total coronary revascularization with the internal thoracic arteries t graft b. el nakadi, y. de...

Total coronary revascularization with the internal thoracic arteries

T graft

B. El Nakadi, Y. De Bruyne, M. Joris

C.H.U. de Charleroi, Belgium

Total coronary revascularization with the internal thoracic arteries T graft

• 1960 : RITA RCA

• 1965 : LITA LAD

• 1973 : RITA + LITA in situ

• 80’s : LITA on LAD improves long-term survival


Follow-up Survival Freedom of ischemic events

sITA bITA sITA bITA

GreenAnn.Thor.surg.1994

5 years 62% 88%

FioreAnn.Thor.surg.1990

15 years 59% 74% 18% 32%

GalbutAnn.Thor.surg.1990

17years 60% 75%

sITA > < bITA grafting


Patients Mortality%

Bleeding%

M.I.%

I.A.B.P%

sternalinfection

%KouchoukosAnn.Thor.Surg.1990

1566 3.7 5.3 2 4.5 6.9

GalbutAnn.Thor.Surg.1990

1087 2.7 1.7 2 - 1.5

AccolaAnn.Thor.Surg.1990

674 1.9 2.1 - 2.8 3.69.6(diab.)

Complications of bITA grafting


• Sternal infection risk factors– Univariate analysis :

• bITA grafting

• Obesity

• Diabetes

• Prolonged mechanical ventilation

– Multivariate regressive analysis :• bITA grafting p=0.0001

• Obesity p=0.0014

• Prolonged ventilation p=0.0018

Kouchoukos. Ann. Thorac. surg. 1990


• ITAs have proved to be the best bypass graft but have an inadequate length to bypass Cx pl and RC arteries to achieve a complete revascularization.


Patients Age Fem/

male

Ejectionfraction

Diabetis redo

TectorAnn.Thor.Surg.1994

287+4 64.6 1/ 3.5 0.2- 0.7 ? 11%

BarraAnn.Thor.Surg.1991

25 57 1/ 8 ? ? 0

NicholsonAnn.Thor.Surg.1997

71+2 55 1/5 > 0.50 20% ?


Anast. Cross-clamptime

(min.)

IABP MI/

st .

Bleeding sternalinfection

/instability

- S.test

Follow-up

Tector 4.4 78 +/-15 5% 2%/?

5.6% 5.6%/?

1.7% 90% 2 years

Barra 2.3 ? 12% 4%/?

? 8%/?

0 73% 4months

Nicholson 4.5 ? 0 0 3% 0/

3%

0 92% 2 years


• Material:( jan. 94 sept.97 ) – 106 patients , 1/10– Age: 51 ys (35-69)– Redo: 8 %– Diabetes: 21%– Obesity: 38 %


• Material:– NYHA: II: 49 %

III: 13 %

IV: 22 %– Stress test: 58 patients.

90 % – EF: 0.60 (0.22-0.85)

+


• Operative data:– Anastomoses: 4.25 (3-6)

3 (2-4) redo patients.– Aortic cross clamping: 94 18 min.– IABP: 1 (EF:0.25) – Exploration for bleeding: 0


• Morbidity:– Transient s-t elevation: 12 (11 %)– Q wave infarction: 3 (3 %)– Sternal infection: 1 (1%)

• Mortality: 0


• Follow-up(105 patients)– 26 13 months– Survival: 99 %– Stress test: 90 %– Recurrent angina: 7 NYHA II (7 %)– infarct: 0– Sternal instability: 2 % rewiring

-


• Is the blood supply sufficient?– clinical results .

– Experimental studies.

• What about subclavian artery atherosclerosis?– before surgery free LITA + in situ RITA.

– after surgery - Extraanatomic bypass.

-Angioplasty.


• Follow-up:– Symptoms, stress test, thallium test.– Graft evaluation:

• Duplex(supraclavicular fossa) :qualitative flow information in 95 % of cases.

• Spiral CT scan : graft patency

sensitivity 85 %& specificity 100%

• Angiography.


• Has the potential to increase event-free survival and reduce the need for reoperation in patients with three-vessel disease.

• Can be performed with a low mortality and morbidity in a selected population, even in patients requiring reoperation.

total coronary revascularization with the internal thoracic arteries t graft b. el nakadi, y. de...

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