Single Internal Mammary Artery Grafting Research Articles

Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts

ObjectiveHybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery (LIMA)–left anterior descending artery (LAD) bypass with percutaneous intervention of non-LAD vessels. The purpose of this study was to compare outcomes of HCR to conventional coronary artery bypass graft (CABG) surgery with single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting. MethodsBetween October 2003 and September 2013, 306 consecutive patients who underwent HCR were compared with 8254 patients who underwent CABG with SIMA (7381; 89.4%) or BIMA (873; 10.6%) at a US academic center. The primary outcome was a composite of 30-day death, myocardial infarction, and stroke (major cerebrovascular and cardiac event [MACCE]). In addition to multiple logistic and linear regression analysis, a propensity score–matched analysis was used to compare HCR with SIMA and with BIMA. ResultsThe Society of Thoracic Surgeons–predicted risk of mortality was 1.6% for HCR, 2.1% for SIMA, and 1.1% for BIMA (P < .001). Factors associated with HCR use were older age, lower body mass index, history of percutaneous coronary intervention, and 2-vessel disease. In propensity-matched groups, 30-day MACCE rates were comparable (3.3% for HCR vs 1.3% for BIMA [odds ratio (OR), 2.50; P = .12] and vs 3.6% for SIMA [OR, 1.00; P = 1.00]). In-hospital complications were lower after HCR versus SIMA or BIMA (OR, 0.59; P = .033 and OR, 0.55; P = .015, respectively), as was the need for blood transfusion (OR, 0.44; P < .001 and OR, 0.57; P < .001). HCR was associated with shorter hospital stay compared with SIMA (OR, 1.28; P = .038) or BIMA (OR, 1.40; P = .006). No survival difference between matched groups was found at midterm follow-up (HCR vs SIMA: hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.32-1.38; P = .66; HCR vs BIMA: HR, 1.05; 95% CI, 0.48-2.29; P = .91). ConclusionsHCR may represent a safe, less invasive alternative to conventional CABG in carefully selected patients, with similar short-term and midterm outcomes as CABG performed with either SIMA or BIMA grafting.

Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit

Extensive evidence documents a survival benefit for bilateral internal mammary artery (BIMA) grafting compared with single internal mammary artery (SIMA) grafting for patients with advanced coronary artery disease. However, controversy continues to exist regarding the incremental benefit of broadly applied BIMA grafting in elderly patients. Retrospective analysis was conducted of 4,503 consecutive isolated coronary artery bypass grafting operations (SIMA, n = 2,340 and BIMA, n = 2,163) performed from 1972 to 1994. Multivariate analysis was used to created propensity score-matched groups of SIMA (n = 1,063) and BIMA (n = 1,063) to compare patients 65 years of age and older, and 70 years of age and older (n = 612), with similar baseline characteristics. Survival status was obtained by periodic follow-up, query of the US National Death Index, and other Internet searches, and was 99.6% complete. The propensity score-matched groups experienced similar perioperative mortality and morbidity. Survival benefits were found for BIMA versus SIMA grafting across both age categories. Actuarial curves after 23,593 patient-years of follow-up (mean BIMA = 11.7 years; 6 weeks to 33.1 years; mean SIMA = 10.5 years; 6 weeks to 30.7 years) demonstrated improved long-term survival for BIMA versus SIMA patients at 12 years (51.0 ± 1.5% versus 39.0 ± 1.5%) and at 24 years (3.5 ± 0.7% versus 4.5 ± 0.7%; p < 0.001). Similarly, in matched groups of patients age 70 and older, overall survival was also enhanced with BIMA grafting (p = 0.005). Advanced age should not be a contraindication for BIMA grafting. Long-term follow-up clearly demonstrates that BIMA grafting when broadly applied in elderly patients results in improved long-term survival over SIMA grafting.

