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Keywords: Coronary artery bypass grafting; Arterial grafting; Radial artery; Internal thoracic artery; Bilateral internal thoracic artery; Meta-analysis EN Coronary artery bypass grafting Arterial grafting Radial artery Internal thoracic artery Bilateral internal thoracic artery Meta-analysis 1 5 5 03/02/23 20230201 NES 230201 We are grateful for the opportunity to reply and comment on the Taggart I et al. i [[1]] and Freemantle I et al. i [[2]] pieces. Taggart I et al. i [[1]] raise the following points in their commentary: The mean age of the left internal thoracic artery (LITA) and radial artery (RA) group was younger than the other groups: this is incorrect. Apparent exclusion of the Radial Artery Patency and Clinical Outcomes (RAPCO) trial: RAPCO patients were excluded from the propensity score-matched analysis due to the high rate of missing baseline data which would have not allowed the application of a non-parsimonious model to calculate the propensity score. However, the RA effect is qualitatively consistent with the 30% mortality reduction with RA versus BITA at 15 years recently reported by the RAPCO trial and, despite all the described limitations, cannot be ignored or dismissed as implausible. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)—a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan–Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P  =   0.020), were less likely female (24.3% vs 14.3%, P  =   0.002) and diabetic (28.8% vs 15.2%, P  <   0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P  =   0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P  =   0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P  =   0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P  =   0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P  =   0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P  =   0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P  =   0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P >  0.99). CONCLUSIONS In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Bilateral internal thoracic artery (BITA) bypass provides long-term survival benefits over strategies that use single internal mammary arteries during coronary artery bypass grafting (CABG). However, the rate of adoption of this strategy remains very low. Moreover, optimal BITA configuration and the use of cardiopulmonary bypass still remain a matter of debate. We investigated the longterm results of a coronary revascularization strategy, utilising exclusively BITA-Y composite grafts using off-pump platform and sequential anastomoses. METHODS: From March 2000 to November 2010, all isolated CABGs (n = 2057 patients) were performed using an off-pump platform. Of these, 1240 patients had three-vessel coronary disease (60.3%), with severe coronary disease defined as >70% stenosis and three-vessel disease defined as the presence of 3 vessels with >70% stenosis, of which 784 (63.2%) were treated with two internal thoracic artery grafts in a composite fashion with a no-touch technique avoiding any manipulation of the ascending aorta. The primary end-point was the longterm survival and freedom from major adverse cerebral and cardiovascular events (MACCEs). The follow-up was completed using the annual anniversary method. RESULTS: The mean number of anastomoses per patient was 4.0. Hospital mortality occurred in 8 patients (1%). Ninety-day stroke, myocardial infarction and repeat revascularization rates were respectively 0.7, 0.6 and 0.3%. The mean follow-up was 6.6 ± 3.2 years and was obtained for 99% of the patients. The 5- and 10-year survival rates were 93.1 ± 1.6 and 83.8 ± 3.2%, respectively. Freedom from major adverse cardiac and cardiovascular event (MACCE) at 5 and 10 years was: cardiovascular event: 98.7 ± 1.6 and 96.1 ± 1.7%, documented ischaemia: 90.5 ± 2 and 80.2 ± 3.8%, revascularization: 94.0 ± 1.5 and 89.7 ± 2.5%, infarction: 98.1 ± 0.8 and 96.0 ± 1.6%. The patency of left and right internal thoracic artery in a BITA-Y configuration was 91.1 and 88.8% at 5 ± 3 years, respectively. CONCLUSION: Performance of an exclusive composite BITA off-pump revascularization strategy optimal and sustained long-term protection from MACCE. [ABSTRACT FROM AUTHOR]

Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. [Extracted from the article]

