Use Of Left Internal Thoracic Artery Research Articles

Prevalence of Atherosclerotic Lesions in the Left Internal Thoracic Artery, Evidenced by Selective Angiographic Findings

Abstract Background: By observing the high prevalence of failures in the surgical treatment of myocardial revascularization (MR), with the use of the Left Internal Thoracic Artery (LITA) as a graft, evidenced by the international literature, it was sought to demonstrate the prevalence of lesions that would not allow the use of LITA as a graft in myocardial revascularization surgery, with possible alteration in the surgical management performed by the cardiac surgeon, and reduction of the morbimortality of these patients. Objectives: To evaluate the prevalence of atherosclerotic lesions of the LITA, through selective preoperative angiography, in patients submitted to coronary angiography and indicated for myocardial revascularization. We also analyzed other lesions that made the use of LITA unfeasible as a main graft in cases of myocardial revascularization surgery (MRS). Methods: This was a cross-sectional, prevalence study that evaluated, through selective angiography, the LITA of 39 patients with a median age of 63 years, submitted to coronary angiography, with indication of Coronary Artery Bypass Graft (CABG). Categorical variables were compared by chi-square test and Fisher's exact test. The single continuous variable, age, was tested for normality by the Kolmogorov-Smirnov test, described in median (P25; P75) and the groups compared with the Mann-Whitney test. The level of statistical significance adopted was p < 0.05. The analyzes were performed in SPSS® software version 20. Results: It was identified the presence of 7.7% of disorders in the LITA that made it unfeasible to be used. In all of the patients there was no specific symptomatology evidencing the lesion. No variable was shown as a predictor for the occurrence of the outcomes. Conclusion: The prevalence of the lesions found in the study was significant, indicating that a preoperative evaluation of LITA could bring future benefits to the patients submitted to CABG.

Long-term survival after use of internal thoracic artery in octogenarians is gender related

ObjectiveThe goal of this study is to assess the benefits of a left internal thoracic artery as a bypass conduit in octogenarians undergoing elective coronary artery bypass grafting. We hypothesize that there is no survival advantage and that outcome may be gender related. MethodsIn a retrospective analysis of 1141 octogenarians (aged >80 years) undergoing isolated coronary artery bypass grafting from 1996 to 2012, patients were divided into 2 groups: Group I (coronary artery bypass grafting–left internal thoracic artery) included 870 patients (339 female/531 male), and group II (coronary artery bypass grafting–saphenous vein graft) included 271 patients (131 female/140 male). ResultsThe overall 30-day mortality was 5.7%: 4.3% in group I and 7.0% in group II (P = .1). Group II had a lower trend of any postoperative complication (P = .05) and pneumonia (P = .05). When analyzed by gender, there were no discernable differences in long-term survival for male patients in group I (65% at 5 years and 29% at 10 years) versus male patients in group II (65% at 5 years and 31% at 10 years) (P = .2). However, survival was significantly greater for female patients in group I (70% at 5 years and 35% at 10 years) versus female patients in group II (63% at 5 years and 21% at 19 years) (P = .01). Multiple logistic and Cox regression analysis showed that left internal thoracic artery use is associated with improved survival in female patients (hazard ratio [HR], 0.72; confidence interval [CI], 0.56-0.93) but not in male patients (HR, 1.14; CI, 0.9-1.4). Advanced age was associated with an increased risk of mortality (HR, 1.08 per year; CI, 1.05-1.1). Both patient age (P = .01) and Society of Thoracic Surgeons–predicted 30-day mortality (P = .03) remain in the final model for 30-day mortality. The benefit of the left internal thoracic artery after coronary artery bypass grafting in octogenarians may be gender related. ConclusionsThis study shows that the benefit of the left internal thoracic artery in the octogenarian population undergoing coronary artery bypass grafting may be gender related. For elderly female patients, the use of the left internal thoracic artery as a bypass conduit was associated with better long-term survival, whereas no significant difference was found among the male population. The use of the left internal thoracic artery was associated with a greater postoperative pulmonary morbidity for the study population as a whole. The present study does not refute the benefit of the left internal thoracic artery–left anterior descending graft, but instead distinguishes a subset who might benefit more.

Graft selection in elderly patients undergoing coronary artery bypass grafting

This study aimed to assess the clinical and angiographic outcomes after coronary artery bypass grafting (CABG) in elderly patients (≥75 years). We reviewed the records of 1021 patients who underwent CABG between September 2004 and December 2009. We divided these patients into two groups: ≥75 years (group E, n = 292) versus <75 years (group N, n = 729). We compared operative and postoperative variables and early and 1-year angiographic patency rates of grafts between the groups. The rates of female sex (P < 0.01), unstable angina (P = 0.04), and history of congestive heart failure (P < 0.01) were higher in group E than in group N. More patients in group N had diabetes (P = 0.03) and hyperlipidemia (P < 0.01) than those in group E. Operative mortality (1.0% in group E vs. 0.3% in group N; P = 0.14) and the rate of major complications were not significantly different between the groups. The mean number of anastomoses per patient was similar in the groups. The rate of left internal thoracic artery use was not significantly different between the groups, although the use of other arterial grafts was significantly higher in group N than in group E. There were no significant differences in the early (98.5% vs. 97.2%, P = 0.08) or 1-year (91.6% vs. 89.3%, P = 0.28) patency rates of all grafts in the groups. The clinical and angiographic outcomes after CABG in elderly patients were almost identical to those in nonelderly patients.

