Long-Term Radial Artery Grafts with Previous Midterm Proven Patency.

INTRODUCTION: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of coronary artery bypass grafting (CABG). This grafting has led to an increased use of other arterial conduits, of which the radial artery (RA) is the most popular. Whether RA can have the same long-term patency as LITA is controversial. The objective of this study is to access the long-term clinical follow-up and, when available, the patency rate of RA grafts. METHODS: Twenty-six patients from a previous study with critical stenosis in all target vessels underwent complete arterial CABG with LITA and RA grafts from 1996 to 2003. They all underwent midterm multidetector computed tomography after surgery with the association of at least one patent LITA and one patent RA graft. RESULTS: Twelve patients (46%) are alive with no angina symptoms. Six patients underwent a second image exam 12 to 16 years (average of 14 years) after surgery, with a total of six LITA-LADA and 14 RA grafts with 100% patency rate. Clinical follow-up five to 23 years after surgery (average of 14 years) showed only one death 12 years after surgery related to coronary artery disease (CAD) (3,8%). Another 12 patients died of non-CAD. CONCLUSION: Patients with midterm associated LITA and RA patent grafts show similar optimal long-term patency rates of both types of grafts with excellent clinical outcome.

Long-Term Radial Artery Grafts with Previous Midterm Proven Patency

ABSTRACT Introduction: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of coronary artery bypass grafting (CABG). This grafting has led to an increased use of other arterial conduits, of which the radial artery (RA) is the most popular. Whether RA can have the same long-term patency as LITA is controversial. The objective of this study is to access the long-term clinical follow-up and, when available, the patency rate of RA grafts. Methods: Twenty-six patients from a previous study with critical stenosis in all target vessels underwent complete arterial CABG with LITA and RA grafts from 1996 to 2003. They all underwent midterm multidetector computed tomography after surgery with the association of at least one patent LITA and one patent RA graft. Results: Twelve patients (46%) are alive with no angina symptoms. Six patients underwent a second image exam 12 to 16 years (average of 14 years) after surgery, with a total of six LITA-LADA and 14 RA grafts with 100% patency rate. Clinical follow-up five to 23 years after surgery (average of 14 years) showed only one death 12 years after surgery related to coronary artery disease (CAD) (3,8%). Another 12 patients died of non-CAD. Conclusion: Patients with midterm associated LITA and RA patent grafts show similar optimal long-term patency rates of both types of grafts with excellent clinical outcome.

Techniques and Outcomes of the No-Touch Vein Conduit as a Y-Composite Graft.

Although the saphenous vein is a widely used conduit for coronary artery bypass grafting, revascularization using the saphenous vein as an aortocoronary bypass graft has shown disadvantages of lower long-term graft patency rates and subsequently worse clinical outcomes, compared with revascularization using the internal thoracic artery. Of the various efforts to overcome the limitations of vein conduit that are resulting from structural and functional differences from arterial conduit, recent technical improvement in no-touch vein composite graft construction and outcomes of revascularization using no-touch vein composite grafts based on the left internal thoracic artery will be discussed in this topic.

Impact of Single versus Double Clamp Technique on Blood Lactate Levels and Postoperative Complications in Coronary Artery Bypass Surgery