Double versus single internal thoracic artery in coronary artery bypass grafting: role in sterna wound healing

Objective To investigate the effect of double versus single internal thoracic artery on sterna wound healing in coronary artery bypass grafting (CABG). Methods Patients undergoing CABG were randomly divided into experimental group (double internal thoracic artery group) and control group (single internal thoracic artery group) according to the number of internal thoracic artery used in operations. Experimental group: skeletonized double internal mammary arteries were harvested in all 50 cases (37 males and 13 females). Control group: skeletonized left internal mammary artery was harvested in all 50 cases (34 males and 16 females). Sterna wound healing and post-operational complications were observed. Results The incidence of poor sterna wound healing and volume of drainage after operation in the experimental group were more than those in the control group [volume of drainage on the first day: (350.67±56.86)ml vs (240.72±48.35)ml; total volume of drainage: (595.65±102.35)ml vs (398.85±75.84)ml; poor sterna wound healing rate: 20% vs 0; P<0.05 or P<0.01]. The sterna wound healing rate of high-risk patients between two groups had significant difference (8 cases vs 0 case, P<0.05). Conclusions Compared to the single internal mammary artery grafting, the double internal mammary artery grafting increased the risk of sternal wound healing. Key words: Coronary artery bypass/MT; Mammary arteries/SU; Sternum/IN/SU; Fracture healing

Impact of pump status and conduit choice in coronary artery bypass: A 15-year follow-up study in 1412 propensity-matched patients

Previous studies have demonstrated that bilateral internal mammary artery (BIMA) grafts lead to superior outcomes compared with single internal mammary artery grafts. This study examines whether cardiopulmonary bypass affects conduit-dependent outcomes of coronary artery bypass grafting (CABG) surgery. From 1994 to 2013, a total of 6666 patients underwent isolated CABG surgery at our institution. Of these procedures, 3548 (53.2%) were performed off pump. A BIMA-saphenous vein graft (SVG) was used in 1544, and 5122 had left internal mammary artery-SVGs. These 2 conduit groups differed significantly in baseline characteristics. Propensity matching based on 22 preoperative variables and using a nearest-neighbor matching algorithm was used to make balanced cohorts, resulting in 2 groups of 1006. To account for the influence of pump status on conduit selection, a second propensity score was developed for pump use. These cases were matched to create 4 patient cohorts of 353 patients each (a total of 1412), balanced for both conduit use and pump status. Late mortality was determined using the Social Security Death Index. No difference was found in survival between patients receiving BIMA-SVGs on or off pump (78.9% vs 79.1%). BIMA-SVGs outperformed the left internal mammary artery-SVGs regardless of whether the procedure was performed off pump (73.9%) or on pump (69.9%). This study demonstrates that the use of cardiopulmonary bypass does not significantly affect the long-term outcomes in these patients as long as full revascularization is achieved. In addition, these results are consistent with prior research showing that the use of BIMAs produces better outcomes than use of a single internal mammary artery when performing CABG.

Effects of on-pump and off-pump surgery in the Arterial Revascularization Trial.

The Arterial Revascularization Trial (ART) is a randomized comparison of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting in coronary artery bypass graft (CABG) surgery and is one of the largest randomized trials of surgery ever conducted. ART is also one of the largest studies of contemporary CABG with a high proportion of off-pump surgeries (41%). The objective of this post hoc analysis was to evaluate the surgical process and 1-year outcomes for surgery performed on-pump compared with off-pump. ART randomized 3102 patients with multivessel coronary artery disease (CAD) to SIMA or BIMA grafts to determine if BIMA grafts have an additional survival advantage at 10 years. The 1-year interim analysis showed an overall very low mortality and major morbidity rate irrespective of whether the procedure was with an SIMA or BIMA. The surgical process and 1-year outcomes were analysed according to whether surgery was performed on-pump or off-pump. Baseline variables were not statistically significantly different between on- and off-pump surgery within each treatment group after taking account of the effects of clustering by individual surgeons. At both 30 days and 1 year, there was a low incidence of death (1.2%, 2.3%), stroke (1.1%, 1.7%), myocardial infarction (MI) (1.4%, 1.9%), repeat revascularization (0.5%, 1.5%) and wound reconstruction (1.2%). A similar average number of grafts were performed with on- and off-pump surgery (median = 3), but the duration of surgery was 20-30 min and ventilation time ∼ 2 h shorter with off-pump surgery. Blood loss and platelet transfusions were lower in the off-pump group, with no difference in the need for balloon pump or renal support. Sternal wound reconstruction was similar with off-pump surgery in the SIMA group (0.5 vs 0.6%) and lower with off-pump surgery in the BIMA group (1.4 vs 2.2%). Repeat revascularization was marginally higher in off-pump patients at 30 days (0.8 vs 0.3%) and at 1 year (1.7 vs 1.3%). The outcomes of contemporary CABG are excellent with low mortality, stroke, myocardial infarction and need for wound reconstruction and repeat revascularization whether performed on-pump or off-pump. Controlled-trials.com (ISRCTN46552265).

