Bilateral Mammary Artery Grafting Research Articles

Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries.

Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

On-Pump Coronary Artery Bypass Graft: The State of the Art.

Coronary artery bypass grafting (CABG) remains the standard of care for patients with coronary artery disease (CAD). Debate exists concerning several factors, which include percutaneous coronary intervention (PCI) vs. CABG, single vs. bilateral mammary artery grafts, radial artery vs. saphenous vein grafts, right internal mammary artery vs. radial artery grafts, endoscopic vs. open vein-graft harvesting, and on-pump vs. off- pump surgery. Moreover, challenging is the management of diabetic patients with CAD undergoing CABG. This review reports current indications, practice patterns, and outcomes of CABG. Randomized controlled trials comparing CABG to other therapeutical strategies for CAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Large multicenter randomized and observational studies (SYNTAX, BEST, PRECOMBAT, ASCERT) have reported excellent outcomes in CABG patients, with always fewer rates of operative mortality and major morbidity, than PCI. The 10-year follow-up of ARTS II trial showed no difference between single and bilateral mammary artery. BARI 2D, MASS II, CARDia, FREEDOM trials showed that CABG is the best choice for diabetic patients. CABG still represents one of the most widespread major surgeries, with well-known benefits on symptoms and prognosis in patients with CAD. However, further studies and follow-up data are needed to validate these evidences.

CABG: A continuing evolution.

Use of coronary artery bypass grafting (CABG) has had a resurgence, as clinical trial data emerged showing that it remains the standard of care for patients with complex lesions. Debate exists regarding various factors, including endoscopic vs open vein-graft harvesting, single vs bilateral mammary artery grafts, radial artery vs saphenous vein grafts, right internal mammary artery vs radial artery grafts, and on-pump vs off-pump surgery. More recent developments include minimally invasive approaches, robotics, and hybrid revascularization, which are changing the risk-benefit ratio for this patient population.

Direct Aortic CoreValve Implantation via Right Anterior Thoracotomy in a Patient with Patent Bilateral Mammary Artery Grafts and Aortic Arch Chronic Dissection

<p>Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease.</p><p>We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection.</p>

Abstract 15732: Impact of Bilateral Mammary Artery Grafting for Coronary Revascularization in the Obese Population, a Retrospective Study

Context: The prevalence of obesity has increased over the last decade. Although bilateral internal mammary artery (BIMA) grafting for coronary revascularization is associated with better survival in the general population, it is also a risk factor for deep sternal wound infection (DSWI), a complication more frequently seen in the obese population. The aim of this study is to determine the short and long-term outcomes of the use of BIMA in obese patients undergoing cardiac surgery, assessing the impact on survival and the incidence of DSWI. Methodology: This is a single center retrospective cohort study with prospectively collected data. We included obese patients (BMI ≥ 30 kg/m2) undergoing coronary artery bypass grafting (CABG) between April 1991 and April 2014 in our institution. Propensity score matching was conducted for the entire population studied. Results: Results showed that 5608 obese patients underwent CABG during the study period. After propensity scoring, 494 patients receiving BIMA revascularization were matched to 5089 patients receiving single internal mammary artery (SIMA) revascularization. All pre-operative characteristics were comparable except for a higher prevalence of heart failure in the SIMA group. In-hospital post-operative mortality in the two groups was comparable (1.0% BIMA vs 1.8% SIMA, p=0.86). In-hospital DSWI was also comparable (1.2% BIMA vs 1.0% SIMA, p=0.63). However total DSWI (including post-discharge DSWI, median time 19 days) was significantly higher in the BIMA group compared to the SIMA group (3.6% vs 2.2%; p<0.0001). Over a median follow-up of 7.2 years (mean follow-up 7.7 ± 4.2 years), there was no observed long-term survival advantage in the BIMA vs the SIMA group (p=0.22). Conclusion: Using BIMA instead of SIMA increases the risk of DSWI in obese patients. The use of BIMA is not associated with better survival compared to the use of SIMA in this population. These results suggest that the increased short-term risk of post-operative infection associated with BIMA revascularization is not offset by a long-term survival benefit. Given the increased risk of DSWI and absence of mid- to long-term survival benefit, caution should be exerted when selecting the use of BIMA grafting in the obese population.

Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery?' Altogether 214 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the included studies were follow-up studies; eight studies used prospective data collection, and five studies collected the study data retrospectively. No randomized controlled trials were found. Nine of the 13 included papers used a propensity-score-matched comparison of the survival of bilateral mammary artery graft [or, bilateral internal thoracic artery (BITA) graft] patients vs single mammary artery graft [or, single internal thoracic artery (SITA) graft] patients. These studies consistently showed an enhanced survival of BITA patients compared with propensity-score-matched SITA patients. Three of the 13 included papers used Cox proportional hazards regression analysis to compare survival of BITA vs SITA patients; one larger study showed better crude survival of BITA patients, but did not identify BITA grafts as independent predictor of enhanced survival. The remaining two studies also did not identify BITA grafts as independent predictor of enhanced survival. One study only presented crude survival estimates of BITA vs SITA patients and therefore was of limited informative value. We conclude that the use of BITA grafts seems to offer a long-term survival benefit compared with a SITA graft for patients undergoing coronary artery bypass grafting surgery. Although randomized evidence is lacking, observational evidence supporting this hypothesis is mounting.

Is Bilateral Internal Thoracic Artery Use Safe in the Elderly?

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. 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. 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)]. 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.

Topical use of autologous fibrin glue in high-risk CABG patients

BACKGROUND: Surgical site wound complications following cardiothoracic surgery are associated with increased costs, morbidity, and mortality. Several factors have been shown to be associated with an increase in deep and superficial wound healing problems. Recent publications have suggested protective effects of topical autologous blood components with regard to wound healing disturbances after various surgical procedures. The aim of this retrospective analysis was to assess the impact of autologous fibrin glue on surgical site complications in high-risk coronary artery bypass graft patients. METHODS: 1394 consecutive patients who underwent CABG surgery from a single centre were included in the study. Autologous fibrin glue was used in 122 patients (8.8%) with elevated risk for wound complications according to institutional guidelines. The demography of both groups was compared and the following outcome variables were analyzed: deep sternal wound infection, sternal re-wiring, bleeding, re- exploration rate, and the use of a vacuum assisted closure system. RESULTS: No treatment-related adverse events were noted. The group of patients who received autologous fibrin sealant had significantly higher BMI levels, included more diabetics and repeat cardiac procedures and they underwent percutaneous coronary intervention more often. Furthermore, they were more likely to receive bilateral mammary artery grafts. Despite the high-risk profile of the Fibrin glue group rates of revision, deep sternal wound healing problems tended to be lower than in the control group. CONCLUSIONS: In our experience autologous fibrin glue does not invoke any adverse events and serves as a useful adjunct to haemostasis in cardiac surgery. However, the incidence of wound disturbances was similar in both arms of the study. In light of the ever-increasing clinical use a prospective randomized controlled trial examining the impact of autologous fibrin glue is warranted.

Successful Linking of The Society of Thoracic Surgeons Database to Social Security Data to Examine Survival After Cardiac Operations

Long-term evaluation of cardiothoracic surgical outcomes is a major goal of The Society of Thoracic Surgeons (STS). Linking the STS Database to the Social Security Death Master File (SSDMF) allows for the verification of "life status." This study demonstrates the feasibility of linking the STS Database to the SSDMF and examines longitudinal survival after cardiac operations. For all operations in the STS Adult Cardiac Surgery Database performed in 2008 in patients with an available Social Security Number, the SSDMF was searched for a matching Social Security Number. Survival probabilities at 30 days and 1 year were estimated for nine common operations. A Social Security Number was available for 101,188 patients undergoing isolated coronary artery bypass grafting, 12,336 patients undergoing isolated aortic valve replacement, and 6,085 patients undergoing isolated mitral valve operations. One-year survival for isolated coronary artery bypass grafting was 88.9% (6,529 of 7,344) with all vein grafts, 95.2% (84,696 of 88,966) with a single mammary artery graft, 97.4% (4,422 of 4,540) with bilateral mammary artery grafts, and 95.6% (7,543 of 7,890) with all arterial grafts. One-year survival was 92.4% (11,398 of 12,336) for isolated aortic valve replacement (95.6% [2,109 of 2,206] with mechanical prosthesis and 91.7% [9,289 of 10,130] with biologic prosthesis), 86.5% (2,312 of 2,674) for isolated mitral valve replacement (91.7% [923 of 1,006] with mechanical prosthesis and 83.3% [1,389 of 1,668] with biologic prosthesis), and 96.0% (3,275 of 3,411) for isolated mitral valve repair. Successful linkage to the SSDMF has substantially increased the power of the STS Database. These longitudinal survival data from this large multi-institutional study provide reassurance about the durability and long-term benefits of cardiac operations and constitute a contemporary benchmark for survival after cardiac operations.

