantly better patency than other grafts.

Efficacy of atrial fibrillation predictors including MVP ECG risk score compared between single or bilateral internal thoracic artery use

BackgroundAtrial fibrillation (AF) is the most common complication after Coronary Artery Bypass Surgery (CABG). Despite advanced treatment methods, primary prevention is crucial. Many factors have been investigated as markers for AF, but further research is required.CABG is currently superior to Primary Coronary Intervention (PCI) in some cases due to Left Anterior Descending Artery (LAD)- Internal Thoracic Artery (ITA) anastomosis. However, graft choice for non-LAD vessels is still controversial. Our study compared the incidence of arrhythmia between patients with single ITA or bilateral ITA (BITA).MethodsThe study included 84 isolated CABG patients. The patients were divided into two groups: single ITA and BITA. Patients who developed AF were recorded and compared.Results73.8%(n = 62) of the patients were male and 26.2%(n = 22) were female. While single ITA was used in 48.8%(n = 41) of the patients, BITA was used in 51.2%(n = 43). AF was detected in 15.5%(n = 13) of the patients. AF was observed in 5(12.2%) patients in the single ITA group and 8(18.6%) in the BITA group. 76.9%(n = 10) of the patients with AF rhythm had Diabetes Mellitus (DM)(p = 0.011). Biphasic P wave, length of P wave duration, and total Morpholog-Voltage-P Wave ECG (MVP ECG) score height were statistically significantly different.ConclusionsThe development of AF was similar in both groups. The presence of DM, high blood glucose levels, and ECG findings can detect a predisposition to postoperative AF. MVP ECG risk score is effective as an AF marker and can be used in surgical patient groups.

Total Arterial Multivessel Minimally Invasive Coronary Artery Bypass Surgery: 5-Year Outcomes

BackgroundTotal arterial revascularization is associated with superior outcomes to conventional coronary artery bypass graft (CABG) surgery performed with the left internal thoracic artery (ITA) and veins. It is often performed with bilateral ITAs that increase risk of sternal wound infection. Minimally invasive multivessel CABG through a left anterior minithoracotomy eliminates sternal wound complications. However, being performed only in a few specialized centers, there is a paucity in follow-up outcome data. We, therefore, describe our 5-year single-center experience with such operations. MethodsBetween 2015 and 2021, 186 patients underwent elective, total arterial minimally invasive CABG in our institution. Patient data were prospectively collected in the institutional database and retrospectively analyzed. Primary end points were in-hospital mortality and 5-year survival. The secondary end points included freedom from major adverse cerebrovascular and cardiac events. ResultsPatients were a mean age of 66 ± 9 years, and 23 (12%) were women. The mean number of bypass grafts performed was 2.4 ± 0.5 (range, 2-4 grafts). Bilateral ITAs were used in 163 patients (88%) and left ITA and radial arteries in 22 (12%). The mean procedure time was 277 ± 58 minutes. There was 1 hospital death. Perioperative myocardial infarction, repeat thoracotomy, and conversion to sternotomy was observed in 6 (3%), 12 (6.5%), and 2 patients (1.1%), respectively. The mean 5-year survival was 93.3% ± 2.2%, and freedom from major adverse cardiac and cerebrovascular events was 83.8% ± 4.1%. ConclusionsTotal arterial minimally invasive CABG is a feasible surgical approach yielding excellent short- and midterm results when performed in selected patients in specialized high-volume cardiac centers.

A decade of robotic beating-heart totally endoscopic coronary bypass (TECAB) at a single institution: Outcomes with 10-year follow-up

