Bilateral Mammary Artery Research Articles

Complete arterial revascularization with the bilateral mammary artery

ZusammenfassungDie Offenheitsrate der A. mammaria ist in der Koronarchirurgie denen aller anderen Bypass-Grafts überlegen. Dieser Beitrag beschreibt die komplett arterielle Revaskularisation unter Verwendung der bilateralen A. mammaria als universelles Verfahren in der Koronarchirurgie, inklusive der T‑ und I‑Graft-Technik. Neben möglichen Kontraindikationen werden Einzelheiten des Operationsprotokolls und das Vorgehen bei eingeschränktem A.-mammaria-Material beschrieben. Außerdem werden Besonderheiten der Antikoagulation in der Off-pump-Koronarchirurgie herausgestellt.

Utilization of Vein Grafts in Coronary Artery Bypass Grafting: Reasons and Outcomes in a Bilateral Mammary Artery First Center

Objectives. Despite guideline recommendations for use of bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG), a large proportion of patients still receive saphenous vein grafts (SVG). We herein aimed to identify reasons for SVG use at a center with a BIMA utilization rate between 60 and 70% and compare outcomes of patients undergoing CABG with either BIMA or left internal mammary artery (LIMA) plus SVG. Methods. Between 2013 and 2022, 4145 consecutive patients underwent isolated CABG at our center. Of those, 2067 patients received BIMA (group 1) and 1206 patients received LIMA/SVG (group 2). A propensity score-matched analysis was performed to adjust for baseline differences. Results. Group 2 presented with higher age, more female patients, and more patients with acute coronary syndrome including NSTEMI/STEMI with more urgent/emergency CABG. In unadjusted analysis group 2 presented adverse 30-day outcomes compared to group 1 with a higher mortality (18/2067, 0.9% vs. 34/1206, 2.8%; p<0.001), higher rate of re-revascularization (52/2067, 2.5% vs. 50/1206, 4.1%; p<0.001), more stroke (20/2067; 1.0% vs. 33/1206, 2.7%; p<0.001), and more postoperative renal failure (17/2067, 0.8% vs. 27/1206, 2.2%; p=0.001). After adjustment for baseline characteristics, 30-day outcomes were comparable. Conclusions. After adjustment for baseline characteristics no differences in outcomes were found between groups suggesting a safe applicability of BIMA even in patients with acute coronary syndrome undergoing urgent/emergency CABG. Reasons for SVG use were higher age, female gender, and acute coronary syndrome with urgent/emergency CABG. Outcomes of both groups were excellent with low rates of primary endpoints.

Left Main Coronary Artery and Bilateral Mammary Artery Aneurysms in a Patient With Extensive Aortopathy.

Left Main Coronary Artery and Bilateral Mammary Artery Aneurysms in a Patient With Extensive Aortopathy.

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.

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.

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Sternal healing after bilateral internal mammary arteries use for Coronary artery bypass grafting in diabetic Patients; short-term results

Background: Bilateral internal mammary artery (BIMA) use may improve long-term outcomes after coronary artery bypass grafting (CABG); however, the risk of infection is high. Skeletonization of the internal mammary may decrease the risk of infection, especially in patients with diabetes. Our study aimed at evaluation of sternal healing in diabetic patients with different techniques of bilateral internal mammary artery harvesting.&#x0D; Methods: This prospective randomized study included 200 diabetic patients who underwent CABG using BIMA between 2017 and 2019. We divided patients into two groups; Group A had skeletonization of both internal mammary arteries, and Group B had pedicled left mammary and skeletonized right mammary. Patients were observed for three months, post-operatively for any sternal wound problems.&#x0D; Results: There was no significant difference regarding the baseline variables. Type I diabetes mellitus was present in 25% in group A (n= 24) and 13.64% in group B (n= 12) (p= 0.324). There was no difference in harvest time between groups (83 ±4 vs. 81 ±3 minutes in group A vs. B, respectively. P= 0.1). The mean number of grafts was 3± 0.5 in Group A and 3± 0.6 in Group B (p= 0.8). Postoperative drainage was 402.9 ± 174.1 ml in Group A vs. 387.2 ± 153.6 ml in Group B (p= 0.474). The duration of ICU stay did not differ significantly between groups (2± 0.7 in Group A vs. 2± 0.5 in Group B; p= 0.8). Deep sternal wound infection occurred in 4.17% in group A (n= 4) and 4.55% in group B (n= 4) (p= 0.705). Superficial wound infection occurred in eight patients in group A (8.33%) and eight patients in group B (9.1%) (p= 0.59). No patient had sternal dehiscence in group A vs. four patients in group B (4.55%) (p= 0.39).&#x0D; Conclusion: We did not find differences between bilateral mammary artery harvest with skeletonization of both arteries versus skeletonization of the right mammary only on sternal healing nor wound infection in diabetic patients undergoing CABG. A larger study is recommended.

