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Outcomes and Patency of Complex Configurations of Composite Grafts Using Bilateral Internal Thoracic Arteries

  • Shih, Beatrice Chia-Hui (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Chung, Suryeun (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kim, Hakju (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Chang, Hyoung Woo (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Kim, Dong Jung (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Lim, Cheong (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Park, Kay-Hyun (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Kim, Jun Sung (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine)
  • Received : 2019.09.02
  • Accepted : 2019.10.28
  • Published : 2020.04.05

Abstract

Background: It is generally agreed that using a bilateral internal thoracic artery (BITA) composite graft improves long-term survival after coronary artery bypass grafting (CABG). Although the left internal thoracic artery (LITA)-based Y-composite graft is widely adopted, technical or anatomical difficulties necessitate complex configurations. We aimed to investigate whether BITA configuration impacts survival or patency in patients undergoing coronary revascularization. Methods: Between January 2006 and June 2017, 1,161 patients underwent CABG at Seoul National University Bundang Hospital, where the standard technique is a LITA-based Y-composite graft with the right internal thoracic artery (RITA) sequentially anastomosed to non-left anterior descending (LAD) targets. Total of 160 patients underwent CABG using BITA with modifications. Their medical records and imaging data were reviewed retrospectively to investigate technical details, clinical outcomes, and graft patency. Results: Modifications of the typical Y-graft (group 1, n=90), LITA-based I-graft (group 2, n=39), and RITA-based composite graft (group 3, n=31) were used due to insufficient RITA length (47%), problems using LITA (28%), and target vessel anatomy (25%). The overall 30-day mortality rate was 1.9%. Among 116 patients who underwent computed tomography or conventional angiography at a mean interval of 29.9±33.1 months postoperatively, the graft patency rates were 98.7%, 95.3%, and 83.6% for the LAD, left circumflex artery, and right coronary artery territories, respectively. Patency rates for the inflow, secondary, and tertiary grafts were 98.2%, 90.5%, and 80.4%, respectively. The RITA-based graft (group 3) had the lowest patency rate of the various configurations (p<0.011). Conclusion: LITA-based Y composite graft, showed satisfactory clinical outcomes and patency whereas modifications of RITA- based composite graft had the lowest patency and 5-year survival rates. Therefore, when using RITA-based composite graft, other options should be considered before proceeding atypical configurations.