ObjectiveRobotic beating-heart totally endoscopic coronary bypass (TECAB) is performed using single or bilateral internal thoracic arteries with good results. Despite slow adoption and limited industry support, we have evolved our practice and continue to routinely perform TECAB. We describe our series of 874 patients undergoing robotic beating-heart TECAB with up to 10-year follow-up. MethodsA retrospective review of all patients (n = 874) undergoing robotic beating-heart TECAB (July 2013 to April 2024) was performed. Patients were contacted for midterm follow-up, and angiographic data were collected in those undergoing hybrid revascularization. Multivariate regression analysis and Cox proportional hazard modeling were used to analyze risk factors for early/midterm outcomes. Primary end points were midterm all-cause mortality and major adverse cardiac/cerebrovascular events. ResultsMean Society of Thoracic Surgeons score was 1.5 ± 2.2%. In total, 470 (54%) underwent multivessel TECAB, of whom 86% received bilateral internal thoracic arteries. There was 1 intraoperative conversion (0.11%). Mean length of stay was 2.3 ± 0.8 days. Hospital mortality was 0.80% (observed/expected 0.54). A total of 393 patients (45%) underwent hybrid revascularization. Early graft patency was 97% (left internal thoracic artery-left anterior descending artery patency 98%). Midterm follow-up was 100% at mean 48 months (longest 10.6 years). Cardiac-related mortality and all-cause mortality were 2.2% and 18%, respectively. Freedom from major adverse cardiac/cerebrovascular events was 93%. In multivariate analysis, left-main disease ≥70% was a risk factor for midterm cardiac mortality (odds ratio, 6.7; confidence interval, 1.9-24, P = .003). ConclusionsIn this series of 874 patients with up to 10-year follow-up, we show that robotic TECAB can be performed with excellent early and midterm results using an iterative approach, despite significant challenges. Further industry support and wider surgeon adoption are necessary to ensure sustainability of this procedure.

Meta-analysis of BITA versus SITA grafting in diabetic patients: evidence from propensity score-matched studies.

It has been demonstrated that the use of bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) improves long-term survival in comparison to the use of a single internal thoracic artery (SITA) graft. However, the optimal transplantation technique for diabetic patients remains undetermined. The purpose of this meta-analysis was to compare the effectiveness and safety of BITA and SITA CABG in diabetic patients. A comprehensive search of Google Scholar, Science Direct, and PubMed was conducted for studies with propensity score-matched comparing between BITA and SITA grafting in diabetic patients. The main goal was to knowmid- to long-term mortality, and the supplementary results included incidence of deep sternal wound infection, 30-day mortality, and incidence of reoperation due to hemorrhage. The meta-analysis included 11 studies involving 3762 diabetic patients with matched propensity scores. Compared to SITA grafting, BITA grafting was associated with a significant reduction in long-term mortality (HR 0.78; 95% CI 0.67-0.91), P = 0.03, I2 = 54%. There were no significant differences between the two groups in terms of 30-day mortality, reoperation for bleeding, cerebrovascular accident, or renal failure. BITA grafting appears to provide better overall survival than SITA grafting in patients with diabetes. However, using BITA grafting is associated with a greater risk of deep sternal wound infection. These findings may help guide the choice of grafting technique in diabetic patients undergoing CABG.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Subcostal bilateral internal thoracic artery harvesting with the da Vinci Single Port system: an experimental feasibility study.

We evaluated the feasibility of harvesting bilateral internal thoracic arteries with the da Vinci Single Port system (SP)through a single left-sided subcostal incision. Complete bilateral mobilization with sufficiently long conduits for multivessel grafting was possible in 2 human cadavers and 2 live porcine. Creating the subcostal access and docking the SP system took between 14 and 21 min and the total harvest time ranged from 65 to 125 min in all models. No major bleeding was observed in the live porcine and hemostasis was managed with the available instrumentation. One porcine deceased during surgery due to ventricular fibrillation followed by cardiac arrest. The robotic harvesting was technically easily reproduced by the surgeons and required no additional rib-spreading. Further studies will be required to assess if this subcostal approach with the da Vinci SP system yields true clinical benefits in patients.

Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction

Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women’s Medical University).

Visualization of the Internal Thoracic Arteries in Giant Cell Arteritis on 18 F-FDG Semiconductor PET/CT.

A 72-year-old woman presented with the fever and the pain of skull and face for 2 weeks. 18 F-FDG PET/CT equipped with semiconductor detectors revealed strong uptake not only in the temporal, cervical, subclavian arteries, and aorta, but also in the bilateral internal thoracic arteries. The diagnosis of giant cell arteritis was made. Semiconductor PET can visualize small arteries such as the internal thoracic artery. The patients with giant cell arteritis are at a high risk of ischemic heart disease, and inflammatory involvement of the internal thoracic arteries may affect the outcome of coronary artery bypass grafting.

