Seventeen-year experience with bilateral internal mammary artery grafts

Effect of skeletonisation and pedicled bilateral internal mammary artery grafting in coronary artery bypass surgery on post-operative wound infection: A meta-analysis

The results showed that different internal thoracic artery (ITA) was associated with the rate of postoperative wound infection and the severity of pain following coronary artery bypass grafting (CABG). In order to ascertain if there was any genuine difference in the rate of postoperative infection and severity of the pain, we conducted a meta-analysis to evaluate if there was any actual difference in the wound complication that had been identified with the ITA method. Through EMBASE, Cochrane Library and Pubmed, and so forth, we systematically reviewed the results by August 2023, which compared the impact of skeletonised versus pedicled internal mammary artery (IMA) on wound complications following CABG. The trial data have been pooled and analysed in order to determine if a randomisation or fixed-effect model should be applied. The meta-analysis of data was performed with Revman 5.3 software. The results of this meta-study included 252 related articles from four main databases, and nine articles were chosen to be extracted and analysed. A total of 3320 patients were treated with coronary artery transplantation. Based on current data analysis, we have shown that the rate of postoperative wound infections is reduced by the use of the skeletonised internal mammary artery (SIMA) (OR, 1.84; 95% CI, 1.13, 3.01; p = 0.01). But the results showed that there were no statistically significant differences in the post-operation pain score of the patients (MD, 0.09; 95% CI, -0.58, 0.76; p = 0.79). Furthermore, the duration of the operation was not significantly different between the SIMA and pedicled internal mammary artery (PIMA) (MD, 3.30; 95% CI, -3.13, 9.73; p = 0.31). Overall, the SIMA decreased the rate of postoperative wound infection in CABG patients than the PIMA.

Left Internal Mammary Artery as an Endocrine Organ: Insights Into Graft Biology and Long-term Impact Following Coronary Artery Bypass Grafting

The left internal mammary artery (LIMA) is considered the criterion standard vessel for use in coronary artery bypass grafting. In recent decades, countless studies have documented its superiority over other arterial and venous coronary artery bypass grafting conduits, although the full mechanisms for this superiority remain unknown. A growing body of literature has unveiled the importance of extracellular vesicles known as exosomes in cardiovascular signaling and various pathologic states. In this review, we briefly compare the clinical longevity of the LIMA relative to other conduits, explore the effects of varying grafting techniques on clinical and angiographic outcomes, and provide physiologic insights into graft function on a cellular and molecular level. Finally, we explore exosome signaling as it pertains to atherosclerosis in support of the LIMA as an "endocrine organ."

The Value of Inflammation Indexes in Predicting Patency of Saphenous Vein Grafts in Patients With Coronary Artery Bypass Graft Surgery

Aim:Our study aimed to investigate the predictive values of inflammation markers in predicting postoperative saphenous vein graft patency in patients who underwent coronary artery bypass grafting (CABG).

Method: We retrospectively analyzed 89 patients who undergone CABG, and 49 patients diagnosed with non-critical coronary artery disease (less than ≤50% stenosis) on coronary angiography were included in the study as a control group. Eighty-nine patients who underwent CABG were divided into two groups according to the presence of 50% or more stenosis in saphenous vein grafts. In these three groups of patients, neutrophil to lymphocyte ratio (NLR), derived NLR (dNLR; neutrophils/white blood cells-neutrophils), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), systemic inflammation response index (SIRI; neutrophils × monocytes/lymphocytes), systemic inflammation index (SII; platelet × neutrophil/lymphocyte), and the aggregate index of systemic inflammation (AISI; neutrophil × platelet × monocyte/lymphocyte ratio) were calculated from blood tests. The primary endpoint was more than 50% of saphenous vein stenosis or occlusion, and the aim is to predict this saphenous vein graft disease by inflammation indexes.