Análise angiográfica tardia dos enxertos empregados na revascularização miocárdica de pacientes com retorno de sintomas

Left internal thoracic artery (LITA) grafting has become the gold standard in coronary artery bypass graft procedure (CABG). In order to optimize the use of LITA or other grats, sequential anastomosis has been used. There is no consensus on equivalence of results between isolated and sequential grafts. The aim of this study is to compare the patency of isolated versus sequential grafts. From January 2000 to August 2007, a retrospective patency analysis of the grafts used in 88 symptomatic patients who underwent CABG procedure in our Service was performed through cinecoronariography. Statistical analysis was performed through Student's t test. Each distal anastomosis was considered an independent graft. The mean postoperative period was of 53 +/- 138 months and mean age was 64 +/- 11 years. LITA isolated grafts presented patency rate significantly higher than the sequential grafts, respectively 92% (46/50) and 77% (30/39) P = 0.02. However, in injured coronary arteries of >or= 70%, isolated LITA patency rate was similar to sequential grafts, (95%; 37/39) and (93%; 26/28) respectively; P = 0.37. Mean radial artery patency rate was similar to isolated 71% (5/7) and sequential 90% (19/21) grafts; P = 0.10. Saphenous vein patency rates were similar for isolated 72% (31/43) and sequential 81% (73/90) grafts; P = 0.12. There was no difference between radial artery and saphenous vein patency rates. In symptomatic patients, isolated LITA patency is superior than sequential LITA. However, in coronary injuries of >or= 70%, the isolated and sequential patency rates are similar. Sequential grafts from radial artery and saphenous vein are similar to their respective isolated grafts.

Totally arterial off-pump vs. on-pump coronary revascularization: comparison of early outcome

Our objective was to assess differences in early outcome after completely arterial myocardial revascularization with (on-pump coronary artery bypass grafting or ONCAB) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting or OPCAB). Fifty-eight OPCAB and 91 ONCAB patients receiving exclusively arterial grafts were analyzed. OPCAB patients had more single-vessel (P<0.0001), less triple-vessel (P<0.0001) or left main disease (P=0.0021), higher angina class (P=0.003), more unstable angina (P<0.0001) and previous percutaneous transluminal coronary angioplasty (PTCA; P<0.0001), but similar EuroScores (P=n.s.). ONCAB was associated with longer operation time (P=0.0001) and more anastomoses/patient (P<0.0001). Internal thoracic artery (ITA) use was identical, whereas single left ITA use (P<0.0001) and left ITA jump anastomoses (P<0.0001) were more frequent in OPCAB. Radial artery (RA) use (P<0.0001) and RA jump anastomoses (P<0.0001) were more frequent in ONCAB. Complication rates were similar concerning mortality, arrhythmias, cerebro-vascular accidents (CVA), and renal failure with shorter ventilatory support (P<0.0001) and a trend towards less perioperative myocardial infarction (PMI) (P=0.12) and low output (P=0.089), and more respiratory complications (P=0.056) after OPCAB. Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or intensive care unit and hospital stay, but with shorter ventilatory support and a trend towards lower PMI and low output, and higher respiratory complication rates after OPCAB.

Myocardial revascularization with the left internal thoracic artery Y graft configuration

Background. The proved long-term patency of the left internal thoracic artery (LITA) has made it the conduit of choice for myocardial revascularization. Maximal utilizable LITA length can be achieved by using a semi-skeletonizing harvest technique. Expanded LITA use with sequential and Y graft techniques allows for a wider territory of myocardial revascularization. Methods. A retrospective analysis of 30 patients undergoing coronary artery bypass surgery with a LITA- Y graft between December 1994 and November 1996 was performed. In selected patients the LITA was cut to length and anastomosed to the left anterior descending artery (LAD), with the redundant length of LITA used as a free graft to the lateral circumflex and diagonal systems. The proximal end of the free LITA was anastomosed to the in situ LITA to form the Y graft. Selection criteria included: a) minimal distal disease in the LAD and circumflex systems; and b) graftable circumflex branches proximal to the mid free wall of the left ventricle, allowing total revascularization of the left coronary system with the Y graft. Results. Thirty patients (22 male, 8 female) underwent the LITA- Y graft procedure. There were no deaths or episodes of myocardial infarction. One patient required inotropic and intraaortic balloon pump support. Two patients with isolated coronary ostial stenosis developed recurrence of angina due to occlusion of the free limb of the LITA. Conclusions. In patients with suitable coronary artery anatomy, the LITA- Y graft can be successfully performed with good short-term outcome, but may be contraindicated in the management of isolated coronary ostial stenosis.