Bilateral mammary artery vs. single mammary artery grafting: promising early results: but will the match finish with enough players?

This editorial refers to ‘Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART)’, by D.P. Taggart et al. , doi:10.1093/eurheartj/ehq318 A single internal mammary artery (SIMA) rather than vein graft to the left anterior descending coronary artery is undoubtedly the standard therapy in coronary bypass surgery. Surprisingly, the usage of two mammary arteries has not been accepted as the standard of care and the benefits and disadvantages have been a matter of debate for years. Numerous compelling retrospective studies have documented a clear benefit for bilateral mammary artery (BIMA) grafting over SIMA grafting in reducing the long-term risk of death, cardiac death, and late cardiac events.1 Nevertheless, there is a wide discrepancy between these findings in the literature and clinical practice. In the USA, BIMA usage is only around 4%2 and in Europe 12%.3 The saphenous vein is still a widely used graft because of its accessibility, sufficient length, and ease of manipulation. Bilateral mammary artery grafting has been associated with an increased rate of sternal dehiscence a potential complication, particularly in diabetics.4 It seems however that using skeletonized BIMA grafts may lower the incidence of sternal complications.5 Another argument that is often used against BIMA usage is that composite grafting is susceptible to the effect of flow competition and may lead to a higher incidence of graft occlusion or string sign in up to 20% of the patients.6 Nonetheless, this compares favourably with an astonishing 45% …

Closed chest bilateral mammary artery grafting in double-vessel coronary artery disease

A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease.

Bilateral mammary artery grafting: Avoidance of complications with extended use

This study was undertaken to more clearly define the operative risks and appropriate strategies for the selection of patients who might be candidates for bilateral internal mammary artery grafting. A review of the 674 patients who underwent this procedure was performed over a 10-year period from January 1982 through 1991. These patients represented 5% of the 12,824 patients who underwent bypass grafting during this period. The mean patient age was 54 ± 9.4 years, and 92% of the patient were male. Diabetes was present in 17.5%, with 24% of this group insulin dependent. The ejection fraction was less than 0.50 in 26.7% and 14% had had previous bypass procedures. Hospital mortality was 1.9% (n = 13). Hospital morbidity included wound infection in 3.6%, reoperation for bleeding in 2.1%, and stroke in 1.6%. Postoperative intraaortic balloon pump support was necessary in 2.8%. Univariate and multivariate analysis revealed that advanced age, an emergent operative status, and the number of diseased vessels (especially left main obstruction) were predictors of hospital death. Except for wound infection (9.3% versus 2.5%) and length of hospital stay (10.8 ± 11.8 days versus 8.8 ± 7.6 days), the complications in diabetics were similar to those in patients without diabetes, respectively. At 5 years, freedom from death, death or infarctions, and death, myocardial infarction, or coronary reoperation was 90%, 70%, and 62%, respectively. The only significant multivariate correlates of long-term survival were diabetes and reoperative surgery.

Multivessel Coronary Revascularization Without Saphenous Vein: Long-term Results of Bilateral Internal Mammary Artery Grafting

When the saphenous vein is absent or inadequate, options for multivessel coronary revascularization include bilateral mammary artery grafting and the use of conduits of unproven durability (arm vein, homologous umbilical vein, prosthetic graft). To evaluate the long-term effectiveness of bilateral mammary artery grafting, we reviewed the cases of 76 consecutive patients with multivessel disease (33 with two-vessel disease, 43 with three-vessel disease) who underwent revascularization with bilateral mammary artery grafts only during the period from 1971 to 1980. No hospital deaths occurred. Thirty-three free and 119 in situ grafts were used. Late follow-up was complete, ranging from 12 to 132 months (mean interval, 67 months) and revealed improvement by at least one New York Heart Association functional class in 59 of 71 survivors. Postoperative arteriograms (mean interval, 26 months) of 55 grafts in 28 patients showed that 49 grafts were patent (89%). Five late deaths (2 noncardiac) occurred. Actuarial survival was 97.2% to seven years and 90.2% at nine years after operation. Bilateral mammary artery grafting yielded excellent graft patency, relief of symptoms, and long-term survival. When saphenous vein is unsuitable for grafting, bilateral mammary artery grafts should be utilized before other conduits are considered.