The influence of bilateral internal mammary arteries on short- and long-term outcomes: A propensity score matching in accordance with current recommendations

We undertook a single-center, 12 years outcomes analysis of the influence of bilateral internal mammary arteries (BIMA) over single internal mammary artery (SIMA) on short-term outcomes and long-term outcomes by means of propensity score matching technique in accordance to current recommendations. A propensity score was generated for each patient from a multivariable logistic regression model based on 20 pretreatment covariates. The study population consisted of 4195 patients undergoing coronary artery bypass graft procedure using SIMA (n = 3445; 78.3%) or BIMA (n = 750; 21.7%). A total of 750 matching sets were derived. The BIMA group was associated with an increased rate of superficial sternal wound infection (5.6% vs 1.7%; P = .0001) but the incidence of deep sternal wound infection was comparable between the 2 groups, at 2.1% and 1.5% in BIMA and SIMA groups, respectively (P = .43). With regard to other postoperative complications the 2 groups were comparable. Operative mortality rate did not significantly differ between the 2 groups, at 0.7% and 1.2% in the BIMA and SIMA groups, respectively (P = .28). After a mean follow-up time of 4.8 ± 3.2 years, BIMA use was associated with a significantly lower risk for late mortality (hazard ratio, 0.61; 95% confidence interval 0.38-0.97; P = .03) and need for repeat revascularization (hazard ratio, 0.75; 95% confidence interval, 0.53-0.96; P = .03). When compared with SIMA grafting, BIMA use did not increase operative morbidity and mortality and was associated with a better long-term survival.

Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach.

Although the potential survival benefit of bilateral internal mammary artery (BIMA) grafting in comparison with single internal mammary artery (SIMA) grafting has been emphasized by many investigators, the use of BIMA is still low in clinical practice in the absence of randomized trials and long-term results. In the current study, we aimed to assess if there is a long-term survival benefit of BIMA up to 10 years after coronary bypass surgery. We selected published articles comparing survival between SIMA and BIMA patients with follow-up duration of more than a mean of 9 years. We evaluated the log hazard ratio with 95% confidence interval for included studies by using a random-effects meta-analysis. Nine eligible observational studies provided 15 583 patients (8270 SIMA and 7313 BIMA) for meta-analysis. Five studies used propensity score methods for statistical adjustment, 2 with a propensity score-based patient-matching method and 3 with quintile-based stratification. A significant reduction in mortality by using BIMA was observed (hazard ratio, 0.79; 95% confidence interval, 0.75-0.84); no study showed any significantly harmful effect of BIMA on survival. Subgroups of studies using different statistical approaches-unmatched, quintile-based propensity score analysis, and propensity score-based exact patient matching-all showed the survival benefit of BIMA grafting. BIMA grafting appears to have better survival with up to 10 years follow-up in comparison with SIMA grafting. Long-term survival benefit of BIMA seems to continue in the second decade after surgery. An ongoing randomized trial comparing SIMA and BIMA groups will add evidence on this issue.

Bilateral versus single internal mammary coronary artery bypass grafting in Sweden from 1997-2008.

BackgroundPrior observational studies have suggested better outcomes in patients who receive bilateral internal mammary arteries (BIMA) during coronary artery bypass grafting (CABG) compared with patients who receive a single internal mammary artery (SIMA). The aim of this study was to analyze the association between BIMA use and long-term survival in patients who underwent primary isolated CABG.Methods and ResultsPatients who underwent primary isolated non-emergent CABG in Sweden between 1997 and 2008 were identified. The SWEDEHEART registry and other national Swedish registers were used to acquire information about patient characteristics and outcomes. Unadjusted and multivariable adjusted regression models were used to estimate the association between BIMA use and early mortality, long-term survival, and a composite of death from any cause or rehospitalization for myocardial infarction, heart failure, or stroke in the overall cohort and in a propensity score-matched cohort. The study population consisted of 49702 patients who underwent CABG with at least one internal mammary artery, and 559 (1%) of those had BIMA grafting. In the adjusted analyses, BIMA use was not associated with better survival compared with SIMA use in the overall cohort (hazard ratio (HR) for death: 1.16, 95% confidence interval (CI): 0.97 to 1.37) or in the matched cohort (HR: 1.04, 95% CI: 0.78 to 1.40). The results were similar for early mortality and the composite endpoint. Reoperation for sternal wound complications was more common among BIMA patients (odds ratio: 1.71, 95% CI: 1.01 to 2.88).ConclusionsBIMA grafting was performed infrequently and was not associated with better outcomes compared with SIMA grafting in patients undergoing non-emergent primary isolated CABG in Sweden during 1997–2008.