Background: Pedicled bilateral internal thoracic artery grafting (BITA) has been discouraged in historical high-risk groups such as diabetes mellitus (DM), renal failure, old age, and obesity because of reported high incidence of mediastinitis. However, considering the fact that there are abundant short and long-term results including angiography study about the conventional pedicled grafts, it might be worthwhile reassessing the results of pedicled BITA grafting with modern techniques by a disciplined surgical team before abandoning the method. Methods: Between September 1989 and September 1999, 1371 patients underwent isolated coronary artery bypass grafting (CABG) in Kumamoto central hospital. Of these patients, 558 patients who had bilateral ITA strategy (mean age 63.0±9.2 years, 13–79) were studied. The method of harvest of ITAs is consistently the use of conventional pedicled grafts. The use of bone wax and unnecessary electrocautery injury to the periostium or cartilage were avoided as much as possible. The only change in the surgical technique in the study period is the application of the pinpoint hemostasis for the presternal tissues from August 1997 (late period). Results: In late period, there were significantly more patients with sternal sepsis risk factors such as diabetes mellitus (early: late; 19.3% vs. 34.8%, P<0.00003), and renal failure (0.3 vs. 9.7%, P<0.0001) as well as patients who had gastroepiploic artery grafting (16.9 vs 48.5%, P<0.0001) and those who required aortic non-touch technique (2.1 vs. 7.9%, P<0.001). The percentage of the patients receiving BITA grafting among the isolated CABG patients increased in the late period from 31.7% (331/1043) to 69.2% (227/328) (P<0.001), reflecting that a more aggressive approach towards bilateral ITA and arterial grafting has been taken in the late period. Overall operative mortality was 1.1% (n=6). Mediastinitis occurred in seven patients (1.3%). Of these, only one mediastinitis occurred in late period (0.4%). No mediastinitis occurred in 23 chronic renal dialysis patients. Among the 143 DM patients, there were three mediastinitis (2.1%). Of three, only one occurred in late period, yielding 1.3% mediastinitis rate. There was one mediastinitis (0.7%) among 134 elderly patients more than 70 years of age. Univariate analysis identified obesity as a risk factor for mediastinitis. And there was a trend of decreasing mediastinits in late period but did not reached a statistical significance (P<0.2). Multivariate analysis identified obesity and arteriosclerosis obliterates as independent risk factors. Neither diabetes mellitus, dialysis, female gender, nor old age were significant independent predictors of mediastinitis. Despite the significantly high percentage of high-risk patients in late group, there were no significant difference in mortality and morbidity between the two groups. Conclusion: Pedicled BITA grafting is feasible with acceptable morbidity and shouldn''t be abandoned even in high-risk patients such as DM, old age, and dialysis, especially combined with pinpoint-hemostasis, avoiding excessive use of bone wax, and strict aseptic technique. These point require a surgical team familiar with these techniques to maintain adequate skills in conduit procurement. [Copyright &y& Elsevier]

Coronary artery bypass grafting, Bilateral internal thoracic artery Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. [Extracted from the article]

We report our initial experience of an off-pump total arterial minimally invasive coronary arterial bypass grafting (MICS CABG) with the use of bilateral internal thoracic arteries (BITA) and the right gastroepiproic artery. A 47-year old male with renal dysfunction secondary to diabetes mellitus was admitted for heart failure due to severe triple-vessel disease. Off-pump MICS CABG with total arterial grafts was elected because the patient refused to undergo median sternotomy due to the strong desire to regain the baseline function promptly. Total arterial grafts were selected to maximize the potential long-term outcome. There were no postoperative complications except temporary dialysis. Postoperative coronary computed tomography revealed the patency of all grafts. Our experience suggests that BITA can be safely harvested under direct vision in MICS CABG. Total arterial graft revascularization with BITA via minimally invasive approach may offer the benefits of MICS CABG while providing the undetermined but potentially superior conduit longevity of arterial grafts. [ABSTRACT FROM AUTHOR]

The author reflects on prospects of retrospective studies that compares the effectiveness of bilateral internal thoracic arteries (BITA) grafting with single internal thoracic arteries (SITA) grafting.