Results: The groups were similar in terms of the frequency of stroke, diabetes mellitus, and chronic obstructive pulmonary disease. The frequency of heart failure and hypertension was higher in group 2 (p=0.045, p=0.005), respectively. Multivariate logistic regression analysis showed that LMR and NLR levels were independent predictors of saphenous vein graft disease (SVGD; OR: 0.896; 95%CI: 0.465-0.957; P<0.001) , (OR: 0.592; 95%CI: 0.450-0.875; P=0.034, respectively).The cut-off value of the LMR <2.625 was associated with 78.4% sensitivity and 78% specificity to predict saphenous vein graft disease in patients with CABG.

Conclusion: LMR and NLR may be useful predictors for SVGD.

The Growth Potential and Patency of Free Right Internal Thoracic Arteries Verified by Computed Tomography Angiography

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Deep sternal infections after in situ bilateral internal thoracic artery grafting for left ventricular myocardial revascularization: predictors and influence on 20-year outcomes

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.

Bilateral internal thoracic arteries: what is the State of the ART?

PURPOSE OF REVIEW

To provide a broad overview of the current state of knowledge of coronary artery bypass grafting with bilateral internal thoracic artery (BITA).

RECENT FINDINGS

There exists a large body of literature from mostly observational studies supporting the use of BITA in patients undergoing coronary artery bypass grafting but selection bias is a major issue with nonrandomized data. The precise method of BITA use does not appear to impact graft patency nor clinical outcomes - in other words, BITA in any configuration appears to be protective. The major downside is the increased risk of sternal complications, which can be mitigated with sternal-sparring adjuncts. The 5-year interim results of the landmark Arterial Revascularization Trial comparing BITA versus single internal thoracic artery did not show a clinical benefit for BITA but the end-of-trial results are pending. Despite wide guideline support for BITA use, uptake in the surgical community remains low and this is likely because of technical and institutional barriers.

SUMMARY

The published literature thus far supports surgical revascularization with BITA and we eagerly await the 10-year Arterial Revascularization Trial results. The general consensus is that a greater proportion of surgical revascularization should be performed using BITA.

Novel no touch technique of saphenous vein harvesting: Is great graft patency rate provided?

Coronary artery bypass grafting surgery effectively relieves signs and symptoms of myocardial ischemia. The left internal thoracic artery (LITA) graft is the gold standard having 90-95% patency rate at 10 years, whereas only 50% of saphenous vein (SV) grafts are patent at 10 years. However, there is a novel "no touch" technique in order to harvest an SV complete with its cushion of surrounding tissue, thus maintaining its endothelium-intact. Significantly superior short- and long-term graft patency rates comparable to LITA grafts can be achieved. Consequently, the SV may be revived as an important conduit in coronary artery bypass surgery.

Semi-Skeletonized Internal Mammary Artery Grafts and Sternal Wound Complications

This study aimed to evaluate the risk factors for sternal wound complications in patients undergoing myocardial revascularization using bilateral semi-skeletonized internal mammary arteries. Prospectively collected data on 751 patients undergoing coronary artery surgery from September 1994 to August 2002 were analyzed. The mean age of the patients was 56 years, 633 (84%) were male, 44 (6%) were over 66 years of age, and 170 (23%) were diabetic. Forty-four (5.9%) patients developed sternal wound complications. Among these cases, sternal infection occurred in 22 (2.9%) patients, of which 15 (2.0%) had sternal infection with mediastinitis and 7 (0.9%) had sternal infection alone. Independent risk factors for any sternal wound complications were peripheral vascular disease, diet-controlled diabetes, and delayed sternal closure. The risk factors for sternal infection were diabetes, postoperative pulmonary complications, and postoperative stroke. The perioperative mortality rate was 1.5% (11 patients), including 2 patients who had sternal wound complications. The use of bilateral semi-skeletonized internal mammary artery conduits carries a comparable sternal wound complication rate as conduits harvested by other techniques.

