On-Pump versus Off-Pump Complete Arterial Revascularization Using Bilateral Internal Mammary Arteries and the T-Graft Technique: Clinical and Angiographic Results for 3,445 Patients in 13 Years of Follow-Up.

BACKGROUND: This is an investigation of complete arterial coronary artery bypass grafting (CACABG) using bilateral internal mammary arteries (IMA) and the T-graft technique either on- or off-pump as a routine approach to treat coronary artery disease. METHODS: Between January 2000 and December 2012, 3,445 patients underwent on-pump (n = 2,216) or off-pump (n = 1,229) CACABG. A 30-day follow-up was performed prospectively, a long-term follow-up by a questionnaire, and coronary angiography in selected patients. RESULTS: End points at 30 days were death, myocardial infarction, stroke, repeat revascularization, renal replacement, reoperation, sternal wound infection and atrial fibrillation. FitzGibbon A patency rates were 89.8 vs. 91.4% (p = 0.464) with consecutive percutaneous coronary intervention in the grafted area of 1.8 vs. 1.1% (p = 0.693) on- vs. off-pump, and no reoperation in the grafted area in both groups. CONCLUSION: CACABG by use of skeletonized bilateral IMA with the T-graft technique performed either on- or off-pump is a safe and effective approach.

Congenital fistula between the left internal mammary artery (LIMA) and the pulmonary artery: cause of LIMA bypass occlusion?

Congenital fistulas from the left internal mammary artery to the pulmonary artery are rare. We describe a 49-year-old patient with severe aortic valve regurgitation and coronary artery disease. Percutaneous transluminal coronary angioplasty and left anterior descending artery (LAD) stenting had been performed because of a significant proximal LAD lesion. Repeated coronary angiogram 3 months later revealed a patent stent but severe sclerosis up to a 40% stenosis of the LAD after the area of stenting. An aortic valve replacement and a left internal mammary artery (LIMA) bypass to LAD were performed during standard cardiopulmonary bypass (CPB). Because of patient chest pain, a control angiogram was carried out 2 years after surgery and revealed a LIMA-bypass occlusion and a large fistula deriving from the proximal part of the LIMA to the pulmonary artery. The fistula was occluded by coils during an interventional cardiological procedure. Diminished flow in the LIMA bypass due to the fistula in combination with a nonsignificant proximal LAD stenosis are possible reasons for IMA-bypass occlusion. From this case we conclude that angiography of the IMA to detect malformations preoperatively should be mandatory in all cases of arterial coronary revascularization using IMA bypasses.