Early Angiographic Patency Research Articles

No-Touch Saphenous Vein as Y-Composite vs Aortocoronary Graft: Early Outcome Analysis

BackgroundA randomized controlled trial was designed to compare 1-year morphologic changes of the no-touch saphenous vein (SV) as a Y-composite graft (composite group) vs an aortocoronary graft (aorta group) in coronary artery bypass grafting. This study evaluated early clinical and angiographic outcomes as a preliminary analysis. MethodsThe primary end point of the trial was the intima-media thickness measured by intravascular ultrasound at 1-year angiographic follow-up. Patients were screened to enroll 25 patients in each group based on a superiority design. Early postoperative clinical and angiographic outcomes were compared between the 2 groups. ResultsThe numbers of distal anastomoses per SV graft were 2.7 ± 1.1 and 2.6 ± 0.8 in the composite and aorta groups, respectively. There was no operative death, and postoperative complications in the 2 groups did not significantly differ. All patients underwent early postoperative graft angiography at a median of 1 (interquartile range, 1-1) day after operation. Early angiographic patency rates were 98.9% (93/94 anastomoses) and 100% (90/90 anastomoses) in the composite and aorta groups, respectively. There was no distal anastomosis showing competitive flow in the aorta group, whereas 3 anastomoses with competitive flow were found in the composite group. All 3 anastomoses with competitive flow were SV grafts that were anastomosed to the right coronary artery territory with moderate stenosis. ConclusionsEarly clinical outcomes and angiographic graft patency rates were not significantly different with use of no-touch SV as a Y-composite graft or an aortocoronary graft.

Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts

IntroductionThe left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. MethodsWe retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. ResultsSociety of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. ConclusionsGrafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

Transit Time Flow Measurement in Robotic Totally Endoscopic Coronary Artery Bypass: What Do the Numbers Mean?

Transit time flow measurement (TTFM) is valuable for assessing intraoperative graft patency in coronary artery bypass surgery (CAB). The significance of competitive native coronary flow on patency, as predicted by percentage of backflow (%BF) on TTFM, is unknown. This study aims to evaluate intraoperative TTFM parameters, and specifically %BF, in predicting graft patency in robotic totally endoscopic CAB (TECAB). We reviewed TTFM parameters in 311 patients undergoing robotic off-pump TECAB at our institution between February 2016 and January 2020. Patients with sequential or Y grafts were excluded, leaving 277 patients with a total of 387 isolated end-to-side grafts (248 left internal mammary artery [LIMA], 149 right IMA [RIMA]). Mean graft flow, diastolic flow, pulsatility index, and %BF were measured intraoperatively. Early postoperative angiograms were obtained in 83 patients undergoing percutaneous coronary intervention for hybrid revascularization, with a total of 125 grafts. Angiograms were independently analyzed and separated into 2 groups based on IMA graft patency, which were patent (FitzGibbon A/B) and nonpatent (FitzGibbon O) groups. Early angiographic patency at a median of 31.0 days after surgery showed 123 (97.1%) patent grafts and 3 (2.9%) occluded grafts in both LIMA and RIMA grafts to both left anterior descending (LAD) and non-LAD targets. Mean graft flow was 77.4 ± 41.6 mL/min. There was no difference in mean flow, pulsatility index, or %BF between the patent and occluded grafts. Excellent intraoperative flow parameters and early angiographic patency can be obtained via robotic, off-pump TECAB. Our data did not demonstrate an association between intraoperative TTFM evidence of competitive native coronary flow and early angiographic graft outcomes.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients.

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years. Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization. The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%. We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Simple Anastomotic Techniques for Coronary Artery Bypass Surgery in Patients with Small Coronary Arteries or a Marked Size Discrepancy Between the Coronary Artery and Graft.

Different suture techniques have been used for anastomosis in coronary artery bypass graft surgery. Bypass surgery may be difficult for patients who have small coronary arteries or marked size discrepancies between target coronary arteries and grafts. For proximal and distal anastomoses, three continuous stitches are first placed in the heel and toe of the small coronary arteries; for sequential anastomosis, an interrupted eight-stitch technique is used. We applied these anastomotic suture techniques in patients requiring coronary artery bypass graft surgery, achieving an early angiographic patency rate of 100%.