Myocardial Revascularization with Multiple Arterial Grafts

From October 1991 10 July 1994, 439 patients underwent elective or urgent coronary artery bypass grafting utilizing 2 or more arterial conduits. Age ranged from 28 to 79 years (mean, 62.3 years). Most of the patients had 3-vessel disease (301); the remaining had 2-vessel (120) or 1-vessel (18) disease. A stenosis of the left main trunk greater than or equal to 50% was present in 73 patients; in 16 cases it was a redo operation. The left ventricular ejection fraction ranged from 0.19 to 0.84 (mean, 0.53). We utilized 1110 arterial conduits (430 left internal mammary arteries, 259 right internal mammary arteries, 136 right gastroepiploic arteries, 120 inferior epigastric arteries, 165 radial arteries) together with 113 saphenous veins (2.63 arterial anastomoses per patient, ranging from 2 to 6). In 347 patients (79%) we performed a complete arterial myocardial revascularization with an average of 2.80 anastomoses per patient. Two arterial conduits were used in 245 patients, 3 in 163, 4 in 30, and 5 in 1 patient. The myocardial protection was achieved by means of intermittent antegrade warm blood cardioplegia. The mean cross-clamping time was 47.3 ± 16 minutes (range, 16 to 142 minutes). Five patients (1.1%) died in the postoperative period, none were in the operating theater. The causes of death were cardiac (2), sepsis (1), pneumonia (1) and pancreatic necrosis (1). In 7 patients (1.6%) a perioperative myocardial necrosis occurred without any hemodynamic sequelae. Out of 430 patients alive, 419 (97.4%) are asymptomatic. At the postoperative angiographic control all the arterial grafts explored showed complete patency; the midterm angiography (mean, 14 months) revealed a cumulative patency of 96% (range, 100% for the left internal thoracic artery to 94.1% for the radial artery). We conclude that on the basis of the early results the technique herein described is effective and reproducible, even if long-term follow-up is needed to confirm these data.

Bilateral internal mammary artery grafting: rationale and evidence

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.

Sternal Surgical-Site Infection Following Coronary Artery Bypass Graft Prevalence, Microbiology, and Complications During a 42-Month Period

Objective:

Surgical-site infection (SSI) is a serious and costly complication following coronary artery bypass graft (CABG). We analyzed surgical factors, microbiology, and complications at a 608-bed community teaching hospital to identify opportunities for prevention.

Methods:

All patients undergoing CABG procedures from June 1997 through December 2000 were analyzed. Hospital records and postdischarge surveillance data were reviewed for demographics, surgical information, timing and classification of infection, microbiology, and bacteremic events.

Results:

Of 3,443 patients undergoing CABG, sternal SSI developed in 122 (3.5%); 71 (58.2%) were classified as superficial SSI and 51 (41.8%) as deep SSI. Surgical antimicrobial prophylaxis was employed in all cases. On average, infection occurred 21.5 days (range, 4 to 315) after CABG. Most cases were diagnosed on readmission (59%); 20 cases (16%) were identified by postdischarge surveillance. Microbiological data were positive in 109 (89.3%), with a single pathogen implicated in most (86.2%). Gram-positive cocci were most frequently recovered (81%); gram-negative bacilli (17%), gram-positive bacilli (1%), and yeast (1%) were less common.Staphylococcus aureuswas the most frequently isolated pathogen (49%). Bacteremia was noted in 22 instances (18%). It was significantly associated with deep SSI (P=. 002) and identified only inS. aureuscases.

Conclusions:

SSI complicated 3.5% of the procedures.S. aureuswas implicated in most of the cases and was significantly associated with deep SSI. It was the only pathogen associated with secondary bacteremia. In addition to standard guidelines, targeted methods againstS. aureusshould help reduce the overall rate of SSI.