Abstract Introduction: Cardiopulmonary bypass (CPB) is associated with hyperlactatemia, which leads to adverse clinical outcomes. No study has examined the effect of different clamping techniques on postoperative hyperlactatemia (PHL). Thus, we aimed to evaluate the impact of two different techniques on PHL and the clinical outcomes in patients undergoing isolated coronary artery bypass surgery. Methods: This retrospective study included 100 patients who underwent isolated CPB either with single clamp technique (SCT, n=47) or double clamp technique (DCT, n=53). Demographic and preoperative laboratory data, as well as operative features and arterial blood lactate levels at the onset and at the end of CPB, were collected from patient charts. Results: Blood lactate levels collected at the end of CPB did not differ significantly between groups whereas intraoperative lactate increased significantly in both groups (P<0.005). PHL developed in 16 patients (32%). There was no meaningful difference in SCT and DCT in this regard. Left internal mammary artery was used more frequently in the DCT group than in the SCT group. While the cross-clamp time was significantly longer in the SCT group, there was no difference regarding CPB time. Among postoperative complications, only the incidence of stroke was significantly higher in the DCT group than in the SCT group (10.6% vs. 0%, P=0.020). CPB time, cross-clamp time and numbers of proximal saphenous graft and distal anastomosis showed a significant positive correlation with the postoperative lactate level. In the regression analysis, CPB time emerged as the only independent predictor of PHL (OR 1.04, CI 95% 1.01-1.07, P=0.011). Conclusion: There was no difference in postoperative blood lactate levels between SCT and DCT groups.

Impact of Single versus Double Clamp Technique on Blood Lactate Levels and Postoperative Complications in Coronary Artery Bypass Surgery.

INTRODUCTION: Cardiopulmonary bypass (CPB) is associated with hyperlactatemia, which leads to adverse clinical outcomes. No study has examined the effect of different clamping techniques on postoperative hyperlactatemia (PHL). Thus, we aimed to evaluate the impact of two different techniques on PHL and the clinical outcomes in patients undergoing isolated coronary artery bypass surgery. METHODS: This retrospective study included 100 patients who underwent isolated CPB either with single clamp technique (SCT, n=47) or double clamp technique (DCT, n=53). Demographic and preoperative laboratory data, as well as operative features and arterial blood lactate levels at the onset and at the end of CPB, were collected from patient charts. RESULTS: Blood lactate levels collected at the end of CPB did not differ significantly between groups whereas intraoperative lactate increased significantly in both groups (P<0.005). PHL developed in 16 patients (32%). There was no meaningful difference in SCT and DCT in this regard. Left internal mammary artery was used more frequently in the DCT group than in the SCT group. While the cross-clamp time was significantly longer in the SCT group, there was no difference regarding CPB time. Among postoperative complications, only the incidence of stroke was significantly higher in the DCT group than in the SCT group (10.6% vs. 0%, P=0.020). CPB time, cross-clamp time and numbers of proximal saphenous graft and distal anastomosis showed a significant positive correlation with the postoperative lactate level. In the regression analysis, CPB time emerged as the only independent predictor of PHL (OR 1.04, CI 95% 1.01-1.07, P=0.011). CONCLUSION: There was no difference in postoperative blood lactate levels between SCT and DCT groups.

Techniques and Outcomes of the No-Touch Vein Conduit as a Y-Composite Graft

ABSTRACT Although the saphenous vein is a widely used conduit for coronary artery bypass grafting, revascularization using the saphenous vein as an aortocoronary bypass graft has shown disadvantages of lower long-term graft patency rates and subsequently worse clinical outcomes, compared with revascularization using the internal thoracic artery. Of the various efforts to overcome the limitations of vein conduit that are resulting from structural and functional differences from arterial conduit, recent technical improvement in no-touch vein composite graft construction and outcomes of revascularization using no-touch vein composite grafts based on the left internal thoracic artery will be discussed in this topic.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics

Abstract Introduction: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. Methods: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. Results: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). Conclusion: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

A Simplest Method to Enhance the Benefits of Internal Thoracic Artery Distal Occlusion

Abstract A common element of internal thoracic artery harvesting techniques is a distal vascular clamp placement at the end of the procedure, not only to avoid bleeding, but also to increase the internal hydrostatic pressure, diameter and flow. The logic indicates that the placement of this clamp at the beginning of the dissection will allow the artery to benefit earlier from these advantages. After more than five years of experience, we present a modification in the classical technique of skeletonized harvesting of the internal thoracic artery, consisting of artery distal occlusion at the beginning of the procedure. Some of its advantages are discussed.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics.

