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Introduction Function of naturally existing internal mammary artery (IMA)-to-coronary artery anastomoses has been shown by augmented blood supply to the coronary collateral circulation in response to IMA occlusion. Theoretically, this functional connection is invertible and can cause coronary steal, the verification of whose hypothesis would provide alternate proof to the mentioned functional evidence. Method This was a prospective observational study including 40 patients with chronic coronary syndrome and IMA occlusion, and 40 propensity score matched controls (placebo group) without IMA occlusion. Primary study endpoint was the inter-group difference in coronary collateral function (i.e., collateral flow index, CFI) as obtained at 30, 45 and 60 seconds following a proximal coronary artery balloon occlusion. CFI is the ratio between simultaneous mean coronary occlusive pressure divided by mean aortic pressure both subtracted by central venous pressure. To provoke a steal phenomenon, upper limb hyperemia was induced by upper arm blood pressure cuff deflation following a 5-minute supra-systolic inflation ipsilateral to the sensor-wired coronary artery with release immediately after the first CFI measurement. Results Between the first and the second CFI-measurement, CFI change (i.e., CFI@45s minus CFI@30s) was absent in the verum group while there was CFI recruitment in the placebo group: 0.000±0.023 and +0.009±0.013, respectively; p=0.032. Conclusion Among patients with artificial IMA occlusion, induction of ipsilateral upper limb hyperemia provokes extracardiac coronary steal as expressed by temporarily absent collateral recruitment as it normally takes place without upper limb hyperemia. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Sciences Foundation

Background The gold standard for coronary artery bypass grafting to the left anterior descending artery is use of the left internal mammary artery. Better long-term survival has been reported using bilateral internal mammary arteries compared to left internal mammary artery only, but many surgeons are reluctant to employ bilateral internal mammary arteries in coronary artery bypass grafting. This study aimed to evaluate the effectiveness and safety of bilateral internal mammary artery use. Methods From 2014 to 2017, 1703 patients underwent coronary artery bypass grafting in our institute. Of these, 772 met the inclusion criteria and were randomly assigned to receive bilateral ( n = 387) or left ( n = 385) internal mammary artery grafts. The mean age was 67.1 ± 6.0 years (range 48–85 years) and 474 (61.4%) were male. The mean number of diseased vessels was 3.1 ± 0.9, and mean EuroSCORE II was 3.4% ± 1.1%. Results Hospital mortality was 1.2% in the left internal mammary artery group vs. 1.8% in the bilateral internal mammary artery group ( p = 0.55). There was no difference in procedure-related complications between groups. Mean follow-up was 65.9 months. Survival in the bilateral internal mammary artery group at 1, 3, and 5 years was 98.7%, 98.7%, and 94.8% vs. 98.1%, 98.1%, and 90.9%, respectively, in the left internal mammary artery group ( p = 0.63). Conclusion Application of bilateral internal mammary arteries in coronary artery bypass grafting is safe and effective, with comparable midterm results to those with the left internal mammary artery only.

Background Single-inflow coronary bypass through left internal thoracic artery and Y graft is effective in myocardial revascularization, but left sublavian diseases may affect its safety. Aim of the study To assess that, in presence of a composite Y graft, issues involving the origin of the left internal thoracic artery are relatively easy to manage, even in reoperations. Methods A critical stenosis of the subclavian artery involving the origin of a bilateral internal thoracic artery Y graft was bypassed using a free radial artery graft. Results Bypass was performed between the left thoracic artery and the ascending aorta, off-pump and with excellent results. Conclusions In consideration of the excellent long term results of total arterial revascularization, radial artery is a feasible graft option, even in case of a composite Y graft in place.

We describe a case of severe peripheral vascular disease in a patient presenting for coronary artery bypass grafting (CABG). There was an occlusion of the abdominal aorta with collaterals from the internal mammary arteries (IMA) and inferior epigastric arteries (IEA) supplying the lower limb. Off-pump CABG was carried out without harvesting the IMA. In presence of concomitant severe peripheral vascular disease, lower limb blood flow should be evaluated with Doppler ultrasound, and in selected cases, computed tomography angiogram should be performed to rule out IMA-IEA collaterals dependent limb perfusion.