Bilateral internal mammary artery grafting

The superiority of the left internal mammary artery over the saphenous vein graft led many surgeons to adopt bilateral internal mammary artery (BIMA) as a good surgical option for further improving late outcome of patients undergoing myocardial revascularization. However, routine use of BIMA was limited by some potential drawbacks: the increase of deep sternal wound problems, especially in diabetic patients; the shortness of right internal mammary artery (RIMA), which limited its utilization as an in situ graft; the low patency rate if grafted to the right coronary artery; and the longer operative time. The skeletonization of the internal mammary artery along with a better glucose control in diabetic patients significantly reduced the incidence of deep sternal problems. Another problem to solve was finding the optimal target of the RIMA. The general consensus is that RIMA appears to be more efficient if grafted to the lateral wall. The Y or T configuration of double mammary arteries could be more helpful to reach the lateral target vessels. Finally, recent reports clearly demonstrate the superiority of BIMA over single internal mammary artery in terms of survival or quality of life. The latter finding has also been reported in diabetic patients.

A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting

BACKGROUND

Increasing evidence continues to demonstrate a survival advantage for bilateral internal mammary artery (BIMA) over left internal mammary artery (LIMA) for coronary artery bypass grafting (CABG). We performed an updated meta-analysis of published studies comparing BIMA versus LIMA in CABG operations and assessed differences in long-term survival.

METHODS

Electronic searches for studies comparing BIMA versus LIMA were performed using three databases from 1972 to December 2012. Studies with at least four years of follow-up and at least 100 patients in each group were included for review. We used a random-effect model and pooled hazard ratios from across all included studies.

RESULTS

No randomized controlled trials and 27 observational studies totaling 79,063 patients (19,277 BIMA, 59,786 LIMA) were included for final analysis. The BIMA group demonstrated significantly better long-term survival than the LIMA group [hazard ratio, 0.78; confidence interval, 0.72-0.84; P<0.00001].

CONCLUSIONS

In an updated meta-analysis, we demonstrate an increase in long-term survival in patients receiving BIMA as a primary grafting strategy over those receiving a LIMA. Although no randomized controlled trials were included in this meta-analysis, the survival benefit seen with a BIMA cannot be overlooked when determining which operation to perform in CABG patients. Until the long-term results of the ART trial are published, we offer best available evidence in favor of BIMA over LIMA for CABG surgery.

Human internal thoracic artery grafts exhibit severe morphological and functional damage and spasmic vasomotion due to oxidative stress

Background

The internal thoracic artery (ITA) is the first choice for myocardial revascularization, but atherosclerotic lesions and perioperative vasospasm may still limit its functionality. Oxidative stress via the peroxynitrite – poly-(ADP-ribose) polymerase (PARP) cascade plays an important role in the pathogenesis of impaired vascular tone via endothelial injury. We aimed to investigate and describe the histology, PARP activation and functionality of ITA grafts and to assess the possible beneficial effect of PARP-inhibition.

Material/Methods

ITA specimens from 47 patients (26 men, mean age 66.2±1.7 years) who underwent coronary bypass surgery were processed for histological and immunohistochemical studies for oxidative stress and PARP activation, and were functionally tested with acetylcholine (ACh) and sodium nitroprusside (SNP) with or without PARP inhibition.

Results

The sections showed atherosclerotic alterations and oxidative and nitrosative stress were evidenced by positive 3-nitrotyrosine, 4-hydroxynonenal and PAR stainings. Functionally, 88.1% reacted to K-Krebs, 68.7% exhibited contraction after 1 μM phenylephrine, 29.9% exhibited relaxation to 30 μM Ach, and all precontracted segments relaxed to 30 μM SNP. High amplitude vasomotion was observed in 47.8% of the segments, which could be abolished by the application of 10 μM SNP. Incubation of the preparations with PJ34 did not improve endothelium-dependent vasodilation.

Conclusions

ITA grafts are severely damaged both morphologically and functionally in patients undergoing coronary artery bypass surgery, but PARP inhibition cannot improve their functional characteristics. The topical use of SNP to the ITA during the operation may improve vascular functions by dilating the vessels and eliminating the eventual spasmic vasomotion.

Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups

BACKGROUND

The value of the left internal mammary artery (LIMA) graft is well established. However, the incremental value of a second IMA graft is controversial. Despite reports of improved survival with bilateral IMA (BIMA) grafting, the Society of Thoracic Surgeons reports its use in 4% of coronary artery bypass graft operations. We report the influence of BIMA vs SIMA grafting on hospital and late mortality in comparable groups.

METHODS

Retrospective review was conducted of 4584 consecutive isolated coronary artery bypass graft operations (2369 SIMA and 2215 BIMA) performed from 1972 to 1994. The influence of the second IMA was assessed by multivariate analyses of risk factors associated with hospital and late mortality and by propensity score analysis that compares patients with similar baseline characteristics for receiving a second IMA graft. All patients were monitored clinically to assess outcomes.

RESULTS

Hospital mortality was 4.5% for SIMA vs 2.6% for BIMA patients (p = 0.001). When stratified by propensity score to undergo BIMA grafting, no difference in hospital mortality was found. Multivariate analyses showed SIMA grafting was significantly associated with late but not hospital mortality. Survival curves after 52,572 patient-years of follow-up (mean, 11.5 years; range, 6 weeks to 32 years) demonstrated improved long-term survival for BIMA vs SIMA patients in all quintiles except those with the greatest propensity for SIMA, wherein late survival was comparable between groups. In matched groups, survival favored BIMA patients (p = 0.001).

CONCLUSIONS

BIMA grafting offers a long-term survival advantage over SIMA grafting in propensity-matched groups.

Effect of pleurotomy on blood loss during coronary artery bypass grafting

BACKGROUND

We conducted a retrospective study to compare two different techniques of internal mammarian artery (IMA) preparation concerning pleurotomy upon the effects of blood loss and pulmonary functions.

METHODS

Between January 1998 and November 2006, 1357 consecutive patients undergoing coronary artery bypass grafting (CABG) using the left IMA, either alone or in combination with saphenous vein graft, were included in this study. The patients were divided into two groups according to the pleural opening: Group I (n = 1046) patients underwent IMA harvesting with pleurotomy and Group 2 (n = 311) patients with intact pleura.

RESULTS

During the study, 27 hospital deaths (1.9%) occurred. The amount of postoperative blood loss and blood transfusion requirements were significantly higher in Group 1 than in Group 2 (p = 0.029 and p = 0.0001). The mechanical ventilation stay was significantly higher in Group 1 than in Group 2 (p = 0.0001). The incidence of left pleural effusion and atelectasis was significantly higher in Group 1 than in Group 2 on day 1 and day 3 after operation.

CONCLUSIONS

These results demonstrate that preserving pleural integrity has beneficial effects on the postoperative blood loss. Postoperative blood loss and transfusion requirements were higher in patients with pleurotomy. Left pleural effusion, atelectasis, and mechanical ventilatory stay were significantly reduced in patients with preserved pleural integrity.

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m(2) (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.

Blood supply of the sternum and its importance in internal thoracic artery harvesting

BACKGROUND

The internal thoracic artery (ITA) is the conduit of choice in coronary bypass grafting, due to the excellent long-term results achieved using it. However, increased incidence of sternal infections after pedicled ITA harvesting has revived interest in the morphology of sternal blood supply. Our aim was to discuss the topography of the sternal branches with emphasis on internal thoracic artery harvesting.

METHODS

This study was conducted on 50 fresh specimens of the anterior thorax wall. Radio-opaque material was injected and angiograms of the ITA were performed. Subsequently, the specimens were preserved and a dry dissection of each ITA and its branches was carried out.

RESULTS

In dry dissected specimens, four types of vessels were identified that have the potential to carry blood to the sternum after harvesting the ITA. In the first group, the artery to the sternum also supplies the intercostal space. In the second morphologic variant, the sternal branch gives off the perforating and anterior intercostal arteries. In the third group, we classified the common branch of the sternal and perforating arteries. In the fourth group, the sternal artery originated from the ITA as an independent branch.

