Left Internal Thoracic Artery Research Articles

Long-Term Radial Artery Grafts with Previous Midterm Proven Patency.

Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of coronary artery bypass grafting (CABG). This grafting has led to an increased use of other arterial conduits, of which the radial artery (RA) is the most popular. Whether RA can have the same long-term patency as LITA is controversial. The objective of this study is to access the long-term clinical follow-up and, when available, the patency rate of RA grafts. Twenty-six patients from a previous study with critical stenosis in all target vessels underwent complete arterial CABG with LITA and RA grafts from 1996 to 2003. They all underwent midterm multidetector computed tomography after surgery with the association of at least one patent LITA and one patent RA graft. Twelve patients (46%) are alive with no angina symptoms. Six patients underwent a second image exam 12 to 16 years (average of 14 years) after surgery, with a total of six LITA-LADA and 14 RA grafts with 100% patency rate. Clinical follow-up five to 23 years after surgery (average of 14 years) showed only one death 12 years after surgery related to coronary artery disease (CAD) (3,8%). Another 12 patients died of non-CAD. Patients with midterm associated LITA and RA patent grafts show similar optimal long-term patency rates of both types of grafts with excellent clinical outcome.

Evaluation of anastomosis quality with intraoperative transit time flowmeter in minimally invasive multi-vessel coronary artery bypass grafting via left anterior mini-thoracotomy.

In this study, we aimed to describe our intraoperative transit-time flow measurement results as an integral component of the operation and evaluate the graft patency and anastomosis quality in patients who underwent minimally invasive multi-vessel coronary artery bypass grafting via mini-thoracotomy. Between May 2020 and September 2021, a total of 45 consecutive patients (32 males, 13 females; mean age: 51.2±8.6 years; range, 41 to 72 years) who underwent minimally invasive multi-vessel coronary artery bypass grafting via left anterior mini-thoracotomy were retrospectively analyzed. We used the technique of intraoperative transit-time flowmetry in all patients. The patients were operated under cardiopulmonary bypass. A saphenous vein graft was used in all anastomoses, except for the left internal thoracic artery. The mean left internal mammary artery flow rate was 36.2±14.1 mL/min, mean flow rate of the diagonal grafts was 48.2±13.1 mL/min, mean flow rate of the circumflex grafts was 41.2±21.1 mL/min, and mean flow rate of the right coronary artery grafts was 52.2±11.3 mL/min. Wave patterns and flow parameters of all grafts were normal in the intraoperative measurements, since the pulsatility index values in all anastomoses were within normal limits. The operation was completed after anastomotic openings and graft patency were ensured. The use of an intraoperative flowmeter to show the graft patency and anastomosis quality gives confidence both to the surgeon and the patient. In multi-vessel coronary artery bypass grafting via mini-thoracotomy, anastomosis quality can be evaluated well with this technique.

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents.

Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. The mean age of patients was 65±10years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26±1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311±54minutes, and the mean hospital length of stay was 2.7±1.1days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14±0.4, and the mean number of vessels stented was 1.23±0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39±26months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.

Relapsed Chronic Lymphocytic Leukemia Presenting with a Cardiac Mass: A Case Report