Recent trends in cardiac surgery have encouraged total arterial coronary revascularization, citing advantages in long-term patency and overall mortality. Often relying on sequenced, composite, and free-graft strategies, total arterial coronary revascularization is limited by conduit availability and surgical complexity. We present the use of bilateral internal mammary artery grafts to achieve nonsequential 3-vessel total arterial coronary revascularization using the preserved distal bifurcation of the right internal mammary artery. Utilization of distal internal mammary artery branches should be considered a viable strategy in select patients and can broaden the opportunities for total arterial coronary revascularization in patients with multivessel coronary disease.

Absztrakt: A tünetes koszorúér-betegség kezelésében ma is kiemelkedő szerepet játszanak a revascularisatiós műtétek (coronary artery bypass grafting – CABG). Az első beavatkozások elvégzése óta eltelt több mint ötven év alatt számos klinikai megfigyelés igazolja, hogy a koszorúér-áthidalásra az arteria mammaria interna (IMA) használható a legkedvezőbb eredménnyel. Az IMA szövettani struktúrája és élettani tulajdonságai ellenállóvá teszik az eret az érelmeszesedéssel szemben. Cikkünkben a Magyarországon IMA-graft felhasználásával elsőként végzett CABG-műtétről emlékezünk meg, egyúttal az IMA kedvező tulajdonságait az irodalomban eddig közölt leghosszabb (harmincöt éves) utánkövetéses coronarographia eredményeivel illusztráljuk. Az eset alátámaszthatja azt a feltételezést is, hogy a mammariagraft prosztaciklintermelése megvédi a kiáramlási pályát az atherosclerosis progressziójától. Ennek igazolására nagy esetszámú vizsgálat javasolható, amely sztentimplantációval hasonlítaná össze az IMA-graft feltételezhető védőhatását a kiáramlási pályán. A hosszú távú követés során a bal coronaria elülső leszálló ágának (LAD) sztentelését versus az arteria mammaria interna graftnak a felhelyezését követően a LAD kiáramlási pályájának alakulását kellene értékelni. Orv Hetil. 2020; 161(9): 354–358.

Internal mammary artery graft dissection is a rare condition and is usually caused by iatrogenic complications or mechanical stress. We experienced a case of acute myocardial infarction due to spontaneous internal mammary artery graft dissection that was triggered by emotional stress and was successfully treated by percutaneous intervention using drug-eluting stents. (Level of Difficulty: Beginner.), Graphical abstract, Internal mammary artery graft dissection is a rare condition and is usually caused by iatrogenic complications or mechanical stress. We experienced a…

Introduction Arterial graft physiology influences the long‐term outcome of coronary artery bypass grafting (CABG). We studied factors that can affect the overall resistance to flow using internal mammary artery grafting to the left anterior descending artery. Methods This was a prospective, nonrandomized observational study of 100 consecutive patients who underwent elective on‐pump isolated or combined valve surgery and CABG. Coronary stenoses were assessed using conventional and quantitative coronary angiography assessment. The flow and pulsatility index (PI) of the grafts were assessed by transit‐time flowmetry during cardioplegic arrest and at the end of the operation. Fractional polynomials were used to explore linearity, followed by multivariable regression analysis. Results Univariate analysis demonstrated higher flows at the end of the operation in patients who had higher flows with the cross‐clamp on (P

Summary This meta-analysis was designed to assess the effect of the use of arterial conduits (ACs) versus great saphenous vein (GSV) grafts as a third conduit for revascularization of the right coronary artery system, in addition to the bilateral internal mammary artery on the left coronary artery. PubMed and OVID’s version of MEDLINE were searched from January 2000 to September 2017 for relevant publications. The primary end point was the long-term mortality rate. The secondary end point was early mortality, defined as either in-hospital death or death within 30 days after the operation. Meta-regression was used to evaluate the effect of female gender and diabetes on the primary and secondary outcomes. A total of 10 studies (4121 patients) were selected for the systematic review and meta-analysis comparing ACs (1619) versus the GSV (2502), 6 (2548) comparing the GSV (2548) versus the right gastroepiploic artery (1023) and 5 comparing the GSV (2548) versus the radial artery (596). The pooled analysis did not show any difference between ACs and the GSV in terms of long-term mortality rates [hazard ratio (HR) = 0.75, 95% confidence interval (CI) = 0.56–1.01; P = 0.061]. When using the leave-one-out analysis, after the exclusion of 1 study (outlier), ACs were significantly associated with lower long-term mortality rates (HR = 0.67, 95% CI = 0.54–0.83; P