CONCLUSIONS

For sternal-intercostal, perforating-intercostal, and sternal-perforating branches to function as collaterals after ITA harvesting, the common trunk of origin must remain intact. Based on morphologic data, we recommend ligating the common trunk as close as possible to the ITA; in this way, collateral blood flow to the sternum remains intact.

Does periadventitial fat-derived nitric oxide play a role in improved saphenous vein graft patency in patients undergoing coronary artery bypass surgery?

BACKGROUND/AIMS

The saphenous vein is commonly used for coronary artery bypass surgery but its patency is poor. Vascular damage occurs during conventional surgery. However, patency improves when the graft is harvested with minimal surgical trauma, partly due to preservation of vascular endothelial nitric oxide synthase (eNOS) and tissue sources of nitric oxide (NO), a factor possessing both dilatory and anti-proliferative properties. Apart from these grafts exhibiting an intact luminal endothelium they are harvested complete with a surrounding cushion of tissue, much of which is fat.

METHODS

Immunostaining for eNOS was performed on vein graft sections and reverse-transcriptase polymerase chain reaction and Western blotting were used to identify eNOS mRNA and protein. NO synthase activity was measured using the citrulline assay.

RESULTS

Immunohistochemistry identified eNOS staining of vein graft segments, including dense staining of the cushion of perivascular fat and associated structures surrounding the vein. eNOS protein was confirmed in both the vein and surrounding fat by Western blot analysis. Using the citrulline assay, the perivascular fat and underlying vein possessed comparable NO synthase activity.

CONCLUSIONS

Our observations suggest that perivascular fat-derived NO plays a beneficial role in saphenous veins harvested atraumatically and used as grafts in patients undergoing coronary artery bypass surgery.

Perioperative and clinical-angiographic late outcome of total arterial myocardial revascularization according to different composite original graft techniques

Total arterial myocardial revascularization (TAMR) is advisable because of the excellent long-term patency of arterial conduits. We present early and midterm outcomes of five different surgical configurations for TAMR. Between January 1998 and May 2004, 112 patients (aged 56.5 +/- 4.5 years, 20% female) with three-vessel disease underwent TAMR. The internal mammary arteries (IMAs) were harvested in a sketelonized fashion. The surgical techniques for TAMR consisted in Y or T composite grafts (n = 88, 78%) constructed between the in situ right IMA (RIMA) and the free left IMA (LIMA) graft (n = 58) or the radial artery (n = 30) (RA) in three different configurations. The other techniques consisted in T- and inverted T-graft (n = 24, 22%) constructed between the RA conduit and the free LIMA graft in two different configurations. The mean follow-up time was 40 +/- 23 months. Postoperative angiographic control was performed in 76/111 (70%) patients. Overall, 472 arterial anastomoses (average 4.2 per patient) were performed. One (0.9%) patient, undergoing the inverted T-graft technique, died on postoperative day 2. Another patient (0.9%), undergoing the lambda-graft technique using both IMAs and RA, suffered a new myocardial infarction probably due to RA conduit vasospasm. One week after surgery, after the transthoracic echocardiographic Doppler with adenosine provocative test, the coronary flow reserve (CFR) at the LIMA and RIMA main stems were 2 +/- 0.4 and 2.4 +/- 0.3, respectively. At 12-month follow-up, after adenosine provocative test, the CFRs at the LIMA and RIMA stems were significantly higher than the values at 1 week after surgery within the same group; (LIMA)CFR (1 week) 2.4 +/- 0.3 (12 months) vs 2 +/- 04 (1 week), P = 0.002; (RIMA)CFR 2.58 +/- 0.4 vs 2.4 +/- 0.3, P = 0.001. The CFR at the RIMA main stem was higher in all measurements within the same group than in the LIMA main stem, but not significantly. In one patient undergoing the lambda-graft technique using both IMAs, the RIMA was found to have a string sign. Postoperative angiography in 50 patients showed that the patency rate for the LIMA was 100%, for the RIMA 97.3%, and for the RA 96.7%. Angiography at 3-year follow-up in 76 patients documented excellent patency rates of the LIMA (97.4%), RIMA (95%), and RA (87%). Survival at 7 years was 92.5%, event-free survival 89.3%, and freedom from angina 94%. Total arterial myocardial revascularization using different surgical configurations is safe and effective. The use of composite arterial grafts provides excellent clinical and angiographic results, with a low rate of angina recurrence and late cardiac events. These configurations allow for complete arterial revascularization.