INTRODUCTION: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. METHODS: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. RESULTS: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). CONCLUSION: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: the Conventional Procedure Performed Through a Smaller Incision.

Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Aortic valve replacement via right anterior mini-thoracotomy: the conventional procedure performed through a smaller incision

Abstract Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

A Simplest Method to Enhance the Benefits of Internal Thoracic Artery Distal Occlusion.

A common element of internal thoracic artery harvesting techniques is a distal vascular clamp placement at the end of the procedure, not only to avoid bleeding, but also to increase the internal hydrostatic pressure, diameter and flow. The logic indicates that the placement of this clamp at the beginning of the dissection will allow the artery to benefit earlier from these advantages. After more than five years of experience, we present a modification in the classical technique of skeletonized harvesting of the internal thoracic artery, consisting of artery distal occlusion at the beginning of the procedure. Some of its advantages are discussed.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique

ABSTRACT Purpose: To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team. Methods: Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel. Results: Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods. Conclusions: The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

Comparison of the Apoptotic Effects of Topically Applied Papaverine, Diltiazem, and Nitroprusside to Internal Thoracic Artery.

OBJECTIVE: To detect and to compare the apoptotic effects of intraoperatively topically applied diltiazem, papaverine, and nitroprusside. METHODS: Internal thoracic artery segments of ten patients were obtained during coronary bypass grafting surgery. Each internal thoracic artery segment was divided into four pieces and immersed into four different solutions containing separately saline (Group S), diltiazem (Group D), papaverine (Group P), and nitroprusside (Group N). Each segment was examined with both hematoxylin-eosin and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) method in order to determine and quantify apoptosis. RESULTS: Apoptotic cells were counted in 50 microscopic areas of each segment. No significant difference was observed among the four groups according to hematoxylin-eosin staining. However, the TUNEL method revealed a significant increase in mean apoptotic cells in the diltiazem group when compared with the other three groups (Group S=4.25±1.4; Group D=13.31±2.8; Group N=9.48±2.09; Group P=10.75±2.37). The differences between groups were significant (P=0.0001). No difference was observed between the samples of the diabetic and non-diabetic patients in any of the study groups. CONCLUSION: The benefit of topically applied vasodilator drugs must outweigh the potential adverse effects. In terms of apoptosis, diltiazem was found to have the most deleterious effects on internal thoracic artery graft segments. Of the analyzed medical agents, nitroprusside was found to have the least apoptotic activity, followed by papaverine. Diabetes did not have significant effect on the occurrence of apoptosis in left internal thoracic artery grafts.

Comparison of the apoptotic effects of topically applied papaverine, diltiazem, and nitroprusside to internal thoracic artery

Abstract Objective: To detect and to compare the apoptotic effects of intraoperatively topically applied diltiazem, papaverine, and nitroprusside. Methods: Internal thoracic artery segments of ten patients were obtained during coronary bypass grafting surgery. Each internal thoracic artery segment was divided into four pieces and immersed into four different solutions containing separately saline (Group S), diltiazem (Group D), papaverine (Group P), and nitroprusside (Group N). Each segment was examined with both hematoxylin-eosin and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) method in order to determine and quantify apoptosis. Results: Apoptotic cells were counted in 50 microscopic areas of each segment. No significant difference was observed among the four groups according to hematoxylin-eosin staining. However, the TUNEL method revealed a significant increase in mean apoptotic cells in the diltiazem group when compared with the other three groups (Group S=4.25±1.4; Group D=13.31±2.8; Group N=9.48±2.09; Group P=10.75±2.37). The differences between groups were significant (P=0.0001). No difference was observed between the samples of the diabetic and non-diabetic patients in any of the study groups. Conclusion: The benefit of topically applied vasodilator drugs must outweigh the potential adverse effects. In terms of apoptosis, diltiazem was found to have the most deleterious effects on internal thoracic artery graft segments. Of the analyzed medical agents, nitroprusside was found to have the least apoptotic activity, followed by papaverine. Diabetes did not have significant effect on the occurrence of apoptosis in left internal thoracic artery grafts.