In coronary artery bypass grafting (CABG), the use of an internal mammary artery (IMA) to graft the left anterior descending coronary artery (LAD) improves survival and reduces the need for repeat revascularization. The other IMA, radial artery (RA), and saphenous vein (SV) have contested to complete the surgical revascularization. For that purpose, SV remains the most commonly used conduit despite current evidence in favor of arterial grafts. To determine which conduit is best for grafting the second most important coronary artery, Buxton and colleagues have recently published the long term results of their “Radial Artery Patency and Clinical Outcomes (RAPCO)” trial.

OBJECTIVE To compare postoperative and long-term results (angina, myocardial and cerebrovascular events and coronary re-intervention) using single versus bilateral internal mammary arteries (SIMA vs. BIMA) in the setting of off-pump revascularisation (OPCAB) within a single-surgeon practice. METHODS Retrospective analysis of all isolated OPCAB performed in our institution by a single surgeon in the last 12 years.Two groups were analysed: SIMA (n = 681) and BIMA (n = 342). A propensity score matching was performed to compare the groups, reducing the sample to 684 patients.Follow-up (mean 6.5 ± 3.5 years) was done by telephone interviews or clinical visits, registering also late mortality and coronary re-intervention. Outcomes were compared to literature. RESULTS Demographic characteristics differed between groups, with BIMA offered predominantly to non-diabetic younger males (mean 59.4 years) with less comorbidity. In-hospital mortality was 2% for the SIMA group and 1% for BIMA (p = 0.18). Long-term mortality was also higher for the SIMA group (2% vs. 1% at 1 year, p = 0.22 and 16% vs. 5% at 5 years, p < 0.001). Sternal wound infection was similar in both groups (2-3%). Long-term follow-up revealed good freedom from angina (94%) with low rates of neurological and myocardial events (3%) or need for repeated revascularisation (3%) in both groups. CONCLUSION BIMA offers long-term survival benefit with similar postoperative complications. Rates of deep sternal wound infection were comparable between the two groups.Excellent outcomes can be achieved with OPCAB BIMA in real world practice with adequate patient selection.

ObjectivesDouble (bilateral) mammary artery in situ revascularization seems less attractive to surgeons because of limited mammary length of right mammary artery, scare, or no means of its length estimation.MethodsWe’ve selected patients who have used bilateral mammary artery for revascularization and divvied them into two groups: in situ and y-graft groups. We have used preoperative chest x-rays to build a predictive model with neural networks that could predict feasibility of in situ bilateral mammary revascularization.ResultsThe predictive model was able to predict a positive outcome with 96% percent accuracy (p < 0.01). Models sensitivity and specificity were 96% and 95% respectively. Neural networks can be used to predict double mammary feasibility using chest x-rays. Model is capable of predicting positive outcomes with 95% accuracy.ConclusionsChest x-ray base model can accurately predict the feasibility of in situ bilateral mammary artery revascularization.

Background: Hybrid coronary revascularization (HCR) treats multivessel coronary artery disease by combining a minimally invasive surgical approach to the left anterior descending artery with percutaneous coronary intervention for non–left anterior descending diseased coronary arteries. The objective of this study is to compare HCR and conventional coronary artery bypass graft (CABG) surgery medium-term outcomes. Methods: Data from multivessel disease patients in New York’s cardiac surgery and percutaneous coronary intervention registries in 2010 to 2016 were used to compare mortality and repeat revascularization rates for HCR and conventional CABG after using propensity matching to reduce selection bias. Results: There was a total of 303 HCR (0.80%) patients and 37 556 conventional CABG patients after exclusions. After propensity matching, the respective median follow-up times were 3.72 years and 3.76 years. There was no difference between HCR and conventional CABG in survival at 6 years (80.9% versus 85.8%%, adjusted hazard ratio, 1.44 [0.90–2.31]), but HCR had higher mortality excluding deaths during the first year (adjusted hazard ratio, 1.88 [1.10–3.23]). Conventional CABG patients were more likely to be free from repeat revascularization at 6 years than HCR patients (88.2% versus 76.6%; hazard ratio, 2.22 [1.44–3.42]). Conclusions: HCR is rarely performed for patients with multivessel coronary artery disease. HCR and conventional CABG had no different 6-year mortality rates, but HCR had higher mortality after 1 year and higher rates of subsequent revascularization that were caused by both the need for repeat revascularization in the left anterior descending artery where minimally invasive CABG was performed, and in the coronary arteries where percutaneous coronary intervention was performed. Graphic Abstract: A graphic abstract is available for this article.