The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization

OBJECTIVE

To determine the relative risk of sternal dehiscence in patients undergoing bilateral internal thoracic artery harvesting and to assess whether and to what extent the technique of artery skeletonization might reduce this risk.

METHODS

Prospectively collected data on patients undergoing coronary artery bypass operations with at least a single internal thoracic artery were reviewed. The last 450 patients receiving bilateral internal thoracic artery grafts were compared with 450 patients who received a single internal thoracic artery during the same period. The left internal thoracic artery was always harvested in a pedicled fashion. Among patients receiving a bilateral internal thoracic artery, both arteries were harvested in a pedicled fashion in 300 cases, whereas both internal thoracic arteries were skeletonized in the remaining 150 cases.

RESULTS

Compared with a single internal thoracic artery, harvesting both internal thoracic arteries either in a skeletonized or in a pedicled fashion increased the chance of deep (1.1% vs 3.3% vs 4.7%; P = .01) or superficial (4.8% vs 7.8% vs 12%; P = .002) sternal infection. However, the technique of artery harvesting (odds ratio, 4.1; 95% confidence interval, 1.4-12.1); the presence of peripheral arteriopathy (odds ratio, 3.1; 95% confidence interval, 1.2-8.5), and resternotomy for bleeding (odds ratio, 8.2; 95% confidence interval, 2.0-33.6) were the only independent predictors for deep sternal infection, whereas the technique of artery harvesting (odds ratio, 3.0; 95% confidence interval, 1.6-5.4), female sex (odds ratio, 2.2; 95% confidence interval, 1.2-4.2), and diabetes (odds ratio, 1.7; 95% confidence interval, 1.0-2.9) were the only independent predictors of superficial sternal infection. In diabetic patients, there was no difference in the incidence of deep sternal infection among patients receiving a single internal thoracic artery or double skeletonized internal thoracic arteries ( P = .4).

CONCLUSIONS

Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection.

Off-pump total arterial revascularization: our experience

BACKGROUND AND AIM

Off-pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross-clamp. The aim of the present study is to describe our experience and the results obtained.

METHODS

From April 1998 to December 2003, the off-pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 +/- 9.5 years (23-90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple-vessel disease in 50.3% of the patients, with a mean ejection fraction of 60%+/- 13% (23-88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as "Y" or "T" grafts. Intraoperative graft patency was checked using a Doppler flowmeter.

RESULTS

A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty-four patients (3.2%) died in the first month postoperatively.

CONCLUSIONS

The off-pump Tector technique appears to be safe, showing a low surgical morbidity.

Internal mammary artery

The internal mammary artery (IMA) has been already used in some pioneering experiences since the middle of last century but it became the graft of choice only in the 1980s, after widespread angiographic and clinical demonstration of its superiority over the saphenous vein graft (SVG). The use of both mammary arteries was then explored in order to achieve better long-term results when compared to single IMA and SVG. The IMA can be harvested pedicled or skeletonized and used as an in situ graft or as a source for composite graft (Y-graft, lengthened graft). When the bilateral internal mammary artery (BIMA) is grafted in situ, the left internal mammary artery (LIMA) is generally used for the left descending artery (LAD) and the RIMA for the right coronary artery (RCA), or for the lateral wall, usually going through the transverse sinus. In the case of Y-graft, the left coronary system is more frequently chosen as the target site of revascularization. Our experience shows that: (1) The use of IMA provides better 15-year clinical results when compared to SVG. (2) The use of BIMA in patients younger than 75 years can produce higher 10-year freedom from cardiac-related events than the single one, even in diabetic patients.