Chronic lymphocytic leukemia (CLL) is the most common hematological malignancy in the USA. (American Cancer Society, 2022) It is more prevalent in elderly males and commonly presents with a relatively benign course. Extra-medullary disease is very rare and is not well characterized. Skin and CNS involvement were reported to be the most common but other organs can also be involved. (Ratterman et al., 2014) We report a 51-year-old male patient with a past medical history of mutation negative CLL in remission, who presented with fatigue, dyspnea on exertion, night sweats and a neck mass. The physical examination revealed an enlarged non-tender left supraclavicular lymph node measuring 5-6 cm in diameter but was otherwise unremarkable. Laboratory investigations were notable for leukopenia and thrombocytopenia. Due to high suspicion for an underlying malignant process, a full body computerized tomography (CT) scan was obtained and showed an 8.8 cm soft tissue mass-like lesion occupying the majority of the right atrium and extending into the right ventricle, with probable pericardial involvement. Enlarged left supraclavicular and mediastinal lymph nodes were also present and had a mild mass effect on the traversing left internal thoracic artery and left pulmonary artery. A transesophageal echocardiogram and cardiac magnetic resonance imaging (MRI) (Figure 1) were done to better characterize the cardiac mass. They confirmed a large infiltrating mass (measuring 10 x 7.4 cm) in the right atrium and ventricle, extending into the inferior vena cava inferiorly and coronary sinus posteriorly. A bone marrow biopsy showed normocellular marrow with no infiltration. Left supraclavicular excisional lymph node biopsy was performed and histopathology was consistent with Small Lymphocytic Lymphoma (SLL)/CLL with increased proliferation index (up to 40% by KI-67 immunohistochemical stain) and normal karyotype. This confirmed extramedullary SLL/CLL relapse with lymphadenopathy and cardiac mass. The patient was started on chemo-immunotherapy with Obinutuzumab-Venetoclax with marked improvement in B symptoms and dyspnea. Cardiac infiltration by CLL B-cells has been shown on autopsies of CLL patients. (Schwartz et al., 1981) In practice, clinically significant cardiac or pericardial involvement by SLL/CLL is extremely rare with only a few case reports in literature. (Posch et al., 2021) (Nnaoma et al., 2019) (Goncalves et al., 2002) Extramedullary CLL disease suggests a more aggressive disease and warrants a high level of suspicion for diagnosis. (Ratterman et al., 2014) Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy.

Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported. From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%). Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%. This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.

Reversal flow in the left anterior descending artery after internal thoracic artery grafting

BackgroundThe flow capacity of the in situ internal thoracic artery (ITA) is not necessarily sufficient and can be a cause of hypoperfusion syndrome. We present a catastrophic case of in situ ITA grafting for an isolated left main trunk obstruction 13 years after the modified Bentall operation.Case presentationA 33-years-old woman had undergone the modified Bentall operation. Coronary angiography showed a critical stenosis in the left coronary artery. The patient underwent emergency off-pump coronary artery bypass graft with the left ITA to the left anterior descending artery (LAD). On the 7th day, the patient had severe dyspnoea and hypotension. Catheter angiography showed that the ITA was patent; however, blood flow from the in situ ITA was delayed, and reversal flow from the apex to the proximal LAD was found. The patient underwent implantation of a left ventricular assist device.ConclusionsConcomitant aortocoronary bypass to the circumflex branch will minimise the risk of hypoperfusion, especially for young patients without atherosclerotic disease.

LONG-TERM OUTCOMES OF ARTERIAL CONDUIT CONFIGURATIONS IN MULTIARTERIAL CORONARY ARTERY BYPASS GRAFTING

Multiarterial grafting (MAG) in coronary artery bypass (CABG) has been associated with improved survival and graft patency. Despite this, MAG utilization remains low. Several possible configurations using the left internal thoracic artery (LITA) and the right internal thoracic (RITA) or radial (RAD) artery exist, however, equipoise remains with respect to ideal configurations. This uncertainty has led to complexity in operative planning and may be a factor limiting more widespread adoption of MAG.

Capture of Part of a Vessel Wall by a Coronary Orbital Atherectomy System

An 82-year-old man who had undergone coronary artery bypass grafting, aortic/mitral valve replacement, and tricuspid valvuloplasty was seen for exertional angina. On angiography, a severely stenotic lesion of the distal left internal thoracic artery (LITA) was noted, which was a bypass graft to the left anterior descending (LAD) artery (Fig. 1A, arrow). The LAD artery showed chronic total occlusion (CTO; Fig. 1B, arrow). We thought that if an angioplasty for the stenotic lesion in the LITA failed, then significant damage would occur in the LAD artery area.

Transit-time flow measurement parameters after protamine infusion in CABG surgeries.

The objective of this study is to evaluate protamine sulfate effects on graft's blood flow by comparing transit-time flow measurement (TTFM) values before and after protamine administration. This is an observational study with data collected between years 2018 and 2020. Immediate graft patency was evaluated using TTFM. Only patients with TTFM parameters registered before and after protamine infusion were included. The main three parameters studied were: mean graft flow (MGF), pulsatility index (PI), and diastolic flow (DF). In the first analysis, all conduits were evaluated regardless of the surgical technique used. In a second analysis, on-pump and off-pump groups were compared. Evaluated grafts were left internal thoracic artery, saphenous vein graft (SVG), radial artery, and right internal thoracic artery. Since SVG was numerically the most used graft, an exclusive analysis was created. Our study included 575 patients, resulting in a total of 1686 grafts, mean 2.93 grafts/patient. Off-pump surgery was performed in 158 patients. Before protamine infusion, inadequate TTFM parameters were observed in 3.8% of grafts. Overall, after protamine administration, MGF decreased in all grafts, but its reduction was not statistically significant. PI values increased in the SVG and DF values reduced in LIMA grafts. SVG group analysis showed that after protamine PI values were higher in OM1 and RCA. DF values increased in RCA. The comparison between off and on-pump surgeries, showed that in off-pump cases TTFM measures did not present statistically significant differences. Significant variations were observed in TTFM values before and after protamine administration. Although different, those values remained within the normal reference ranges. We recommend that flow measurement should be performed before protamine infusion.