Purpose The left internal mammary artery in coronary artery bypass grafting (CABG) is considered to be an important intraoperative quality indicator with excellent long-term results. The purpose of this study is to compare the early outcomes of CABG with and without the left internal mammary artery (LIMA) in the South Asian population and to look for the utilization of LIMA as per the recommendations of the Society of Thoracic Surgeons in a developing country. Materials and methods A retrospective review was carried out for all patients who underwent CABG from 2010 to 2015. Patients were divided into two groups on the basis of whether LIMA was used (Group I) or not used (Group II) as a conduit. Both groups were further subdivided into elective and urgent. Preoperative, intraoperative, and postoperative variables were recorded and compared. Results After exclusion, a total of 2619 patients underwent isolated CABG surgery during the required duration. The LIMA was used in 94% of the patients (n=2472) while 147 patients underwent CABG without LIMA. The use of LIMA was associated with significantly lower mortality (2% LIMA vs 8.8% no LIMA), as well as a decrease in major comorbidity, stroke, and prolonged ventilation. In the subgroup analysis, LIMA usage in elective and urgent cases was associated with significantly lower mortality (elective 1.6% LIMA vs 7.4% No LIMA) (urgent 4.8% LIMA vs 15.7 % no LIMA)) and major morbidity. Conclusion The outcomes of CABG procedures without LIMA were not encouraging. Our results support compliance with standard adult cardiac surgery quality-of-care guidelines.

Background Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD. Methods We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD). Results The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p Conclusions The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.

Here we report a rare case of atypical Kawasaki disease (KD) in a patient presenting with systemic arteritis affecting the coronary arteries, brain, and internal mammary arteries (IMAs). A 25-year-old man was referred to our institute with angina pectoris. Coronary angiography revealed coronary artery aneurysms and triple-vessel disease. Three-dimensional brain computed tomography showed multiple small saccular aneurysms on the vertebral and posterior inferior cerebellar arteries. Off-pump coronary artery bypass (OPCAB) grafting ​​​​​​was performed; however, the bilateral IMAs were tightly adhered and not patent. OPCAB was completed using the bilateral radial and gastroepiploic arteries. This is the first report of KD involving the IMA.

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Background: In Situ Skeletonized Bilateral Internal Mam-mary Arteries (BIMA) grafting to the left coronary artery can be used in almost all surgical revascularization patients. We sought to evaluate our early and mid-term patency rate of both arteries to different targets of the left coronary artery territory.Aim of Study: Assess the early and mid-term outcome of using the In Situ BIMA to revascularize the left coronary artery territory and the difference in the outcome between Left Internal Mammary Artery (LIMA) and Right Internal Mammary Artery (RIMA )grafting to the Left Anterior De-scending coronary artery (LAD) as a main target for ischaemic patients scheduled for CABG. We evaluated this technique using the BIMA as skeletonized conduits for technical issues and on beating heart to standardize the methodology.Patients and Methods: Retrospective data collection for two groups of consecutive patients from Jan. 2012 to Jan. 2016 with revascularization to two or more sites in the territory of left coronary artery and In situ BIMA were used. Arrange-ment of the bilateral IMAs is usually decided according to the coronary anatomy, quality and flow of the grafts. (GroupI) (100 patients), LIMA was used to supply the LAD and (Group II) (33 patients), RIMA was used to supply the LAD. Direct coronary angiography was done for post-operative symptomatic patients in both groups (8/100) (8%) and (3/33) (9%) (ns) respectively. Myocardial Perfusion Imaging (MPI) was done to the rest of both groups after written consents.Results: There were no differences in the main pre oper-ative demographics. No significant intraoperative difference between the LIMA and RIMA concerning the diameter, wall thickness and the occurrence rates of atherosclerosis. The average total numbers of anastomoses and bilateral IMA anastomoses per patient were (3.2±0.9) and (2.6±0.6), respec-tively. Significant difference between both groups for the number of BIMA anastomoses (2.2±0.6 vs. 2.7±0.8) (p

