Results of internal thoracic artery grafting over 15 years: Single versus double grafts

doi:10.1016/0003-4975(90)90139-W

The Annals of Thoracic Surgery

Volume 49, Issue 2, February 1990, Pages 202-209

https://doi.org/10.1016/0003-4975(90)90139-W Get rights and content

Abstract

One hundred consecutive patients who had coronary artery bypass grafting using both internal thoracic arteries (ITAs) and saphenous veins, operated on during a 3-year period between 1972 and 1975, have been compared retrospectively with a series of 100 patients operated on during the same period who had one ITA graft along with saphenous vein grafts. The two groups were similar with respect to age, sex, risk factors for coronary artery disease, angina class, extent of coronary artery disease, left ventricular function, number of coronary bypass grafts performed, and completeness of revascularization. Single ITA operative mortality was 2% and double ITA, 9% (p = NS). The mean follow-up of hospital survivors was 14.4 ± 2.7 years; all but 7 patients had follow-up for at least 10 years. At 13 years, the actuarial patency of the right ITA was 85% and the left ITA, 82%. These data strongly suggest a survival benefit for patients with double ITA grafts among hospital survivors (74% versus 59%; p = 0.05). Patients receiving two ITA grafts had a significant freedom from subsequent myocardial infarction (75% versus 59%, p < 0.025), recurrent angina pectoris (36% versus 27%, p < 0.025), and subsequent total ischemic events (32% versus 18%, p < 0.01). These data also suggest improved freedom from coronary artery interventional therapy (percutaneous transluminal coronary angioplasty and reoperation) when two ITA grafts were used. These results support the use of bilateral internal thoracic artery grafting in selected patients.

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Cited by (242)