Coronary artery bypass graft surgery with bilateral internal mammary artery. Medium-term results.

Coronary artery bypass graft (CABG) surgery is one of the main strategies in the treatment of coronary heart disease. The benefit of using the left internal mammary artery (IMA) to revascularize the anterior descending artery is greatly demonstrated, improving long-term survival in patients receiving this graft. On the other hand there are variable currents about the use of two internal mammary arteries, although several studies have already demonstrated the superiority of the use of two mammary arteries over one. Retrospective study of Coronary artery bypass graft surgeries with bilateral mammary artery, performed at Instituto Nacional Cardiovascular - INCOR EsSalud between January 2012 and June 2018. The objective was to determine the mortality rate and major adverse cardiovascular events in a medium term follow-up of 30 months. 121 patients were operated with bilateral internal mammary artery. All patients underwent dissection of mammary artery with skeletonized technique. There was one in-hospital death due to mediastinitis. Major adverse cardiovascular events occurred in 5.8% of patients (death 0.8%, stroke 0%, perioperative myocardial infarction 1.6%, need for new coronary intervention 3.3%). The incidence of mediastinitis and/or sternal reconstruction was 0.8%. : CABG with bilateral IMA is a safe procedure, with low mortality rates and low major adverse cardiovascular events in a 30-month follow-up.

Sequential Versus Individual Saphenous Vein Grafting During Coronary Arterial Bypass Surgery

Although multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) is still the most frequently used CABG conduit, and it accounts for 80% of all CABG conduits. Research focusing on modifiable surgical factors such as anastomosis technique, however, is scarce. This study aimed to compare clinical outcomes and graft patency according to anastomosis methods of vein grafting. From January 2005 through December 2016, patients who underwent CABG using SVG either by a sequential or an individual grafting technique were enrolled in this study. Graft patency was evaluated with coronary computed tomographic angiography. Propensity-score matching was used to compare the clinical outcomes and graft patency of these 2 grafting techniques to reduce treatment selection bias. Overall 2515 eligible patients, 1,037 in the sequential SVG graft group (41.3%) and 1478 (58.8%) in the individual SVG graft group were enrolled. After propensity-score matching, 901 matched pairs of patients and 891 matched pairs of grafts were included in the final outcome analysis. There were no significant differences in unadjusted (P= .83) and adjusted overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.79 to 1.17; P= .67). The composite outcome of death, nonfatal myocardial infarction, and repeat revascularization also did not significantly differ between the sequential SVG and the individual SVG groups for both before (P= .20) and after matching (HR, 0.91; 95% CI, 0.75 to 1.09; P= .30). The sequential grafts showed superior patency as compared with the individual grafts for both before (P= .015) and after adjustment (HR, 0.61; 95% CI, 0.45 to 0.82; P < .001). The sequential grafting technique of SVG showed fairly acceptable safety and efficacy with superior long-term graft patency than individual grafts.Sequential SVG grafts perhaps can be a reasonable option as a second graft in CABG in some clinical situations.

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.

AIncisional Negative Pressure Wound Therapy (INPWT) for Coronary Artery Bypass Grafting Patients

Background: Surgical site infections are major complications of coronary artery bypass grafting using bilateral internal thoracic arteries. In this study we reviewed the results of using INPWT for high risk patients with coronary artery bypass grafting (CABG) using bilateral internal mammary arteries. Patients and methods: From January 2013 to December 2016, patients with coronary artery bypass grafting using bilateral mammary arteries were enrolled in this study. Patients were from Kasr El-Einy, Beni-Suef and Fayoum University Hospitals. The total number was 427 patients, where INPWT was used in 161 patient, and conventional sterilized dressing was done in 266 patients. 2 groups were matched for statistical analysis, the first group was the control and the second group was where INPWT was used. Results: The results related to sternal wound infections were similarly attributed to the conventional group (10.9%) and the INPWT group (10.2%) (P=1.00). Patients treated with INPWT had less rate of infection than those with conventional dressing (5.5% versus 10.2%, P= 0.210), this difference was not statistically significant. Interaction tests also showed comparable results for SSI (surgical site infections) among patients with or without significant co-morbidities. Conclusion: This study suggests that the use of INPWT did not decrease the incidence of sternal wound infections in patients who had CABG surgery using bilateral internal mammary harvesting (BIMA). A larger randomized study is needed to evaluate the efficacy of this technique.