Background: The incidence and potential factors influencing deep sternal wound infection (DSWI) in a cohort of patients undergoing coronary artery bypass grafting (CABG) using skeletonized bilateral internal thoracic artery (BITA) was explored. Furthermore, we studied influence of DSWI on long-term survival, major adverse cardiac events (MACEs) and repeat coronary revascularization (RCR).Methods: The study cohort consisted of 1,325 consecutive patients who were divided in two groups: patients experiencing DSWI (n=33, group 1) and those who did not have sternal infection (n=1,292, group 2). A logistic regression model was employed to find predictors of DSWI whereas Cox regression and a competing risk models were carried out to test predictors of late death, MACE and RCR, respectively. Follow up was 100% complete and ranged from 1 to 245 months. Median follow-up was 103 months (IQR, 61 to 189 months). Cumulative follow-up was 16,430 patient years.Results: The incidence of DSWI was 2.4%. Multivariable logistic regression analysis found any single independent predictor of DSWI. However, the association of peripheral vascular disease (PVD) and diabetes increased the risk by 1.4 and 1.6 times. When DM was associated with obesity the risk increased by 2.1 and 2.6 times compared to the single factors, respectively. Obese female patients were at a 1.6-fold higher risk when compared to the association of DM with obesity. DSWI was not an independent predictor of long-term survival (HR, 2.31; 95% CI: 0.59–9.12), RCR (SHR, 2.89; 95% CI: 0.65–10.12), or MACE (SHR, 1.98; 95% CI: 0.44–8.56).Conclusions: With an accurate patient selection (i.e., exclusion of obese diabetic females) and strict DM control BITA represents a first choice for most of CABG patients, even at high risk for DSWI. The occurrence of DSWI does not influence long-term survival and late outcomes. Our findings should be confirmed by further larger research.

Internal mammary arteries (IMAs), via angiogenesis/arteriogenesis, have great potential for developing collaterals. This generally occurs when ischemia involves the inferior limbs or heart. Although this phenomenon may be spontaneous, it seems to be promoted by iatrogenic or voluntary occlusion of the IMAs. We present a patient who underwent triple coronary artery bypass grafting with two saphenous vein grafts and a free-graft left IMA and suffered an acute myocardial infarction 6 weeks after surgery. Emergency coronary angiography revealed occlusion of the grafts and an amazing branch arising from the proximal stump of the surgically-cut and clipped IMA, leading to the anterior wall of the heart, functionally creating an effective natural bypass, probably stimulated both by anterior wall ischemia and interrupted flow within the proximal left IMA.

INTRODUCTION Coronary artery bypass graft (CABG) surgery remains the reference standard in the treatment of multivessel coronary disease. Several studies have shown that CABG with bilateral internal mammary arteries (BIMA) has better results in long-term survival. METHODOLOGY A retrospective study was conducted on CABG surgeries with BIMA from January 2012 to December 2015 in the National Cardiovascular Institute, INCOR, EsSalud, Peru. The objectives were to determine the mortality and major cardiovascular events at 30 days follow-up. RESULTS Of the 36 patients subjected to CABG surgery with BIMA, the 30-day mortality was 0%, with major cardiovascular events occurring in 5.56% of patients (Stroke 0%, postoperative myocardial infarction 5.56%, need of new coronary intervention 0%). The incidence of mediastinitis and/or sternal reconstruction was 0%. Superficial wound infection was observed in 7 patients, with there being no significant difference between diabetics and non-diabetics (25% vs. 16.66%, OR=3.3, P=.88), or between patients with or without overweight (19.23% vs. 20%, respectively, OR=.95; 95% CI, P=.68). CONCLUSIONS CABG surgery with BIMA is a safe procedure, with low rates of mortality and major cardiovascular events in the short-term.

