Suitability and Durability of Multiple Internal Thoracic Artery Coronary Artery Bypasses

Abstract

ObjectiveThe authors evaluate operative and extended outcomes of coronary artery bypass surgery using the bilateral internal thoracic arteries (ITAs) as bypass grafts. The authors conclude that the procedure is viable and of long-term benefit to most patients. Summary Background DataMultiple ITA grafting was met with early enthusiasm by the surgical profession, but skepticism and controversy arose with reports of increased operative morbidity, insufficient graft blood flow, a high incidence of failure of the right ITA, and uncertainty about durability and long-term benefits. MethodsTo assess the actual incidence and impact of these complications and long-term results, the authors prospectively studied 500 consecutive patients with multiple ITA bypasses, constituting the closely observed and carefully documented experience of one surgeon over an 11-year period. ResultsOperative mortality in the series of 500 patients was 1.8%, perioperative myocardial infarction (new Q wave) rate was 0.6%, and deep sternal wound infection occurred in 1%. Six patients (1.2%) had strokes, and nine patients (1.8%) were returned to the operating room to control bleeding. One hundred ninety-eight patients who had abnormal stress test results before surgery were retested within 3 months of surgery. Ninety-four percent of these were normal, 3% were nondiagnostic, and 3% were abnormal. After a mean followup of 7.1 years (mode, 7.2 years), 87.5% of patients in the sample were alive, and 93.2% of this group have experienced continuing good clinical results (New York Heart Association class or 11). Eighty-nine patients who underwent an angiogram had 90.8% patency rates of ITA bypasses and 84.5% patency of vein grafts. Only two patients required repeat operations. ConclusionsThe operative resufts did not support the contention that the coronary artery bypass using ITA procedure produces higher than acceptable mortality and morbidity rates. Multiple ITA bypasses can be performed without excessive morbidity, with low reoperation rates and longterm outcomes that should encourage skeptics to reconsider the procedure's clinical value. 785

Conduit Selection for Improved Outcomes in Coronary Artery Bypass Surgery

“…Incredibly, only 2 patients out of the 500 required reoperation for myocardial ischemia in the follow-up period. [24]. Interestingly, however, Jones et al point out that if strict criteria for selecting patients for BIMA grafting had been used, nearly 70% of patients in their series would have been excluded [24].…”

“…Jones succinctly summarized the decision point facing conventional, open surgery in the face of rapidly advancing technologies, particularly PCI, and the impact on referral trends for surgical intervention: " improve the long-term outcome, lessen resources used, or both." [24]. Therefore, one important philosophic principle regarding use of multiple arterial conduits is that the focus is on the long-term results, not the short-term.…”

“…This is primarily related to the well-demonstrated risk for sternal wound infection after BIMA grafting in patients with diabetes, obesity, and other comorbidities [96][97][98][99][100]. However, BIMA grafting can be performed safely without significant increased risk for sternal wound infection as has been frequently demonstrated [24,98,100,101]. For example, Jones et al reviewed their experience with 500 consecutive patients undergoing BIMA CABG over an 11-year period, excluding only those with proximal coronary stenoses <70% and emergency cases with HD instability.…”

“…[24]. Interestingly, however, Jones et al point out that if strict criteria for selecting patients for BIMA grafting had been used, nearly 70% of patients in their series would have been excluded [24]. As noted previously, RSVG conduits for CABG have not been compared directly to DES, but comparisons of BIMA grafting with a strategy primarily employing DES for coronary revascularization do exist [102,103].…”

Risk Analysis of Deep Sternal Wound Infection and Mediastinitis in Cardiac Surgery

“…They do not discuss the published conclusions of other investigators that multiple ITA bypasses can be performed without excessive morbidity, with low reoperation rates, and good long-term outcome [4]. Gummert's study suffers from a methodological problem common to research in this area -it concentrates on a limited number of DSWI risk factors, but does not consider all the risk factors reported in large groups of sternotomy patients [2,3].…”