Robot-Assisted MIDCAB Using Bilateral Internal Thoracic Artery: A Propensity Score-Matched Study With OPCAB Patients.

Robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is an attractive strategy for coronary revascularization. Growing evidence supports the use of total arterial grafting in coronary surgery. We evaluated total arterial left-sided coronary revascularization with bilateral internal thoracic artery (BITA) using RA-MIDCAB and compared it with a propensity score-matched (PSM) off-pump CAB (OPCAB) surgery population. We retrospectively included all isolated OPCAB and RA-MIDCAB surgery using BITA without saphenous vein graft from January 1, 2015, to October 31, 2022. We analyzed all our RA-MIDCAB patients and performed PSM to compare them with our OPCAB population. Primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and mortality. Secondary outcomes were surgical parameters, length of hospital stay, and learning curve. We included 601 OPCAB and 77 RA-MIDCAB procedures, which resulted in 2 cohorts of 54 patients after PSM. Mortality and MACCE survival analysis showed no significant difference. There was less blood transfusion in the RA-MIDCAB (16.7%) compared with the OPCAB group (38.9%; P = 0.02). We observed fewer intensive care unit (ICU) admissions (24.1% vs 96.6%), shorter ICU stay (0.78 ± 1.7 vs 1.91 ± 1.01 days), and shorter hospital stay (6.78 ± 2.4 vs 8.01 ± 2.5 days) in the RA-MIDCAB versus OPCAB group (P < 0.01). Surgery time decreased from 400.0 ± 70.8 to 325.0 ± 38.0 min with more experience in RA-MIDCAB BITA harvesting (P < 0.01). This is a first publication of 77 consecutive RA-MIDCAB BITA harvesting for left coronary artery system revascularization. This technique is safe in terms of MACCE and mortality. Additional advantages are shorter length of hospital stay, fewer ICU admissions, and less blood transfusion.

Saphenous vein to the right coronary system from the right thoracic artery or the aorta. Long-term propensity-matched results of 2 groups.

Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported. From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65-93) months. In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P < 0.0001) when right internal thoracic artery was the inflow. Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis.

Single versus bilateral internal thoracic artery grafting in patients with impaired renal function.

The optimal strategy for surgical revascularization in patients with impaired renal function is inconclusive. We compared early and late outcomes between bilateral internal thoracic artery (BITA) and single ITA (SITA) grafting in patients with renal dysfunction. This is a retrospective analysis of all the patients with multivessel disease and impaired renal function (estimated glomerular filtration rate <60mL/min/1.73m2) who underwent isolated coronary artery bypass graft (CABG) in our center during 1996-2011, utilizing either BITA or SITA revascularization. Of the 5301 patients with multivessel disease who underwent surgical revascularization during the study period, 391 were with impaired renal function: 212 (54.2%) underwent BITA, 179 (45.8%) underwent SITA. Patients who underwent BITA were less likely to have comorbidities. Statistically significant differences were not observed between the BITA and SITA groups in 30-day mortality (5.6% vs. 9.0%, p = 0.2) and in rates of early stroke, myocardial infarction, and sternal infection (4.5% vs. 6.1%, p = 0.467; 1.7% vs. 2.8%, p = 0.517; and 2.2% vs. 5.7%, p = 0.088, respectively). Long-term survival of the BITA group was better: median 8.36 vs. 4.14 years, p<0.001. In multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.704, 95% CI: 0.556-0.89, p = 0.003). In analysis of a matched cohort (134 pairs), early outcomes did not differ between the groups; however, in multivariable analysis, BITA revascularization was associated with decreased late mortality ‎‎(HR = 0.35 (95%CI 0.18-0.68), p = 0.002)‎. BITA revascularization did not impact early outcome in patients with CRF, but demonstrated a significant protective effect on long-term survival ‎in the unmatched and matched cohorts.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BackgroundTo compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).MethodsAmong 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.ResultsAfter adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008).ConclusionsBilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.