Relation of quantitative flow ratio with transit time coronary artery bypass graft flow measurement.

BackgroundQuantitative flow ratio (QFR) is a new functional index to assess the functional significance of coronary stenosis. While whether there is an association between QFR and transit-time flow measurement (TTFM) parameters of the target coronary artery has not been well addressed.MethodsA total of 89 patients receiving the in situ left internal thoracic artery (LITA) grafts to the left anterior descending artery (LAD), and 19 patients undergoing the saphenous vein grafts (SVG) were enrolled in this retrospective study. The QFR value of the LAD was evaluated preoperatively. According to the QFR values, patients with the LITA to the LAD bypass grafts were divided into two groups (group A1: QFR < 0.75, group A2: QFR ≥ 0.75), and SVG patients were divided into two groups (V1 group: QFR < 0.75, V2 group: QFR ≥ 0.75).ResultsIn groups A1 and A2, respectively, median graft flow (Qm) was 44 (34) mL/minute and 26.5 (30.0) ml/minute; median pulsatility index (PI) was 2.00 (1.00) and 2.65 (0.90). Significant differences were observed in Qm (P = 0.034) and PI (P = 0.030). And the correlation coefficients of the TTFM variables with QFR were Qm: r = r = −0.226, (P = 0.036), PI: r = 0.265 (P = 0.012) among the LITA to LAD population.ConclusionTTFM variables, especially the PI, of the LITA in situ graft to the LAD during Coronary artery bypass grafting (CABG) are strongly affected by preoperative QFR values. Moreover, in functionally mild coronary stenosis, the chance of competitive flow increases.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy

BackgroundEndovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC.MethodsA total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA).ResultsAll cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05).ConclusionET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

Virtual Reality Simulation for Minimally Invasive Coronary Artery Bypass Grafting With Aortic No-Touch Total Arterial Grafting Technique.

Virtual reality can be applied preoperatively by surgeons to gain precise insights into a patient's anatomy for planning minimally invasive coronary artery bypass grafting (CABG) with in situ arterial grafts. This study aimed to examine virtual reality simulation for minimally invasive CABG with in situ arterial grafts. Preoperative stereolithographic files in 35 in situ arterial grafts were converted using 320-slice computed tomography and workstation. The accurate length and direction of each graft were confirmed through virtual reality glasses. The simulation of graft designs was performed by using an immersive virtual reality platform. The mean harvested lengths of in situ left internal thoracic artery (n = 17), right internal thoracic artery (n = 12), and gastroepiploic artery (n = 6) grafts predicted by virtual reality simulation were 21.4 ± 3.4 cm, 21.2 ± 3.6 cm, and 22.8 ± 4.8 cm. The required lengths of these grafts predicted by virtual reality simulation were 15.8 ± 2.3 cm, 16.4 ± 2.1 cm, and 14.5 ± 4.4 cm. Minimally invasive CABG using virtual reality simulation was completed in 17 patients, of whom 16 patients underwent aortic no-touch total arterial CABG. The surgical strategy was adjusted in 11.8% of the cases due to the 3-dimensional virtual reality-based anatomy evaluation. The early mortality and morbidity were 0%, and the patency of the graft was 100%. The median time to return to full physical activity was 7.1 days. This study demonstrated the successful development and clinical application of the first dedicated virtual reality platform for planning aortic no-touch total arterial minimally invasive CABG. Virtual reality simulation can allow the accurate preoperative understanding of anatomy and appropriate planning of the graft design with acceptable postoperative outcomes.