Is There a Role for Robotic Totally Endoscopic Coronary Artery Bypass in Patients With a Colostomy?

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

EComment. Two internal mammary artery grafts are better than one

We read with great interest the paper by Smith et al. regarding the long-term survival benefit of the usage of bilateral internal mammary artery (BIMA) grafts in coronary revascularization surgery [1]. They included in their results 13 follow-up studies published after 2001. However, we found one additional relevant article investigating the long-term outcomes associated with BIMA grafting compared with single internal mammary artery (SIMA) among diabetic patients [2]. We would like to take this opportunity to briefly extract the relevant information from the above-mentioned study and to add a short comment on this salient subject. Puskas et al. [2] conducted a retrospective cohort analysis by extracting data from the Society of Thoracic Surgeons database at a single referral academic centre. They included a total of 3527 coronary artery bypass grafting procedures (BIMA n = 812, SIMA n = 2715). After adjustment for differences between groups by the Cox model, BIMA grafting portended a 35% reduction in the hazard of long-term death at 8 years of follow-up (adjusted hazard ratio, 0.65; 95% CI, 0.48 to 0.88, P = 0.006). The authors concluded that the usage of BIMA grafting provides significant benefit in late survival compared with SIMA grafting in both diabetic and non-diabetic patients. BIMA grafting should be performed whenever patient risk factors and comorbidities allow an acceptable risk of deep sternal wound infection. As rightly outlined by the authors, all these studies are follow-up studies. However, only one randomized trial comparing these two techniques (ART Arterial Revascularization Trial) [3] is currently under way in Europe that can broaden our understanding. ART primary outcome is survival at 10 years; therefore the results should be available by 2018. Until that date the debate will continue. This uncertainty has been reflected in the rate of adoption of BIMA grafting, the rate of use of the technique varies from 4% in North America to 10% in Europe [4]. The major reasons for not using BIMA grafts are the lack of solid evidence of benefits and the increased rate of sternal wound infection, particularly in diabetics. Of note, in the SYNTAX study [5], BIMA grafting was used in a relatively higher percentage of 28% of patients. The more liberal use of BIMA in this trial entails a paradigm shift in grafting strategies worldwide.

Full myocardial revascularization with bilateral internal mammary artery Y grafts.

Bilateral internal mammary artery (BIMA) grafting in coronary artery surgery provides better long term outcomes than single internal mammary artery and saphenous vein grafting but the optimum configuration of BIMAs has not been established. This study analyzed perioperative and late outcomes of patients who underwent BIMA grafting with a composite Y configuration. Patients (n=922) who underwent BIMA Y grafting were identified from a cardiac surgical database and then cross matched against hospital and cardiology databases and the state death register to identify episodes of repeat coronary angiography, cardiac surgical re-intervention and death. Analysis of repeat angiography was performed after retrieval of the angiogram reports. In 95% of patients, full myocardial revascularization was achieved with BIMAs alone, using a composite Y configuration with an average of 4.1 IMA to coronary artery anastomoses per patient. The perioperative mortality was 1.5% and the 5-, 10- and 15-year survival estimates were 95%, 87% and 77% respectively. Analysis of 166 symptom-driven post-discharge coronary angiograms showed grafts to the left anterior descending artery and increasing severity of coronary artery stenosis at preoperative angiography as predictors of anastomotic patency. Full myocardial revascularization can be achieved with reasonable safety in most patients with triple vessel disease and good left ventricular function, and provides good late survival.

