Off-pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Elderly Patients

Kinoshita, Takeshi; Asai, Tomohiro; Suzuki, Tomoaki; Kuroyanagi, Sachiko; Hosoba, Soh; Takashima, Noriyuki

doi:10.1016/j.athoracsur.2011.09.077

Cited by 41 publications

(37 citation statements)

References 28 publications

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“…Almost all surgeons at our institute use the skeletonized technique when performing bilateral ITA harvest. Our results are comparable to those (0.9%) reported by Kinoshita et al for patients undergoing off-pump CABG with bilateral skeletonized ITAs (32).…”

Section: Discussionsupporting

confidence: 75%

Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience

Davierwala

Leontyev

Garbade

et al. 2018

Ann. Cardiothorac. Surg.

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Background: Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes.Methods: Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing offpump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study.Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery. Results:The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality.Conclusions: Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time.The long-term survival of patients undergoing such an operation is excellent.

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Section: Discussionsupporting

confidence: 75%

Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience

Davierwala

Leontyev

Garbade

et al. 2018

Ann. Cardiothorac. Surg.

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“…9) On the other hand, Medalion et al and Kinoshita et al reported that use of BITA grafts improved late survival and freedom from cardiac events in patients aged >65 years and >70 years, respectively. 10,12) In this study, the rate of MACCE was lower in the BITA group than in the SITA group, but there was no significant difference in overall survival between the two groups. The mean age of patients in this study was 82.7 ± 2.6 years, and the life expectancy in this population was not long enough to show a significant difference in survival between the two groups.…”

Section: Discussionmentioning

confidence: 75%

“…As older age patients have a relatively poor prognosis after cardiac surgery and a relatively short life expectancy, the surgical indications and strategies for elderly patients are controversial. [9][10][11][12]17,18) Kieser et al considered that use of BITA grafts was not yet shown to be beneficial in patients aged >70 years. 9) On the other hand, Medalion et al and Kinoshita et al reported that use of BITA grafts improved late survival and freedom from cardiac events in patients aged >65 years and >70 years, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5] However, some studies reported higher rates of surgical site infection (SSI) after use of BITA grafts because of the decreased blood supply to the sternum and surrounding tissues. [6][7][8] Previous studies investigating the feasibility of using BITA grafts in elderly patients included patients aged >65 or >70 years, [9][10][11][12] but the feasibility of using BITA grafts specifically in octogenarians has not previously been investigated. This study aimed to investigate the feasibility of using BITA grafts for isolated CABG in octogenarians by comparing the early and late outcomes after use of BITA and SITA grafts.…”

Section: Introductionmentioning

confidence: 99%

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Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?

Hashimoto

Fukui

Takanashi

2015

ATCS

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Purpose: The feasibility of using bilateral internal thoracic artery (BITA) grafts for coronary artery bypass grafting (CABG) in octogenarians is not clear. This study aimed to compare outcomes between use of BITA and single internal thoracic artery (SITA) grafts in octogenarians undergoing isolated CABG. Methods: Isolated CABG was performed in 1,566 patients at the Sakakibara Heart Institute between September 2004 and December 2012. Of these, 125 consecutive octogenarians were included and divided into two groups, according to the use of BITA grafts (101 subjects) or SITA grafts (24 subjects). Early and late outcomes were compared between groups. Results: The preoperative patient characteristics were similar between the two groups. Early outcomes were similar, including hospital death or deep sternal infection. The estimated 5-year survival rate was similar in the BITA and SITA groups (78% vs 62%, p = 0.269). Freedom from major adverse cardiac or cerebrovascular events was significantly higher in the BITA group than in the SITA group after 5 years (90% vs 75%, p = 0.032). Conclusions: Our results suggest that use of BITA grafts for CABG is feasible and beneficial in octogenarians, resulting in improved late outcomes without increased operative risk.

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“…Some surgeons may not agree this strategy for the following reasons: 1) skeletonized IMA graft harvesting is technically more demanding than the conventional pedicled IMA harvesting; 2) in situ right IMA graft reaches target sites only with the bifurcated distal part of the artery; and 3) in situ right IMA grafting to the LAD increases the complexity of redo operation. 19) In our practice, with a precise understanding of the local anatomy and a delicate technique, injury to the arterial trunk can be avoided, especially at branch points with complete skeletonization of the whole length of the IMA. The technique of skeletonized IMA grafting was carried out in our center since 2011, and was performed routinely without injury to the IMA after the launch of the trial.…”

Section: Discussionmentioning

confidence: 99%

In Situ Skeletonized Right Internal Mammary Artery Bypass Grafting to Left Anterior Descending Artery

Xia²,

Shi

et al. 2018

Int. Heart J.

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SummaryThis study aimed to evaluate the feasibility and the mid-term efficacy of an in situ skeletonized right internal mammary artery (IMA) bypass grafting to a left anterior descending artery (LAD), and to determine risk factors for IMA graft failure in a single-center study.From January 2012 to December 2015, 189 patients (173 males, 50.6 ± 6.0 years old) undergoing first isolated coronary artery bypass grafting surgery with the in situ skeletonized right IMA grafting to the LAD were included in this study. Baseline characteristics, peroperative data, and follow-up outcomes were investigated and analyzed.The length of the in situ skeletonized right IMA grafts was 18.6 ± 1.2 cm (17.0-22.0 cm). Intraoperative graft flow of the in situ skeletonized right IMA grafting to LAD was 42 ± 9 mL/minute (18-72 mL/minute) associated with measured pulsatility index of 0.8-4.3. In-hospital mortality was 0.5%. Postoperative morbidity included acute myocardial infarction (0.5%), stroke (0.5%), and deep sternal wound infections (1.1%). The midterm survival was 97.2% and the incidence of repeat revascularization was 0.6%. The patency rate of the in situ skeletonized right IMA grafting to the LAD was 97.1% by computed tomography angiography examination during the follow-up period of 23.2 ± 9.7 months. Additionally, logistic regression analysis showed that intraoperative graft flow had an independent influence on the risk of the mid-term right IMA graft failure.The strategy of the in situ skeletonized right IMA grafting to the LAD is feasible and effective. Intraoperative graft flow was an independent risk factor for the mid-term right IMA graft failure.(Int Heart J 2018; 59: 35-42) Key words: Coronary artery bypass grafting, Artery skeletonization, Intraoperative graft flow, Graft patency C oronary artery bypass grafting surgery (CABG) remains one of the most common cardiac surgical procedures today. [1][2][3][4][5] It has been demonstrated to provide symptomatic relief and increase the long-term survival for patients with coronary artery disease, which is mainly attributed to a complete revascularization and a left internal mammary artery (IMA) bypass grafting to a left anterior descending artery (LAD). [1][2][3][4][5] Following the publication of the landmark study by Loop in 1986, which validated positive impacts of the IMA graft on 10-year survival and other cardiac events, the strategy of the left IMA grafting to the LAD is considered as the "gold standard" of coronary revascularization.6) Given the fact that patients who received CABG surgery often require more than one graft, the prospect of bilateral IMA grafting becomes very appealing to cardiac surgeons after recognition of the long-term benefits of left IMA graft. 7)However, the use of bilateral IMA grafting is scarcely diffused. 8,9) Concerns regarding a higher probability of deep sternal wound infections and its ensuing complications, an increased operation time, and technical challenges including utilizing and teaching the technique, have limited the widespread use...

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Off-pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Elderly Patients

Cited by 41 publications

References 28 publications

Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience

Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience

Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?

In Situ Skeletonized Right Internal Mammary Artery Bypass Grafting to Left Anterior Descending Artery

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