The side-to-side fashion for individual distal coronary anastomosis using venous conduit.

Regarding to coronary artery bypass grafting (CABG), the end-to-side anastomosis (ESA) has been performed as a gold standard. Recently, the effectiveness of the distal side-to-side anastomosis (SSA) in CABG using internal mammary artery has been reported. The benefit of SSA comparing to ESA also has been disclosed by computing simulation. However, use of SSA by venous conduit for individual CABG has not been reported. In this study, we investigated feasibility of SSA. From January 2013 to October 2014, we conducted 114 CABGs. There were 92 venous distal anastomoses without sequential anastomotic site (61 SSA and 31 ESA). The anastomosis was evaluated before discharge and at 1year after the procedure by angiography or multi-detector row computed tomographic coronary angiography. The median values for time to anastomosis were 13min in the two group (p=0.89). There was no revision of anastomosis in both groups. Additional stitches for hemostasis were required significantly less in SSA than ESA (18.0 vs 45.2%, respectively, p<0.05). Early angiographic patency; 96.6% for SSA vs 93.5% for ESA (p=0.50), and percentage of good anastomotic figure; 91.2% for SSA vs 87.1% for ESA (p=0.54) were similar in both groups. The angiographic patency at 1year were 92.9% for SSA and 81.0% for ESA (p=0.16). There was no predictive factor for early and late graft failure. Our study showed feasibility of SSA using venous conduit in individual CABG based on early and mid-term angiographic results. This anastomotic fashion is easy to perform and maybe beneficial in blood flow pattern.

A randomized comparison of the Saphenous Vein Versus Right Internal Thoracic Artery as a Y-Composite Graft (SAVE RITA) trial: Early results

The Saphenous Vein Versus Right Internal Thoracic Artery as a Y-Composite Graft trial was designed to evaluate the saphenous vein compared with the right internal thoracic artery as a Y-composite graft anastomosed to the side of the left internal thoracic artery. In this early analysis, we compared early angiographic patency rates and clinical outcomes. From September 2008 to October 2011, 224 patients with multivessel coronary artery disease were randomized prospectively to undergo off-pump revascularization using the saphenous vein group (n = 112) or the right internal thoracic artery group (n = 112) as Y-composite grafts. Early postoperative (1.4 ± 1.1 days) angiographic patency and clinical outcomes were compared. There was 1 operative death in the right internal thoracic artery group. No statistically significant differences in postoperative morbidities, including atrial fibrillation and acute renal failure, were observed between the groups. The number of distal anastomoses using the side-arm Y-composite graft (saphenous vein vs right internal thoracic artery) were 2.3 ± 0.8 and 1.9 ± 0.7 in the saphenous vein and right internal thoracic artery groups, respectively (P < .001). A third conduit was used in 44 patients (saphenous vein group vs right internal thoracic artery group, 4/109 vs 40/110; P < .001) to extend the side-arm Y-composite graft for complete revascularization. Early angiography demonstrated an overall patency rate of 99.4% (771 of 776 distal anastomoses). Patency rates of the side-arm Y-composite graft (saphenous vein vs right internal thoracic artery) were 98.8% (245 of 248) and 99.5% (207 of 208) in the saphenous vein and right internal thoracic artery groups, respectively (P = .629). A third conduit was needed to extend the right internal thoracic artery composite graft and reach the target vessels in 36.4% (40/110) of the patients. The saphenous vein composite graft was comparable with the right internal thoracic artery composite graft in terms of early angiographic patency and clinical outcomes.

A pilot, early angiographic patency study using a direct thrombin inhibitor as adjunctive therapy to streptokinase in acute myocardial infarction.

The success of streptokinase in acute myocardial infarction is hampered by the high failure rate to achieve early reperfusion. This study evaluates the possible benefit of Hirulog (Biogen, Cambridge, Mass), a direct thrombin inhibitor, as adjunct therapy to streptokinase to enhance early patency and prevent rethrombosis. Heparin has been shown to be of very limited benefits in this setting. Forty-five patients were randomized to Hirulog or heparin (2:1 ratio). Coronary angiography documented a TIMI 2 or 3 flow after 90 minutes in 77% of the patients treated with Hirulog and streptokinase and in 47% of patients treated with heparin and streptokinase (P < .05) and after 120 minutes in 87% and 47% of patients, respectively (P < .01). TIMI 3 flow was established in 77% of patients with Hirulog compared with 40% with heparin (P < .02). The clinical outcome and the bleeding rate was also favorable to Hirulog; no reocclusion was observed at late angiography performed 4.7 days later. Hirulog in this pilot study significantly improved the early patency rate of the infarct-related artery with a favorable clinical profile. This new direct thrombin inhibitor exhibits promise as adjunctive therapy to thrombolysis.