Reconstruction of Chest Wall after Extensive Chest Wall Necrosis Caused by Transcatheter Arterial Embolization of Bilateral Internal Mammary Arteries Injured by Cardiopulmonary Resuscitation—A Case Report

Transcatheter Arterial Embolization (TAE) is known to be effective for controlling severe hemorrhage caused by iatrogenic or blunt trauma. Out of more than 100 cases of TAE performed in our hospital, we have treated some cases of skin or muscle necrosis that resulted from embolization of the main arteries. In this study, we report the case of a patient with significant chest wall necrosis after TAE of the bilateral internal mammary arteries (IMAs). A 66-year-old male was transported to our hospital for loss of consciousness while playing golf. Cardiopulmonary resuscitation (CPR) was performed for cardiac arrest, which resulted in several rib fractures and mediastinal hematoma due to bilateral mammary artery injuries. Immediate TAE embolization was performed because of continuous hemorrhage. He was referred to our department 16 days after embolization due to the presentation of chest wall necrosis. Heart, lungs and diaphragm were exposed after surgical debridement under systemic anesthesia. We performed several operations to reconstruct the anterior chest wall. His spontaneous respiration returned, and is now controlled with a tracheostomy tube. Complete epithelialization was achieved, and he was transferred to another hospital for further rehabilitation. To the best of our knowledge, this is the first report of chest wall necrosis resulting from TAE of IMAs. Arterial embolization can cause widespread necrosis of bone, muscle and skin. Although treatment required an extended period, we managed to reconstruct the chest wall with multidisciplinary strategies.

OC81 TOTAL ARTERIAL CORONARY ARTERY REVASCULARIZATION USING BOTH INTERNAL MAMMARY ARTERIES WITH Y CONFIGURATION: LONG TERM RESULTS

Abstract Background and aim: Bilateral internal mammary artery (BIMA) grafts are used for coronary revascularisation by only a minority of surgeons, despite a growing body of evidence suggesting improved survival when compared to use of only one internal mammary artery with additional saphenous vein grafts. Main disadvantages reported, consist in sternal wound infection, increased technical complexity. We report our experience discussing technical considerations and long term follow up. Methods: Between January 2010 and February 2017, 1038 patients with multivessel coronary artery disease underwent myocardial revascularization with bilateral internal mammary arteries (BIMA) adopting Y configuration (male = 877 [84.5%]; mean age 65.7 ± 8.7 years, range 36–87). More than 25 % were obese (body mass index &gt; 30) N°261 and 32.5n% were affected by diabetes mellitus. Results: Both internal mammary arteries are harvested using a completely skeletonized technique. This minimizes chest wall trauma, achieves maximum length, and makes constructing the “Y” graft and performing subsequent sequential grafting easier. An off pump technique was preferred in 114 patients, for the remaining overall cardiopulmonary bypass was 68 ± 28.0 minutes and aortic cross clamping was 50 ± 20 minutes. (Skin to skin median 240 minutes). Thirty days mortality rate resulted 1.4% (15/1038). Other postoperative complications and follow up are collected and reported. Conclusions: data from literature reveals that use of bilateral mammary arteries is associated with improved long term survival, also in diabetic patients. The reported disadvantages as sternal dehiscence are actually not so relevant as well operations times are not so increased.

Coronary Revascularization With Single Versus Bilateral Mammary Arteries: Is It Time to Change?

