Free Internal Thoracic Artery Graft Research Articles

20-year angiographic patency of free internal thoracic artery graft at the time of heart transplant

Whether to accept a donor heart with coronary artery disease (CAD) remains controversial. Herein we report a 20-year of angiographic graft patency after concomitant coronary artery bypass grafting (CABG) at the time of heart transplantation.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis

BackgroundLittle is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients. MethodsFrom 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion. ResultsTwo of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively. ConclusionsAmong patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.

Left-Sided Complete Revascularization With Bilateral Internal Thoracic Arteries in Patients With Diabetes

Reports are few on the long-term patency of bilateral internal thoracic artery (BITA) grafts in patients with diabetes. We evaluated the relationship between the long-term patency of BITAs and the clinical outcomes in diabetes. We retrospectively identified 569 patients (321 with diabetes, 248 without diabetes) who underwent isolated BITA grafting for left-sided complete revascularization at our institution from 2000 to 2015. The primary end point was the incidence of major adverse cardiovascular events comprising death, re-revascularization, and myocardial infarction. The secondary end point was the patency of the BITAs. No differences were found in the major adverse cardiovascular event rate (10-year: diabetic group, 33.7%; nondiabetic group, 22.3%; p= 0.15) or overall mortality rate (24.0% versus 12.2%, p= 0.066) between the patients with and without diabetes. The incidence of cardiac death (3.3% versus 1.8%, p= 0.80) or re-revascularization and myocardial infarction (11.4% versus 11.8%, p= 0.67) was similar between the groups. The patency of free internal thoracic artery (ITA) grafts to the left circumflex artery was associated with greater patency in patients with diabetes than in patients without diabetes (4 years: 99.3% versus 95.5%, p= 0.049); the patency of other ITA grafts did not differ between the groups. All-cause death, re-revascularization, and myocardial infarction showed no differences between patients with and without diabetes who underwent left-sided revascularization with the BITAs. Although diabetes did not affect the patency of the ITA, free ITA grafts to the left circumflex artery showed good long-term patency in patients with diabetes.

Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass

This study compared clinical outcomes between the use of in situ and free internal thoracic artery grafts in patients with upper extremity arteriovenous fistula who underwent coronary artery bypass. We reviewed 85 hemodialysis-dependent patients with upper extremity arteriovenous fistula who underwent coronary artery bypass with internal thoracic artery grafts. The patients were categorized into 2 groups; 48 (56%) with in situ graft ipsilateral to the arteriovenous fistula (group I) and 37 (44%) with free grafts anastomosed to the ascending aorta (group F). The follow-up period was 32.0 ± 38.1 months. The estimated overall survival rates at 3, 5, and 10 years were 89.5%, 81.6%, and 53%, respectively, for all discharged patients. There was no significant difference in in-hospital mortality, all-cause mortality, and freedom from major adverse cardiac events between the groups, although cardiac-related deaths occurred only in group I (n= 5). Ipsilateral in situ grafts were associated with hemodialysis-induced chest pain (odds ratio, 5.528; 95% confidence interval, 1.079 to 28.333; p= 0.040). The incidence of dialysis-induced chest pain in patients with in situ noncomposite, in situ composite, and free grafts was 45.5%, 19.4%, and 5.7%, respectively (p= 0.009). Mortality was not influenced by using the internal thoracic artery as an ipsilateral in situ graft in patients with upper extremity arteriovenous fistula. However, there was a risk of increased incidence of hemodialysis-induced chest pain that is most likely related to coronary steal. A free internal thoracic artery graft would be an alternative option in these patients.

Is internal thoracic artery resistant to reperfusion injury? Evaluation of the storage of free internal thoracic artery grafts

ObjectivesThe in situ internal thoracic artery (ITA) is recognized as the best conduit for coronary artery bypass surgery. The ITA—if it is used as an in situ graft—has a much higher late patency rate than any other arterial graft, including a free ITA graft. We sought to determine if the use of the ITA as an in situ/free graft and its storage in preservation solutions, have an effect on endothelial function. MethodsThe ITA was harvested as either a free or in situ graft in a porcine model. Free grafts were stored in different preservation solutions (saline, Custodiol and Tiprotec [both Köhler Chemie GmbH, Bensheim, Germany]). The ITA was anastomosed off pump to the left anterior descending artery (as in situ/free graft). Freshly harvested ITA served as a control. After 2 hours of reperfusion, the implanted grafts were harvested. The assessment of endothelial function, histopathological analysis, and gene expression were performed. ResultsEndothelial function and integrity were severely impaired after reperfusion in the free ITA groups, however, it was partially preserved in the Tiprotec group. Reperfusion injury resulted in increased nitro-oxidative stress, DNA breakage, vascular cell adhesion protein 1, intercellular adhesion molecule-1, and caspase-3 scores, and a decreased endothelial nitric oxide synthase score in the free ITA groups. The in situ ITA graft showed no signs of injury. mRNA levels were significantly altered among the groups. ConclusionsAn early, severe endothelial dysfunction of the stored, free ITA as described, could be completely prevented by the use of an in situ ITA graft. Tiprotec might be a feasible option for storage of free arterial grafts during coronary artery bypass grafting.