Background Previous studies reported the strategy of in situ skeletonised right internal mammary artery (RIMA) grafting to the left anterior descending artery (LAD). However, few reports have focused on assessing RIMA graft patency rate after grafting to the LAD. This study aimed to assess mid-term graft patency of in situ skeletonised RIMA grafting to the LAD versus in situ skeletonised left internal mammary artery (LIMA) grafting to the LAD in a single-centre propensity-matched study. Materials and methods After propensity score matching, 185 pairs of patients who received first, scheduled, isolated off-pump coronary artery bypass grafting (OPCAB) surgery were assigned to either a RIMA group (patients who received retrosternal crossover in situ skeletonised RIMA-LAD grafting with additional conduits grafting) or a LIMA group (patients who received in situ skeletonised LIMA-LAD grafting with additional conduits grafting). The primary endpoint was mid-term internal mammary artery (IMA) graft failure after grafting to the LAD and was determined by coronary computed tomography angiography examination. The secondary endpoints were mid-term all-cause mortality and the composite mid-term clinical outcome. Results The graft patency rate of in situ skeletonised RIMA-LAD graft was not inferior to in situ skeletonised LIMA-LAD graft during a follow-up period of 36.6 ± 12.1 months (97.2% vs. 96.6%, p = 0.752). Kaplan-Meier curves showed a similar cumulative IMA graft failure between the two groups (χ 2 = 0.092, Log-rank p = 0.762). And Cox regression analysis revealed that grouping was not an independent factor for follow-up IMA graft failure after grafting to the LAD (HR = 0.93, 95% CI: 0.68–2.13). Additionally, Kaplan-Meier curves showed similar cumulative survival free from adverse events between the two groups (χ 2 = 2.365, p = 0.124, respectively). Conclusions Revascularisation of the LAD using a skeletonised RIMA resulted in excellent mid-term graft patency and clinical outcomes.

Coronary artery bypass grafting remains one of the most commonly performed major surgeries, with well-established symptomatic and prognostic benefits in patients with multivessel and left main coronary artery disease. This review summarizes current indications, contemporary practice, and outcomes of coronary artery bypass grafting. Despite an increasingly higher-risk profile of patients, outcomes have significantly improved over time, with significant reductions in operative mortality and perioperative complications. Five- and 10-year survival rates are ≈85% to 95% and 75%, respectively. A number of technical advances could further improve short- and long-term outcomes after coronary artery bypass grafting. Developments in off-pump and no-touch procedures; epiaortic scanning; conduit selection, including bilateral internal mammary artery and radial artery use; intraoperative graft assessment; minimally invasive procedures, including robotic-assisted surgery; and hybrid coronary revascularization are discussed.

Objective: To assess the pressure flow relationship of the internal mammary artery (IMA) in situ, after skeletonisation and after anastomosis to the left anterior descending (LAD) coronary artery, using either halothane, sevoflurane or propofol as an anaesthetic agent. Methods: 15 Pigs were used in total, five received halothane, five sevoflurane and five propofol as an anaesthetic agent. The flow in the internal mammary artery in each of the pigs, was measured at various arterial pressures. This was done with the IMA in situ, then after dissecting the artery off the chest wall using the skeletonisation technique and finally after offpump grafting to the left anterior descending coronary artery. Results: The pressure flow relationship of the internal mammary artery after skeletonisation was found to be linear (r=0.8650). The pressure flow correlation after grafting the skeletonised internal mammary artery to the left anterior descending coronary artery was found to be similarly linear (r=0.8766). In the sevoflurane subgroup, with the IMA still in situ, a degree of autoregulation was found to be present, but after skeletonisation this was subsequently lost (p=0.011). Conclusions: The pressure flow relationship in the internal mammary artery after skeletonising the vessel and after OPCAB anastomosis to the LAD was found to be linear. In the subgroup of pigs receiving sevoflurane, some degree of autoregulation was demonstrated in the in situ IMA. This remnant of autoregulation was lost after skeletonisation and after grafting of the vessel to the left anterior descending coronary artery. SAHeart 2009; 6:222-228

Off-pump, total arterial coronary artery bypass grafting (CABG) is a technically demanding myocardial revascularization strategy that combines the long-term benefits of multi-arterial CABG with a no-touch aortic technique. Dedicated training and mentoring are essential in order to learn how to successfully perform this challenging surgical procedure. In this video-tutorial, we present a complete step-by-step approach to safely reproduce this procedure. We will cover the harvesting techniques adopted for internal mammary arteries (ITAs) and for the radial artery (RA), and the several options to construct and deploy multi-arterial composite grafts ("T/Y", "K", and "I" grafts), with a focus on minimizing aortic manipulation.