The Growth Potential and Patency of Free Right Internal Thoracic Arteries Verified by Computed Tomography Angiography
2021, Annals of Thoracic Surgery
The use of the left internal thoracic artery (LITA) is the gold standard in coronary artery bypass graft surgery (CABG). Multiarterial grafting for CABG is being increasingly emphasized. This study aimed to resolve the utility of the right internal thoracic artery (RITA) for multiple CABG as “free” RITA and described new evidence.
One hundred sixty-three patients received solo CABG with bilateral internal thoracic arteries between 2005 and 2018. The RITA was used as in situ RITA, group A (n = 62), and the composite graft created with saphenous vein graft (SVG), group B (n = 101). The patency rate and graft size of the composite free RITA and SVG were examined by coronary computed tomography angiography.
The average number of distal anastomoses per patient was 3.4 ± 1.0 in group A, and 4.2 ± 1.1 in group B (P < .001). The sequential grafting with free RITA was in 86 patients. The patency rate of both LITA and RITA was similar in both groups. In group B, 40 patients received late computed tomography angiography at a mean of 46 months (range, 17 to 175). The late patency rate was 95.1% in LITA and 96.9% in free RITA. The diameter of free RITA increased from 2.06 ± 0.34 mm to 2.37 ± 0.23 mm (P = .036); that of in situ LITA increased from 2.08 ± 0.51 mm to 2.44 ± 0.49 mm (P = .047); and that of composite SVG decreased from 4.1 ± 0.9 mm to 2.6 ± 0.7 mm (P < .001).
Multiple bypass grafting can be sufficiently achieved with LITA and free RITA. The growth potential of free RITA and in situ LITA might play the important role of expected long-term patency.
Harvesting the skeletonized internal thoracic artery using the harmonic scalpel
2020, Technical Aspects of Modern Coronary Artery Bypass Surgery
The internal thoracic artery (ITA) is the most important conduit for coronary artery bypass grafting. Skeletonized harvesting of the ITA has further enhanced the value of the ITA by alleviating the risk of sternal wound complication in bilateral ITA use and by maximizing conduit length and diameter. The harmonic scalpel has helped us to perform simply a delicate advanced skeletonization technique in ITA harvesting. Here, we describe in detail the surgical technique for skeletonizing the ITA using the harmonic scalpel.
Myocardial Revascularization Exclusively with Bilateral Internal Thoracic Arteries in T-Graft Configuration: Effects on Late Survival
2016, Annals of Thoracic Surgery
We studied long-term survival using bilateral internal thoracic artery (BITA) grafting in a T-configuration exclusively versus using single internal thoracic artery (SITA) grafting in patients with multivessel disease.
Consecutive coronary operations performed at a single center between 1996 and 2014 were reviewed. Long-term survival among patients receiving coronary revascularization exclusively with BITA grafting in a T-configuration (n = 2,098) versus SITA grafts plus other types of conduits (saphenous vein graft [SVG] and radial artery [RA]) grafts (n = 1,659). In patients who underwent BITA grafting, the left internal thoracic artery (LITA) was grafted mainly to the left anterior descending artery, whereas the right internal thoracic artery (RITA) was used more commonly to graft the circumflex (Cx) artery and the right coronary system as T-grafts. A total of 485 pairs of patients were matched using propensity scores. Cox proportional hazard models were generated to examine the association of arterial BITA grafting with mortality.
Patients in the BITA group were more likely to be younger (BITA, 63.7 ± 9.1 versus SITA, 65.0 ± 9.9; p < 0.0001). At 30 days, patients who underwent BITA grafting experienced reduced unadjusted mortality (BITA, 1.2% versus SITA, 4.4%; p < 0.0001). At 10 years, patients who underwent BITA grafting experienced superior unadjusted survival (BITA, 82.6% ± 1.8% versus SITA, 76.1% ± 1.3%; p = 0.001). Cox regression analysis in the entire study cohort showed that BITA grafting was associated with improved survival (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.58–0.87; p < 0.001). In the propensity-score–adjusted analysis, patients who underwent BITA grafting had similar in-hospital mortality (BITA, 1.6% versus SITA, 2.9%; p = 0.196). Patients who underwent BITA grafting still showed improved survival at 10 years (BITA, 81.0% ± 4.1% versus SITA, 71.8% ± 2.5%; p = 0.039).
This study suggests that coronary artery operations exclusively with BITA grafting in a T-configuration may be associated with better long-term survival than grafting with SITA plus other types of conduits.
A mechanical argument for the differential performance of coronary artery grafts
2016, Journal of the Mechanical Behavior of Biomedical Materials
Coronary artery bypass grafting (CABG) acutely disturbs the homeostatic state of the transplanted vessel making retention of graft patency dependent on chronic remodeling processes. The time course and extent to which remodeling restores vessel homeostasis will depend, in part, on the nature and magnitude of the mechanical disturbances induced upon transplantation. In this investigation, biaxial mechanical testing and histology were performed on the porcine left anterior descending artery (LAD) and analogs of common autografts, including the internal thoracic artery (ITA), radial artery (RA), great saphenous vein (GSV) and lateral saphenous vein (LSV). Experimental data were used to quantify the parameters of a structure-based constitutive model enabling prediction of the acute vessel mechanical response pre-transplantation and under coronary loading conditions. A novel metric Ξ was developed to quantify mechanical differences between each graft vessel in situ and the LAD in situ, while a second metric Ω compares the graft vessels in situ to their state under coronary loading. The relative values of these metrics among candidate autograft sources are consistent with vessel-specific variations in CABG clinical success rates with the ITA as the superior and GSV the inferior graft choices based on mechanical performance. This approach can be used to evaluate other candidate tissues for grafting or to aid in the development of synthetic and tissue engineered alternatives.
Bilateral internal mammary artery grafting: Rationale and evidence
2015, International Journal of Surgery
Coronary artery bypass graft (CABG) surgery remains the preferred mode of revascularization in patients with complex multi-vessel coronary artery disease. The left internal mammary artery (IMA) and saphenous vein are the most commonly utilized conduits in CABG surgery and are still considered to be the gold standard by most surgeons. However, there is emerging evidence that use of bilateral IMAs is associated with significantly better long-term outcomes and the benefit increases with time from surgery. In spite of this incremental beneficiary effect, most surgeons are reluctant to use both IMAs, because it is technically more demanding, time-consuming and is associated with marginally higher sternal wound infection rates. This review highlights the histological features, physiological characteristics and genomics of IMAs that provide the basis for the use of these vessels during CABG surgery. Additionally, the superiority of the bilateral IMAs with regard to patency and long-term outcomes is also discussed in detail. Furthermore, the safety of using bilateral IMAs with regard to early postoperative outcomes with special reference to deep sternal wound infections has been addressed. The present review provides enough evidence to convince more surgeons about the advantages of bilateral IMA grafting.
Tissue-engineered cardiovascular grafts and novel applications of tissue engineering by self-assembly (TESA™)
2014, Cardiac Regeneration and Repair: Biomaterials and Tissue Engineering

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^☆: Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11–13, 1989.

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Original articleResults of internal thoracic artery grafting over 15 years: Single versus double grafts☆

Abstract

Influence of the internal mammary artery graft on 10-year survival and other cardiac events

N Engl J Med

Factors influencing long-tern (10-year to 15-year) survival after a successful coronary artery bypass operation

Ann Thorac Surg

Summary of a consensus concerning death and ischemic events after coronary artery bypass grafting

Circulation

Double internal mammary coronary artery bypass

Arch Surg

Twelve-year experience with internal mammary artery for coronary artery bypass

J Thorac Cardiovasc Surg

Calculation of survival rates for cancer

Statistical aspects of the analysis of data from retrospective studies of disease

JNCI

Coronary arterial bypass grafts

Ann Thorac Surg

Crossed double internal mammary to coronary artery grafts: indications, techniques, and results

Arch Surg

Sternal and costochondral infections following open heart surgery: review of 2,594 cases

J Thorac Cardiovasc Surg

Comparison of late changes in internal mammary artery and saphenous vein grafts in two consecutive series of patients 10 years after operation

Circulation

Evaluation of postoperative flow reserve in internal mammary artery bypass grafts

J Thorac Cardiovasc Surg

Comparison of internal mammary artery and saphenous vein bypass grafts for myocardial revascularization exercise test and angiographic correlations

Circulation

Quantitative assessment of myocardiai performance and graft patency following coronary bypass with the internal mammary artery

J Thorac Cardiovasc Surg

Original article
Results of internal thoracic artery grafting over 15 years: Single versus double grafts☆