"Pouch Technique" Makes Proximal Anastomosis of Free Internal Thoracic Artery Graft to Ascending Aorta Easy and Safe in Coronary Artery Bypass Surgery.

The proximal anastomosis of free right internal thoracic artery to ascending aorta is technically difficult when the caliber is not enough. We incise the proximal stump of the graft longitudinally for 10 mm. One side of start point of longitudinal incision is sewn to the end point of incision by 7-0 polypropylene. The folded sideline (5 mm length) is then closed with a running suture, then formation of pouch like anastomotic end is accomplished. We used this technique in consecutive 34 patients who underwent coronary artery bypass surgery including revascularization to circumflex arteries. Postoperative angiography revealed 97% patency. It does not need another graft material like saphenous vein or radial artery, and possible not only in on pump surgery but also in off pump. This new "Pouch technique" will make it easy to use right internal thoracic artery as a free graft in coronary artery bypass surgery.

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Modified Myers and Coronary Artery Bypass Grafting Using Free Internal Thoracic Artery Graft for Complicated Supravalvular Aortic Stenosis

The left main trunk stenosis with Williams syndrome and supravalvular stenosis is a cause of sudden death and a serious disease. We performed modified Myers procedure with patch aortoplasty concomitant with coronary artery bypass grafting (CABG) using a free right internal thoracic artery (ITA) graft for a 2-year-old patient with this disease. The proximal cuff of the free right ITA graft was implanted in the posterior wall of the reconstructed aorta. The postoperative clinical course was uneventful, and aortic regurgitation and ischemic signs were not detected. CABG using this technique is useful for coronary artery stenosis in infants and young children, and favorable long-term outcomes are expected.

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The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery

The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery

Coronary artery bypass grafting for Kawasaki disease.

Five patients with a history of Kawasaki disease underwent coronary revascularization at Children's Memorial Hospital (1988-2000). Acute disease occurred at 11 weeks to 5 years of age and revascularization procedures were performed at 8 months to 12 years (mean 6 years; interval from disease onset 5 months to 9 years). Surgical indications included abnormal stress testing with angiographic confirmation of severe coronary artery stenosis (n = 3), severe coronary artery stenosis with echocardiographic evidence of intracoronary thrombus (n = 1), and ischemic electrocardiogram changes and ventricular tachycardia during angiography (n = 1). All revascularization procedures used internal thoracic arteries including one free internal thoracic artery graft. There were no postoperative deaths (follow-up 1 month to 11 years). All patients are asymptomatic. One patient developed myocardial ischemia 4 years postoperatively with occlusion of the circumflex coronary artery (not previously grafted). This was treated successfully with percutaneous coronary angioplasty and stent placement. All grafts are patent with the exception of a single right internal thoracic artery graft which underwent involution 30 months postprocedure with concurrent recannulization of the right coronary artery. Coronary revascularization should be considered in the young patient with severe coronary abnormalities secondary to Kawasaki disease.

Angiographic Follow-up of Internal Thoracic Artery for Free Bypass Grafting

Background. The use of free internal thoracic artery (ITA) grafts in patients with smaller body surface areas has been questioned because of technical difficulties and inadequate graft flow.Methods. To evaluate postoperative changes in the diameter of free ITA grafts, we performed coronary angiography immediately after coronary artery bypass grafting and then again at a mean of 42 ± 6 months later. In 20 consecutively treated patients, 21 free ITAs were used as bypass conduits. Two ITA grafts that were patent at the time of the first angiography had closed at the second angiography. Postoperative changes in ITA graft diameter were measured in the 19 patent ITA grafts.Results. At the first angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.28 ± 0.45 mm, 2.34 ± 0.39 mm, and 2.12 ± 0.38 mm, respectively. At the second angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.85 ± 0.50 mm, 2.89 ± 0.53 mm, and 2.72 ± 0.53 mm, respectively. All segments of the ITA grafts had dilated significantly between the first and second angiographic evaluations (p < 0.01). The percentage change in graft diameter was greater when the initial ITA diameter was less than 2.3 mm (32.0% ± 28.0%) than when it was 2.3 mm or more (18.8% ± 11.3%) (p < 0.05).Conclusions. The postoperative increase in free ITA graft diameter depends on coronary blood flow requirements.

Five-year follow-up of microsurgical multiple internal thoracic artery grafts

In a consecutive series of 143 patients requiring multiple coronary artery bypass grafts, 317 of 441 anastomoses (72%) were constructed from internal thoracic arteries. Of these 143 patients, 103 had bilateral, 51 sequential, and 49 free internal thoracic artery grafts. When compared with an earlier series of 494 patients who underwent only one internal thoracic artery anastomosis, the surgical morbidity and mortality were not increased, but, during 5 years of follow-up, the incidences of postoperative angina and myocardial infarction were found to decrease significantly—32.5% versus 10.5% ( p < 0.001) and 5.7% versus 1.4% ( P < 0.03), respectively. We conclude that, for patients with multivessel disease, multiple internal thoracic artery grafts confer better protection from the clinical manifestations of ischemic heart disease than does one internal thoracic artery graft. The use of high magnification (8 to 12X, surgical microscope) was essential to the success of this method.