İzole Koroner Arter Baypas Operasyonu Sonrasında Ciddi Plevral Efüzyon Gelişen Hastaların Değerlendirilmesi

Objective: In this study, we aim to determine the causal relationship between isolated coronary bypass surgery development of severe pleural effusion in the early postoperative period.&#x0D; Methods: In this study, 7862 isolated coronary artery bypass surgery cases conducted in our hospital between February 2001 and July 2013 were analyzed retrospectively.&#x0D; Results: Early-severe pleural effusion developed in 175 (2.2%) patients included in the study. The mean age of these cases was 66.3±9.5 (55-76). 149 (85.1%) of the cases were operated under elective conditions and 26 (14.9%) of them were operated under emergency conditions. The mean cardiopulmonary bypass time of the cases was 70±28 (40-100) minutes. Left internal thoracic artery (LITA) and saphenous vein graft (SVG) were used together in 161 (92%) cases. Of the cases, 126 (72%) had shortness of breath, 115 (65.7%) dry cough, 28 (16%) productive cough, 50 (28.6%) tachypnea, 22 (12.5%) chest pain. Early severe pleural effusion developed in the left hemithorax in 154 (88%) of the cases. LITA+SVG was used in 148 (84.6%) of these cases, and only SVG was used in 6 (3.4%) cases. Early severe pleural effusion developed in the right hemithorax in 14 (8%) of the cases. LITA+SVG was used in 10 (5.7%) of these cases, and only SVG was used in 4 (2.3%) cases. The cases with bilateral early severe pleural effusion were 7 (4%). LITA+SVG was used in 3 (1.7%) of these cases, and only SVG was used in 4 (2.3%) cases.&#x0D; Conclusion: It is known that coronary artery bypass surgery causes deterioration of postoperative pulmonary function. One of the most common complications of coronary artery bypass surgery is pleural effusion. It is known that this postoperative picture is associated with increased hospital stay and high postoperative morbidity. It is important to determine preoperative risks in terms of postoperative patient management and morbidity assessment.

Brachial plexus injury and upper rib fracture after median sternotomy in cardiac surgery.

Sternal retractors utilized during open-heart surgeries through median sternotomy can cause upper rib fractures which sometimes further leads to brachial plexus injury. We aimed to investigate the incidence of brachial plexus injury and upper rib fractures in open-heart surgeries and how these injuries are associated with each other. We investigated 1050 cases during the past five years. The incidence of brachial plexus injury and upper rib fractures after median sternotomy was assessed in all patients and the patients who sustained were evaluated for the affected side, the level of paralysis. Ten cases (0.95%) exhibited brachial plexus injury after median sternotomy. Nine cases developed paralysis on left upper extremity. In all ten cases, sensory and motor nerve impairment were exhibited in the lower plexus. Rib fractures were observed in 35.0% of cases after median sternotomy and the usage of asymmetric sternal retractors to harvest left internal thoracic artery (LITA) significantly affected the side of fracture. Sternal retractors utilized during open-heart surgeries through median sternotomy may cause rib fractures and brachial plexus injury, so operators should be aware of these complications.

Bypass Grafting to Circumflex: Left Internal Thoracic Artery versus Saphenous Vein.

This study aimed to compare the short- and long-term outcomes of saphenous vein grafts (SVGs) and in situ left internal thoracic artery (LITA) grafts to the left circumflex artery (LCX) territory. This study included 678 patients who underwent LITA-left anterior descending (LAD) + SVG-LCX grafts and 286 patients who underwent right internal thoracic artery (RITA)-LAD + in situ LITA-LCX grafts from January 2002 to December 2020. Short-term and long-term clinical outcomes were compared using inverse probability of treatment weighting adjustment to reduce selection bias. In-hospital mortality was significantly higher for the SVG-LCX group (p = 0.008), whereas deep sternal wound infection was significantly higher in the LITA-LCX group (p = 0.013).Survival rates at 5 and 10 years were 83.12 and 71.45% in the SVG-LCX group, whereas 75.24 and 65.54% in the LITA-LCX group (log-rank p = 0.114). Rates of freedom from cardiac events at 5 and 10 years were 92.82 and 85.24% in the SVG-LCX group, whereas 94.89 and 89.46% in the LITA-LCX group (log-rank p = 0.179).Univariate and multivariate logistic regression analysis showed that proximal severe stenosis was significantly protective against graft dysfunction before discharge (odds ratio, 0.43; 95% confidence interval, 0.23-0.81). Deep sternal wound infection was significantly higher for LITA to LCX bypass whereas in-hospital mortality was higher for SVG to LCX. In situ LITA to LCX bypass grafting exhibited similar long-term outcomes with SVG to LCX bypass grafting in adjusted patient cohorts. Proximal severe stenosis of LCX was protective against graft dysfunction.