Arterial conduits are preferred to venous conduits for coronary artery bypass grafting because of longer patency. A single internal mammary artery (SIMA) is used routinely. Bilateral internal mammary arteries (BIMA) are used less frequently. We sought to determine whether BIMA were superior to SIMA. From our regional registry of consecutive open heart operations, we identified 47,984 patients who underwent isolated coronary artery bypass grafting from 1992 to 2014. Of the 1,482 BIMA patients, 1,297 were propensity matched to a cohort of SIMA patients. Short-term outcomes were compared using standard statistical techniques. Long-term survival was compared using Kaplan-Meier estimators and compared using a log-rank test. BIMA patients were younger and had fewer comorbid conditions than SIMA patients. After propensity weighting, BIMA and SIMA patients were well matched. There was no difference in in-hospital outcomes for BIMA versus SIMA patients for mortality (1.2% [n= 15] vs 0.8% [n= 10], p= 0.315), stroke (0.7% [n= 9] vs 0.7% [n= 9), p= 1.000), bleeding (2.2% [n= 28] vs 2.8% [n= 36], p= 0.311), or mediastinitis (0.8% [n= 10] vs 0.9% [n= 12], p= 0.667). The median follow-up was 12 years. Survival was better for BIMA than SIMA (adjusted hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.91; p < 0.001). Survival curves began to separate after 5 years. At 15 years, the absolute difference in survival was 8.4%. In a large regional experience, BIMA is associated with no upfront risk of adverse events and improved long-term survival compared with SIMA. Our results indicate that BIMA conduits should be considered more frequently during coronary artery bypass grafting due to their demonstrated survival advantage.

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.

Off-pump Revascularization with Bilateral Mammary Artery -Single Center Proof of Concept after 5 Years

Objective: Off-pump myocardial revascularization using bilateral mammary artery (BIMA) is a promising concept in cardiac surgery during the last years. Beside proven benefits toward off-pump surgery, there is an ongoing debate, whether single mammary artery revascularization (SIMA) is superior to the BIMA revascularization in the short and long term course.

Mammary Artery Calcification a Useful Marker for Coronary Artery Disease

Introduction: The prevalence of ischemic heart disease is steadily increasing, causing huge morbidity and mortality around the world [1]. The scenario is worse in Indian subcontinent [2]. Atherosclerosis is a generalized disease process [3]. Presence of atherosclerotic changes at one place is indicative of possible involvement of another region. Diabetes which is considered to be coronary equivalent is also rising in epidemic proportions, contributing to rise in coronary artery disease (CAD) [4]. It is therefore imperative to look carefully for all possible markers of atherosclerosis and prevent its life threatening complications. Case Presentation: A 62-year-old lady, known diabetic and chronic renal disease patient for last 15 years and hypothyroidism for 5 years presented with acute onset chest pain. ECG revealed ST-T inversions suggesting acute coronary syndrome. Chest radiograph was taken which was unremarkable except for aortic knuckle calcification (Image 1). She was managed on the lines of acute coronary syndrome. During her course of stay she also complained of breast discharge. On examination, a small firm lump was palpated in breast and red coloured discharge was observed. Mammogram was advised for the same, which revealed a spiculated mass and axillary lymph node. Incidentally calcification of bilateral mammary arteries was also noted (Image 2). Carotid intima media thickness (CIMT) measurement was also done (Image 3). Increased CIMT measuring approx. 18 mm was observed in mid common carotid artery. A calcified plaque was noted in left carotid bulb. Discussion: Association of increased coronary artery disease with increased CIMT is well established. Assessment of CIMT is a routine protocol at many Centres in CAD patients [5-7]. Few studies have been published which have suggested that association exists between intramammary arterial calcifications and coronary artery disease [8-10]. Screening mammography is a common procedure for early detection of breast cancer. As the evidence supporting mammary artery calcification as a possible marker for CAD grows, this would establish as an additional utilization of commonly used mammography screening for early detection of breast cancer. This case further supports the belief that presence of mammary artery calcification and CAD coexist. It is therefore essential that mammary artery calcifications and /or aortic calcification must always be reported in radiology reports and the clinicians must not ignore the presence of these calcifications and assess for possible coronary artery disease.

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

&lt;p&gt;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.&lt;/p&gt;&lt;p&gt;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.&lt;/p&gt;

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&lt;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.

78. Coronary bypass using bilateral internal mammary arteries in an achondroplast

Coronary bypass grafting for ischemic heart disease in achondroplastic dwarfs is very rare. Shortage of veins and sometimes, inadequate vein quality can cause difficulties during surgery. Only two achondroplastic cases were reported in literature that underwent coronary bypass surgery, in which the left internal mammary artery and vein grafts were used. To the best of our knowledge using bilateral internal mammary arteries in such patients was not reported. We report here a 55 years old male achondroplastic dwarf who had triple vessels coronary disease that underwent successful coronary bypass surgery using bilateral mammary arteries. Anatomic and surgical challenges in achondroplasia are highlighted