Right internal mammary artery for myocardial revascularization: Early results and indications

The right internal mammary artery (RIMA) was used for coronary artery bypass grafting in 258 patients from October 1985 to October 1991. The RIMA was inserted as the only graft in 8 patients and in combination with the left internal mammary artery (LIMA) in 231 patients, the right gastroepiploic artery in 19, and autologous vein in 184. The patients received a total of 1 to 8 distal anastomoses (mean number, 3.3). A total of 64% of the RIMAs were anastomosed to the left anterior descending coronary artery. The primary indication for use of the RIMA was small-vessel disease in 86 patients, repeat bypass grafting in 32, varicose or stripped saphenous veins in 61, and “selected routine case” in 79. The early (≤30 days postoperatively) mortality rate in these four groups was 8.1%, 6.3%, 0%, and 0%, respectively (p < 0.01). Independent risk factors (logistic regression analysis) for early mortality were small-vessel disease, insufficient grafting, repeat coronary artery bypass grafting, diabetes, history of smoking, age of 60 years or older, and family history of ischemic heart disease. Combined into a risk index, these risk factors identified six risk groups with early mortality of 0% in the four low-risk groups and 5.6% and 58.3% in groups V and VI, respectively (p < 0.0001). No RIMA-related variables were risk factors for significant postoperative myocardial enzyme release. Intraoperative electromagnetic flow measurements revealed no differences between the RIMA and LIMA. Early angiographic patency in 50 patients was 98% for the RIMA and 93% for the LIMA. The RIMA-related variables were risk factors for neither early mortality nor significant enzyme release. The RIMA can be used to revascularize any of the three coronary systems but is primarily suited for the left anterior descending coronary artery. Indications for use of the RIMA (in most instances with the LIMA) include any situation with exhausted venous reserves, small-vessel disease (an indication for primary arterial grafting), isolated right coronary artery disease in selected patients, and selected routine cases (with the LIMA).

Effects of aspirin, dipyridamole, and cod liver oil on accelerated myointimal proliferation in canine veno-arterial allografts.

The effects of the administration of aspirin (ASA), dipyridamole (DPM), and cod liver oil (CLO) on graft patency rate and degree of intimal hyperplasia were investigated in a canine, hypercholesterolemic veno-arterial allograft model in an attempt to modify this immunologically mediated vascular injury. The drug regimens were ASA 1 mg/kg/day, DPM 10 mg/kg/day, combined ASA and DPM (ASA + DPM), and CLO (1.8 g/day eicosapentanoic acid [EPA] and 1.2 g/day docosahexanoic acid [DHA]), and control. The early angiographic patency rate (1-3 weeks) was 81% +/- 10% (+/- 70% confidence limits); the 90-day overall patency rate was 60% +/- 4% (87/144), with no statistically significant differences among the groups (range 46 +/- 10-71 +/- 9%). Qualitatively, there was no difference in luminal thrombus, intimal hemorrhage, or lesion eccentricity. Considering the relatively short time of graft implantation, an extensive amount of microscopic disease was observed; quantitatively, the mean intimal thickness was 515 +/- 17 microgram overall but was not statistically different between the groups. The fraction of potential lumenal area occupied by intimal thickening was 0.37 +/- 0.01 but again did not differ significantly between the groups. These doses of ASA, DPM, ASA + DPM, and CLO did not alter graft occlusion or retard the marked degree of subintimal myointimal cell hyperplasia that was generated in this hypercholesterolemic canine veno-arterial allograft preparation. Possible explanations for these negative findings include inadequate dosage or form of omega-3 fatty acids and the antiplatelet drugs administered, excessive variability in graft response due to uncharacterized immunologic histocompatibility, and the possible influence of non-platelet-mediated mechanisms. Nevertheless, this preparation is attractive as a reproducible model of accelerated (immunologically mediated) experimental arteriosclerosis.