Ultrasound Evaluation of Subclavian Artery and Internal Thoracic Artery Before Coronary Artery Bypass Grafting as Part of Preoperative Vascular Assessment

Noninvasive diagnostic imaging of subclavian artery (SCA) and internal thoracic artery (ITA) is crucial to the patients planning to use ITA for coronary artery bypass grafting (CABG). The guidelines have not yet provided guidance on screening high-risk groups. The present study aimed to evaluate the contribution of ultrasonography in the assessment of SCA and ITA, especially for the patients referred for CABG who planned to use ITA graft. Patients diagnosed with multivessel coronary heart disease were enrolled and some of them planned CABG. Bilateral SCAs and ITAs were routinely evaluated by color Doppler ultrasound (CDUS) before operation. The luminal diameter and the peak systolic velocity of the proximal and distal parts of SCA and ITA were measured. Depending on the Doppler waveform, the lumen narrowing rate was calculated. The final analysis was carried out in 572 patients. Thirty-five patients had moderate (50%-69%), severe (70%-99%) stenosis or occlusion in the SCA (left-sided in 21 and right-sided in 14). One patient had severe proximal stenosis in left ITA and one patient had no flow in left ITA due to the occlusion in left SCA. One patient had anatomic variation of isolated right aortic arch with aberrant left SCA. All of those cases were confirmed with multidetector computed tomography angiography. CDUS could be used for the evaluation of SCA and ITA before CABG as part of presurgical vascular assessment and provide an import basis for the imaging diagnosis and surgical plan.

Occurrence rate and fate of competitive flow of the left internal thoracic artery used in Y-composite grafts

ObjectivesWe evaluated the occurrence rate of competitive flow and the fate of grafts of left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD) anastomosis after coronary artery bypass grafting with Y-composite grafts using early and 1-year angiography. MethodsFrom 2008 to 2017, 923 patients underwent off-pump coronary artery bypass grafting using Y-composite grafting based on the in situ LITA. Early postoperative angiography was performed for all patients. One-year angiography (mean, 13.2 ± 3.1 months) was performed for 86.7% (800 of 923) of patients. ResultsThe early occlusion rate of LITA with Y-composite graft (CompLITA) to LAD was 0.7%. Among 917 patent CompLITA-LAD grafts, competitive flow was observed in 39 patients (4.3%). Multivariable analysis showed that the degree of LAD stenosis (odds ratio, 0.897; 95% CI, 0.875-0.920; P < .001) and 3-vessel disease (odds ratio, 5.632; 95% CI, 1.168-27.155; P = .031) were factors associated with the occurrence of competitive flow of CompLITA-LAD grafts. The receiver operating characteristics curve determined that the cutoff degree of LAD stenosis was 82.5% (sensitivity 82.1% and specificity 85.2%). The failure rate of CompLITA-LAD grafts seen on 1-year angiography was 58.3% in patients with competitive flow. Among patients with competitive flow, left main coronary artery disease was a protective factor (odds ratio, 0.055; 95% CI, 0.009-0.337; P = .002) against graft failure of the CompLITA-LAD seen on 1-year angiography. ConclusionsIn CompLITA-LAD, the degree of LAD stenosis and combined 3-vessel disease were associated with the occurrence of competitive flow. CompLITA-LAD grafts with early competitive flow showed a high 1-year graft failure rate of 58%.

Can Minimally Invasive Multivessel Coronary Revascularization Be a Routine Approach?