Keywords

References

  1. Tabata M, Grab JD, Khalpey Z, et al. Prevalence and variability of internal mammary artery graft use in contemporary multivessel coronary artery bypass graft surgery: analysis of the Society of Thoracic Surgeons National Cardiac Database. Circulation 2009;120:935-40. https://doi.org/10.1161/CIRCULATIONAHA.108.832444
  2. Kappetein AP, Dawkins KD, Mohr FW, et al. Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery disease: insights from the SYNTAX run-in phase. Eur J Cardiothorac Surg 2006;29:486-91. https://doi.org/10.1016/j.ejcts.2006.01.047
  3. Kelleher R, Gimpel D, McCormack DJ, El-Gamel A. Does the use of an in situ or Y-configuration for bilateral internal thoracic arteries influence long-term survival, patency or repeat revascularization in coronary bypass surgery? Interact Cardiovasc Thorac Surg 2019;28:222-6. https://doi.org/10.1093/icvts/ivy195
  4. FitzGibbon GM, Burton JR, Leach AJ. Coronary bypass graft fate: angiographic grading of 1400 consecutive grafts early after operation and of 1132 after one year. Circulation 1978;57:1070-74. https://doi.org/10.1161/01.CIR.57.6.1070
  5. Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001;358:870-5. https://doi.org/10.1016/S0140-6736(01)06069-X
  6. Sabik JF 3rd, Stockins A, Nowicki ER, et al. Does location of the second internal thoracic artery graft influence outcome of coronary artery bypass grafting? Circulation 2008;118(14 Suppl):S210-5.
  7. Toker ME, Omeroglu SN, Kirali K, Balkanay M, Yakut C. Using the bilateral internal mammary artery in the left or right coronary artery system: 5-year comparison of operation techniques and angiographic results. Heart Surg Forum 2005;8:E462-7. https://doi.org/10.1532/hsf98.20051165
  8. Fan T, Lu Y, Gao Y, et al. Hemodynamics of left internal mammary artery bypass graft: effect of anastomotic geometry, coronary artery stenosis, and postoperative time. J Biomech 2016;49:645-52. https://doi.org/10.1016/j.jbiomech.2016.01.031
  9. Glineur D, Kuschner CE, Grau JB. Bilateral internal thoracic artery graft configuration and coronary artery bypass grafting conduits. Curr Opin Cardiol 2016;31:625-34. https://doi.org/10.1097/HCO.0000000000000342
  10. Hori D, Yamaguchi A, Adachi H. Coronary artery bypass surgery in end-stage renal disease patients. Ann Vasc Dis 2017;10:79-87. https://doi.org/10.3400/avd.ra.17-00024
  11. Glineur D, Hanet C, D'hoore W, et al. Causes of non-functioning right internal mammary used in a Y-graft configuration: insight from a 6-month systematic angiographic trial. Eur J Cardiothorac Surg 2009;36:129-36. https://doi.org/10.1016/j.ejcts.2009.02.041
  12. Magruder JT, Young A, Grimm JC, et al. Bilateral internal thoracic artery grafting: does graft configuration affect outcome? J Thorac Cardiovasc Surg 2016;152:120-7. https://doi.org/10.1016/j.jtcvs.2016.03.022
  13. Gaudino M, Taggart D, Suma H, Puskas JD, Crea F, Massetti M. The choice of conduits in coronary artery bypass surgery. J Am Coll Cardiol 2015;66:1729-37. https://doi.org/10.1016/j.jacc.2015.08.395
  14. Dar MI, Dar AH, Bilal M, Ahmad M, Haseeb A. Association of internal mammary artery flow with different comorbidities and postcoronary artery bypass graft complications. Cureus 2017;9:e1584.
  15. Gansera B, Gunzinger R, Angelis, et al. End of the millennium: end of the single thoracic artery graft?: two thoracic arteries: standard for the next millenium?: early clinical results and analysis of risk factors in 1,487 patients with bilateral internal thoracic artery grafts. Thorac Cardiovasc Surg 2001;49:10-5. https://doi.org/10.1055/s-2001-9923
  16. Gatti G, Castaldi G, Morosin M, et al. Double versus single source left-sided coronary revascularization using bilateral internal thoracic artery graft alone. Heart Vessels 2018;33:113-25. https://doi.org/10.1007/s00380-017-1040-1
  17. Di Mauro M, Iaco AL, Allam A, et al. Bilateral internal mammary artery grafting: in situ versus Y-graft: similar 20-year outcome. Eur J Cardiothorac Surg 2016;50:729-34. https://doi.org/10.1093/ejcts/ezw100
  18. Lev-Ran O, Matsa M, Ishay Y, Shabtai A, Vodonos A, Sahar G. Retroaortic right internal thoracic artery grafting of circumflex artery targets. Asian Cardiovasc Thorac Ann 2015;23:543-51. https://doi.org/10.1177/0218492315573360
  19. Bakay C, Onan B, Korkmaz AA, Onan IS, Ozkara A. Sequential in situ left internal thoracic artery grafting to the circumflex and right coronary artery areas. Ann Thorac Surg 2013;95:63-70. https://doi.org/10.1016/j.athoracsur.2012.08.053
  20. Raja SG, Benedetto U, Husain M, et al. Does grafting of the left anterior descending artery with the in situ right internal thoracic artery have an impact on late outcomes in the context of bilateral internal thoracic artery usage? J Thorac Cardiovasc Surg 2014;148:1275-81. https://doi.org/10.1016/j.jtcvs.2013.11.045