Bilateral Internal Mammary Artery Grafting and Risk of Sternal Wound Infection: Evidence From Observational Studies

The advantageous survival outcome of bilateral internal mammary artery grafting (BIMA) has been well established. However, this meta-analysis aims to make clear whether BIMA grafting increases the risk of sternal wound infection (SWI) when compared with single internal mammary artery grafting (SIMA). A literature search was performed in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. The observational studies reporting a comparison between SIMA and BIMA were included. The outcome of interest was the risk of SWI. Literature search, data extraction, and quality assessment were performed. Sensitivity and publication bias were also assessed in this research. We identified 4,701 titles and included 32 studies finally. The meta-analysis showed that the risk of SWI in the BIMA group was higher (relative risk [RR] 0.62, 95% confidence interval [CI] 0.55 to 0.71) than that in the SIMA group. Moreover, BIMA grafting was also associated with a higher risk of SWI in diabetic patients (RR 0.65, 95% CI 0.52 to 0.81) as well as elderly patients (RR 0.45, 95% CI 0.33 to 0.62). When skeletonization technique was adopted, the risk of SWI in BIMA patients was just a little higher than that in SIMA patients, but the difference did not reach statistical significance (RR 0.84, 95% CI 0.54 to 1.31). The BIMA grafting increases the risk of SWI when compared with SIMA grafting. This adverse effect further extends to diabetic and elderly patients. As regarding the method of procurement, skeletonized BIMA is safe and effective, thus it should be the procedure recommended.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Bilateral Internal Mammary Artery Grafting Enhances Survival in Diabetic Patients

Background— The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus SIMA grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. Methods and Results— Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching with the propensity score was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years; mean, 8.9 years) determined long-term survival. There was no difference in operative mortality, sternal wound infection, or total complications between matched SIMA and BIMA groups (operative mortality, 10 of 414 [2.4%] versus 13 of 414 [3.1%]; P =0.279; sternal wound infection, 7 of 414 [1.7%] versus 13 of 414 [3.1%]; P =0.179); total complications, 71 of 414 [17.1%] versus 71 of 414 [17.1%]; P =1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival: SIMA, 9.8 years versus BIMA, 13.1 years; P =0.001). Use of BIMA was found to be associated with late survival on Cox regression ( P =0.003). Conclusion— Compared with SIMA grafting, BIMA grafting in propensity score–matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality.

Robotic totally endoscopic coronary artery bypass grafting for spontaneous coronary artery dissection

Patients with spontaneous coronary artery dissection may require surgical revascularization. Reports on the surgical management of this pathology are primarily limited to classic coronary artery bypass grafting via sternotomy on cardiopulmonary bypass, although a limited number of reports of alternatives also exist. We describe a case of robotic completely endoscopic coronary surgery using the daVinci® Si™ system in a patient with spontaneous coronary artery dissection. Robotically assisted single left internal mammary artery grafting to the left coronary artery system was carried out successfully in a completely endoscopic fashion. Selected patients with spontaneous coronary artery dissection may benefit from a totally endoscopic approach to surgical coronary revascularization.

Propensity matched analysis of bilateral internal mammary artery versus single left internal mammary artery grafting at 17-year follow-up: validation of a contemporary surgical experience

Bilateral internal mammary arteries (BIMA) remains widely underutilized in coronary artery bypass grafting (CABG). Although prior research has demonstrated a long-term benefit of the use of BIMA over left internal mammary artery (LIMA)-only, validation of these results is lacking in a contemporary surgical experience. We compared complications and survival at 17-year follow-up in a large series of consecutive CABG patients from a single institution that underwent BIMA grafting with a propensity-matched group where LIMA only was used. Propensity scores representing the estimated probabilities of patients receiving either BIMA or LIMA alone were developed based on 22 observed baseline covariates in a logistic regression model with procedure group as the dependent variable. The nearest-neighbour-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 928 patients each balanced for baseline factors. We compared 30-day morbidity and mortality, as well as long-term survival at 5-year intervals up to 17-year follow-up. In-hospital and 30-day mortality was 0.8% for the BIMA group and 1.1% for the LIMA-saphenous vein grafting (SVG). No significant difference was found in complications, mortality and/or length-of-stay between these two groups. Off-pump was done in 48.9% of BIMA cases and 51.3% of LIMA cases. Regardless of the types of grafts used, on-pump patients were more likely to have postoperative permanent strokes and longer postoperative lengths of stay. Use of the BIMA over LIMA-only had a statistically significant impact conferring a 10% survival advantage at 10-year and 18% at 15-year follow-up. The Kaplan-Meier survival curves comparing off-/on-pump BIMA and off-/on-pump LIMA-SVG patients demonstrated a 22% survival advantage for off-pump BIMA patients when compared with on-pump LIMA-SVG patients at 15-year follow-up. Perioperative complications do not increase with the use of BIMAs. Long-term survival is optimized with off-pump CABG and BIMA grafting. The low morbidity and mortality rates in this series are likely due to the continuous evolution of technology and the adoption of less invasive options for CABG patients. A more widespread use of BIMAs in CABG patients would continue to improve the overall excellent short- and long-term results of this operation.