Outcomes of surgical patch angioplasty of the coronary artery for diffuse coronary artery disease

Abstract Introduction: Diffuse coronary artery disease (CAD) has a poor prognosis and many patients are ineligible for conventional coronary artery bypass grafting (CABG). This study evaluated the 12-month outcomes of coronary artery reconstruction and surgical patch angioplasty of the coronary artery for diffuse CAD. Methods: A retrospective cohort study of patients who underwent CABG with surgical patch angioplasty of the coronary artery (reconstruction group) or standard CABG alone (standard group) at the Cardiovascular Surgery Department of the local Hospital between January 2014 and January 2016. Follow-up was censored at 12 months after surgery. Results: Cardiopulmonary bypass and aortic cross-clamping durations were longer in the reconstruction group (n=32) than in the standard group (n=125) (P<0.05). There were no differences in graft blood flow and postoperative levels of cardiac markers between the two groups (P>0.05). In the reconstruction group, one patient died; a vein graft showed occlusion. In the standard group, two patients died; one left internal mammary artery graft and three vein grafts showed occlusion. There were no significant differences in mortality, major adverse cardiovascular and cerebrovascular events, and patency between the two groups (P>0.05). Conclusion: Coronary artery reconstruction and surgical patch angioplasty of the coronary artery can be performed for diffuse CAD. Patient outcomes were not significantly different from those of patients who underwent standard CABG.

State-of-the-Art Pediatric Coronary Artery Bypass Surgery: a Literature Review.

OBJECTIVE: To examine the results of various myocardial revascularization techniques in pediatric patients to better understand the strategies for surgical treatment of coronary artery pathologies. METHODS: We analyzed 61 publications dedicated to the indications, methods, and results of coronary bypass surgery in children. Due to the small size of this cohort, case reports are also included in our review. RESULTS: The main indications for coronary bypass grafting in children are Kawasaki disease, myocardial revascularization as a necessary procedure during the congenital cardiac surgery, to manage intraoperative iatrogenic damage to coronary arteries, and homozygous familial hypercholesterolemia. The use of internal thoracic arteries as conduits for coronary bypass grafting in children with Kawasaki disease showed significantly better results in long-term functionality compared to autovenous conduits (87% and 44%, respectively, P<0.001). Acute and late coronary events after arterial switch operation for the transposition of the great arteries, anomalous origin of the left coronary artery from the pulmonary artery, and left main coronary artery atresia are the main congenital heart diseases where surgical correction involves interventions on the coronary arteries. CONCLUSION: The internal thoracic artery is a reliable and durable conduit that demonstrates proven growth potential in children.

State-of-the-art pediatric coronary artery bypass surgery: a literature review

Abstract Objective: To examine the results of various myocardial revascularization techniques in pediatric patients to better understand the strategies for surgical treatment of coronary artery pathologies. Methods: We analyzed 61 publications dedicated to the indications, methods, and results of coronary bypass surgery in children. Due to the small size of this cohort, case reports are also included in our review. Results: The main indications for coronary bypass grafting in children are Kawasaki disease, myocardial revascularization as a necessary procedure during the congenital cardiac surgery, to manage intraoperative iatrogenic damage to coronary arteries, and homozygous familial hypercholesterolemia. The use of internal thoracic arteries as conduits for coronary bypass grafting in children with Kawasaki disease showed significantly better results in long-term functionality compared to autovenous conduits (87% and 44%, respectively, P<0.001). Acute and late coronary events after arterial switch operation for the transposition of the great arteries, anomalous origin of the left coronary artery from the pulmonary artery, and left main coronary artery atresia are the main congenital heart diseases where surgical correction involves interventions on the coronary arteries. Conclusion: The internal thoracic artery is a reliable and durable conduit that demonstrates proven growth potential in children.