Advancement in the field of cardiovascular surgery has emerged with various minimally invasive approaches for the treatment of multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. This study describes our routine technical approach and clinical experience of minimally invasive coronary artery bypass via left anterior minithoracotomy for the treatment of patients with multivessel coronary lesions. Our experience includes 100 consecutive patients who were operated between July 2020 and April 2021. The left internal thoracic artery was harvested in all patients. Radial arterial grafts and saphenous vein grafts were harvested endoscopically. Patients were operated either under cardiopulmonary bypass (CPB) with blood cardioplegia through left anterior minithoracotomy of 5 to 7 cm or off-pump via left anterolateral minithoracotomy. We had single mortality (1%), no early postoperative myocardial infarction was observed. None of our patients was converted to sternotomy (0%). The mean number of bypass was 3.1 ± 0.8, the mean cross-clamping time was 78.1 ± 20.6 minutes, the mean CPB time was 153.2 ± 37.5 minutes, the average intubation time was 6.33 ± 11.29 hours, the mean intensive care unit stay was 1.62 ± 1.78 days, the mean hospital stay was 4.98 ± 3.01 days, the average total operation time was 4.20 ± 0.92 hours, and the average pleural drain was 393.8 ± 169.7 mL. Minimally invasive coronary artery bypass grafting via left anterior minithoracotomy can be routinely performed with safety and it is feasible, reproducible with a short learning curve. Further multicenter studies are needed for the standardization of our technique.

Investigation of the effects of diabetes mellitus on left internal thoracic artery flow patterns in patients scheduled to undergo coronary bypass graft surgery

Diabetes mellitus (DM) plays a key role in the formation and prognosis of cardiovascular diseases. In this study, we aimed to investigate the effects of DM and glycemic control on left internal thoracic artery (LITA) Doppler flow in patients scheduled to undergo coronary artery bypass graft (CABG) surgery. Patients who were hospitalized with a planned isolated CABG operation to our clinic between October 1, 2019 and March 1, 2020 were consecutively included in this prospective study. The patients were divided into three groups as those without DM (Group 1), those with DM and HbA1c values of below 7.5 (Group 2), and those with DM and HbA1c values of 7.5 and above (Group 3). The differences between the LITA Doppler flow patterns of the patients were analyzed. The mean ages of Group 1 (n =103), Group 2 (n =42), and Group 3 (n =47) were 59.8 ± 9.6 years, 60.5 ± 9.3 years, and 61.9 ± 8.1 years, respectively. The groups differed in terms of diameter, volume, Vmax, pulsality index (PI), and resistive index (RI) values, both when the groups were compared among themselves (P < .001, for all), and when they were compared between those with (Groups 2 and 3) and without DM (Group 1) (P < .001, for all). Volume (R=-0.627, P < .001) and Vmax (R=-.450, P < .001) were moderately negatively correlated, while PI (R=.523, P < .001) and RI (R=0.598, P < 0.001) were moderately positively correlated with HbA1c levels. In this study, we showed that increased HbA1c levels may be associated with significant functional and structural changes of LITA.

Competitive Flow in Vein Composite Grafts Based on the Left Internal Thoracic Artery: Early and 1-Year Angiographic Analyses

We assessed the incidence of competitive flow with early postoperative angiograms in patients who received a "no-touch" saphenous vein (NT SV) composite graft and reexamined the status of competitive flow at 1-year. Early postoperative angiograms were performed in 806 patients who underwent myocardial revascularization using a NT SV Y-composite graft based on the in situ left internal thoracic artery (LITA). Competitive conduit flow was observed in 102 distal anastomoses (102 of 3039 [3.4%] anastomoses) of 94 patients (94 of 806 [11.7%]; NT SV competitive flow in 74 and LITA competitive flow in 20). Of the 94 patients, 63 patients (50 with NT SV competition and 13 with LITA competition) were re-evaluated with 1-year postoperative angiograms. Fifty-six competitive NT SV conduits in 50 patients were reevaluated at 1-year postoperatively: 44 (78.6%) early competitive anastomoses had become patent and 12 (21.4%) were occluded. NT SV with pedicle tissue showed a higher tendency of being perfectly patent at 1-year postoperatively than NT SV without pedicle tissue (17 of 40 [42.5%] vs 2 of 16 [12.5%]; P = 0.007). Thirteen competitive LITA conduit anastomoses in 13 patients were reevaluated 1-year postoperatively: 9 (69.2%) early competitive anastomoses had become patent and 4 (30.8%) were occluded. Competitive flow was shown on early postoperative angiograms in 3.4% of distal anastomoses in patients who received NT SV Y-composite grafts. Approximately 80% of the competitive NT SV conduits were patent 1-year postoperatively, and perfect patency rates were higher in patients who had received NT SV with pedicle tissue than in patients who had received NT SV without pedicle tissue.