Robotic total endoscopic coronary artery bypass hybrid revascularization procedure in a patient with a preoperative tracheostoma

Preoperative tracheostoma presents a significant risk of sternal wound complications, mediastinitis, stoma necrosis and tracheal injury in patients requiring cardiac surgery. Several approaches have been described to limit these risks. Robotic totally endoscopic coronary artery bypass grafting in patients with a tracheostoma has not been reported. We describe a case of completely endoscopic coronary surgery using the daVinci(®) Si™ system in a patient with a tracheostoma. Single left internal mammary artery grafting to the left coronary artery system was carried out successfully as the first stage of a hybrid revascularization and followed by percutaneous coronary intervention to the circumflex coronary artery. We regard this technique as the most minimally-invasive method of surgical coronary revascularization with a significant potential to reduce the risk of mediastinitis in patients with a tracheostoma.

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

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

Does the use of bilateral internal mammary artery grafts impact survival of veterans undergoing coronary artery bypass surgery?

Background The impact of bilateral internal mammary artery (BIMA) versus single left internal mammary artery (LIMA) grafts on long-term survival in veterans after coronary artery bypass graft (CABG) surgery is unknown. Methods A review of prospectively collected data identified all patients (n = 784) who underwent primary isolated CABG surgery from December 1991 through December 1998. Grafting was performed with LIMA in 713 (90.9%) patients and with BIMA in 71 (9.1%) patients. We identified 66 propensity-matched patient pairs. Results The matched cohort was all male. The mean follow-up was 9.7 ± 3.8 years. Comparing matched patients showed no significant survival benefit for the BIMA group versus the LIMA group at 5 years (89% versus 86%) and 10 years (73% versus 69%) ( P = .99). Factors associated with decreased survival were advanced age, higher New York Heart Association heart failure class, and diabetes. Conclusions Using BIMA grafting instead of LIMA grafting had no significant survival benefit for male veterans who underwent CABG surgery. Further study is needed to fully evaluate the role of BIMA grafting in this unique patient population.

64-slice computed tomographic monitoring of a repaired symptomatic aneurysm of the right coronary artery

A previously healthy 28-year-old Chinese man presented with progressive exertional angina. He was a nonsmoker, nondiabetic and had a normal serum cholesterol level. There was no history of hypertension and no family history of coronary artery disease. A physical examination was unremarkable. No evidence of acute inflammatory disease or history of Kawasaki disease was elicited. The patient underwent coronary angiography, which demonstrated a proximal aneurysm of the right coronary artery (RCA) (Figure 1A). There were no distal RCA obstructions, and no lesions were identified in the left coronary artery. Figure 1) Coronary angiography demonstrating a right coronary artery (RCA) aneurysm that was treated surgically with a right internal mammary artery (RIMA) graft (A). Follow-up angiography at two years revealed regression of the aneurysm (B), which was confirmed ... The aneurysm was bypassed with a single right internal mammary artery (RIMA) graft to the right coronary artery, after which the symptoms resolved. Follow-up angiography two years following surgery demonstrated regression of the aneurysm. The RIMA had a widely patent anastomosis to the native RCA (Figure 1B). The patient remained symptom-free. Four years after surgery, the patient underwent follow-up with a 64-slice computed tomography scan. Three-dimensional reconstruction (Figure 1C) and curved multiplanar reconstruction (Figure 1D) again demonstrated a patent RIMA to RCA anastomosis (Figure 1D inset), with distal flow in the native RCA. The aneurysm remains obliterated.