Back Ground: The internal mammary artery was the most effective conduit for coronary artery bypass surgery and it was associated with significantly better long term patency, survival, and reintervention rates compared to other bypass conduits. The internal mammary artery (IMA) is not immune to atherosclerosis. IMA interventions constitute low percentage out of all coronary interventions. In addition to the tortuous course, the long length of IMA than native coronaries adds procedural difficulties to IMA PCI.Aim: To analyze the acute outcomes of Percutaneous intervention procedures to the internal mammary artery and to found any association with clinical and demographic parameters to the procedural success at a single tertiary care hospital from IndiaMaterials And Methods: This study was a retrospective analysis of post CABG patient who required and undergone the IMA intervention. We collected the clinical, demographic and procedural details of the IMA intervention. We defined as failure of the procedure when the stent could not be delivered to the lesion site through IMA.Results: Total 21 patients were included in this retrospective analysis. Mean age of the study population was 56.1± 9.98 years and 18 patients were male. Twelve (57.1%) patients presented with chronic stable angina and six (28.6%) had Left ventricular dysfunction (LVD) (mild LVD in 5 and one patient had severe LVD). Mean stent diameter was 2.75±0.442 mm and the mean stent length was 17.71 ±5.63 mm. Transient slow flow occurred in 5 patients, but the end result of PCI procedure was good in them. In 4 (19.1%) patients stent could not be delivered. No LIMA dissections were observed. On binary logistic regression, there was no significant difference between successful PCI to the failed PCI with respect to age (p=0.9, z=0.16, OR=0.99, 95%CI=0.83to1.17), male sex (p=0.7, Z=0.34, OR=1.68), type of presentation (p=0.7, Z=0.38, OR=1.60, 95%CI= 0.14 to 17.7), presence of Left ventricular dysfunction (p=0.7, z=0.38, OR=1.60, 95%CI= 0.14 to 16.97) and with pre-dilatation during PCI (p=0.9, z=-0.16, OR=0.99).Conclusion: PCI to the internal mammary artery was associated with 80.95% of success. Not able to deliver the stent to the target lesion was the major problem with LIMA PCI, in addition, to slow or no flow. The success or failure of PCI were not dependent on the age, sex, type of presentation or LV dysfunction.

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.

Regarding to coronary artery bypass grafting (CABG), the end-to-side anastomosis (ESA) has been performed as a gold standard. Recently, the effectiveness of the distal side-to-side anastomosis (SSA) in CABG using internal mammary artery has been reported. The benefit of SSA comparing to ESA also has been disclosed by computing simulation. However, use of SSA by venous conduit for individual CABG has not been reported. In this study, we investigated feasibility of SSA. From January 2013 to October 2014, we conducted 114 CABGs. There were 92 venous distal anastomoses without sequential anastomotic site (61 SSA and 31 ESA). The anastomosis was evaluated before discharge and at 1 year after the procedure by angiography or multi-detector row computed tomographic coronary angiography. The median values for time to anastomosis were 13 min in the two group (p = 0.89). There was no revision of anastomosis in both groups. Additional stitches for hemostasis were required significantly less in SSA than ESA (18.0 vs 45.2 %, respectively, p

The internal mammary artery (IMA) has been used as a systemic-to-pulmonary artery shunt in selected patients with congenital heart disease. Growth and development of hypoplastic pulmonary arteries have been described. We discuss the surgical and anesthetic management of an infant with an atretic-thrombosed right pulmonary artery originating from the ascending aorta in whom the IMA was used to create a systemic-to-pulmonary artery shunt after failure of a previous shunt and later successful pulmonary artery reconstruction. The IMA should be considered as an alternative conduit in patients requiring a systemic-to-pulmonary artery shunt for growth of pulmonary arteries.

Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.

Background and Aims: Skeletonization has been proposed as a technique to minimize the risk of sternal devascularization during bilateral internal thoracic artery harvest for coronary artery bypass grafting. The impact of this strategy on late radiologic pleuropulmonary changes has not been addressed. Material and Methods: Post-operative chest radiographs from patients ( n = 253 per group) undergoing bilateral internal thoracic artery harvest using skeletonized and non-skeletonized techniques were reviewed by blinded radiologists. The primary outcome was the incidence of atelectasis and pleural effusion. Multivariable linear regression models were derived to assess the relationship of radiologic pleuropulmonary outcomes to patients and operative variables. Results and Conclusion: Patients in the skeletonized group were older ( p

Summary Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Such a combination poses a considerable technical challenge for revascularization because of multiple comorbidities and higher surgical risk. Here, we conducted a literature review on different revascularization strategies, on-pump and off-pump bypass grafting outcomes, harvested internal mammary artery numbers, and potential complications (e.g., steal syndrome) in managing patients with ESRD and comorbid CAD.

A 14-year-old male patient with a history of atypical Kawasaki disease at age 2 presents with triple vessel giant coronary aneurysms. Over the last several years, he began experiencing angina and dyspnea on exertion, which was a result of fully occluded right coronary and left circumflex arteries and 90% stenosis in the left anterior descending artery. He underwent off-pump coronary artery bypass using the left and right internal mammary arteries. At 18-month follow-up, there is no evidence of ischemia. Off-pump bypass is a feasible option for surgical management of the stenotic and occlusive complications of Kawasaki disease.

Diffuse alveolar haemorrhage (DAH) is defined asbleeding into alveolar spaces, and it is caused by the disruption of thealveolar-capillary basement membrane. While various diseases are associatedwith the development of DAH, we describe a rare case of alveolar haemorrhageafter a full arterial revascularisation procedure via bilateral internal mammaryarteries., Difüz alveolar hemoraji (DAH) alveolar-kapillerbazal membranın bozulmasına bağlı olarak gelişen alveolar boşluğa kanama olaraktanımlanır. Çeşitli hastalıklar DAH’ın gelişimi ile ilişkiliyken, bilateralinternal mammarian arter ile tam arteryal revaskülarizasyon sonrası gelişennadir bir alveolar hemoraji olgusu tanımladık.

Coronary artery disease (CAD) has become a common diagnosis. Managing the symptoms of CAD continues to be an ongoing dilemma requiring optimal medication management or potential revascularization with either percutaneous coronary interventions or coronary artery bypass grafting (CABG). We present a case of debilitating refractory angina in a patient with severe CAD after optimal medical therapy and CABG secondary to coronary steal phenomenon via the left internal mammary artery conduit supplying a large unligated side branch to the internal chest wall. While current data are inconclusive on this phenomenon, our patient had complete resolution of angina following coil embolization of unligated side branch of the internal mammary artery.

Background There remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta‐analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long‐term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12–1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17–1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55–0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92–2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long‐term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Cardiac tissue, or heart muscle, relies on blood supply from coronary arteries for oxygen and nutrient delivery. When the coronary arteries are narrowed, or blocked, restoration of blood flow is essential for preservation of heart tissue and avoidance of myocardial infarction (i.e., dead heart muscle). Coronary artery bypass grafting (CABG) has long been the standard surgical treatment option for patients with CAD. The principle of the operation is to create a new route for nutrients and oxygen-rich blood to reach the heart muscle by using a conduit, either a vein or an artery. The most commonly used conduits are the internal mammary arteries or the great saphenous veins. In this chapter, we shed light on this important surgical technique, with emphases on its indications, outcomes, and complications. We also highlight some special considerations and discuss the emergence of new, less invasive techniques like minimally invasive bypass procedures, hybrid CABG, as well as the evolution of technology to include robotic techniques.

The ideal surgical approach is unclear for patients with aortic coarctation whom have other associated coronary artery disease or other cardiac pathologies. A 69 year-old male was admitted to our hospital with carotid artery stenosis and coronary artery disease. During routine preoperative procedures cardiologist revealed an aortic coarctation. Left internal mammary artery was dilated due to coarctation but even so it was used as a graft for coronary artery bypass grafting. We aimed to report our approach for this patient., Eş zamanlı aort koarktasyonu ile koroner arter hastalığı gibi diğer kardiyak patolojileri olan hastalarda ideal tedavi yaklaşımı konusunda fikir birliği bulunmamaktadır. 69 yaşında erkek hasta hastanemize karotid arter darlığı ve koroner arter hastalığı tanılarıyla başvurdu. Ameliyat öncesi hazırlıklar sırasında hastada aynı zamanda aort koarktasyonu olduğu saptandı. Sol internal mammaryen arter dilateydi ancak yine de koroner arter bypass greftleme operasyonu sırasında greft olarak kullanıldı. Biz bu hastadaki yaklaşımımızı sunmak istedik.