Skeletonized Bilateral Internal Mammary Arteries for Total Arterial Myocardial Revascularization

BACKGROUND

Bilateral internal mammary artery (IMA) grafting is associated with an improved long-term survival, low rates of recurrence of angina and late myocardial infarction. However, because of the inadequate length of the conduit, use of bilateral internal thoracic artery grafting occasionally is not suitable for complete revascularization. To overcome this limitation, extra length can be obtained by skeletonization of both IMAs. We decided to prospectively assess the safety of this technique.

METHODS

One hundred patients with a mean age of 52.5 +/- 13.1 years underwent complete revascularization with skeletonized bilateral internal mammary arteries on cardiopulmonary bypass (CPB). The right internal mammary artery (RIMA) was used as a free graft connected to the in situ left IMA (LIMA) in 88 patients. A free LIMA was attached to in situ RIMA in 12 patients. The average number of grafts was 3.2 per patient (range: 2-4 grafts per patient). Mean left ventricular ejection fraction was 60% (range: 25-80%).

RESULTS

No patient required reexploration for bleeding, and no patient died within 30 days after operation. On the basis of electrocardiographic changes, three patients sustained a perioperative myocardial infarction. One patient had a sternal wound infection. Mean follow-up was 24 months (range: 6-36 months). The actuarial survival rate was 99 +/- 1% at 3 years. No myocardial infarctions were reported during the follow-up. Three patients had recurrent angina with conduit occlusion diagnosed on coronary angiography.

CONCLUSION

Complete myocardial revascularization with skeletonized bilateral internal mammary arteries is a safe and reliable technique with excellent early and mid-term results.

Surgical revascularization of coronary bifurcations employing a single arterial graft according to the "omega-anastomosis" technique: initial experience

OBJECTIVES

The aim of this study was to evaluate the early postoperative outcome in patients undergoing "omega-anastomosis" construction, a technique that permits revascularization of coronary bifurcations employing a single arterial graft.

MATERIALS AND METHODS

Between January 2000 and March 2002, omega-anastomosis was employed in 12 patients. The main indication for omega-anastomosis construction was the presence of a significant stenotic lesion involving one of the coronary tree's bifurcations, presenting a relevant secondary branch. There were ten men and two women, with a mean age of 55.4 +/- 4.3 years (range 48 to 66). The omega-anastomosis was constructed employing a single arterial graft (internal mammary artery or radial artery) effectively tailored to obtain a bi-petal shape and anastomosed to the coronary bifurcation according to a three-foliate anastomosis. All patients underwent postoperative coronary angiography.

RESULTS

There were no hospital deaths, neither ECG nor enzymatic alterations. One patient was reoperated for excessive bleeding. The mean aortic cross-clamp time and duration of CPB (cardiopulmonary bypass) were 64 +/- 18 minutes (range 45 to 108) and 89 +/- 26 minutes (range 67 to 135), respectively. Thirty-four arterial conduits were used: 12 LIMA, 12 RIMA, and 10 RA. Twelve omega-anastomoses were constructed, in six patients employing the RA, and in six other patients employing one of the internal mammary arteries (IMAs). Five left Y-grafts between the in situ LIMA and free LIMA graft and one right Y-graft between the RIMA and RA were constructed. The mean ICU stay was 14.4 +/- 5.7 hours. The postoperative coronary angiography revealed a good patency of the "omega-anastomosis." Transthoracic color Doppler echocardiography (TTECD) demonstrated a normal IMAs flow pattern in all cases.

CONCLUSIONS

We define the reported configuration as a possible surgical alternative to achieve total arterial myocardial revascularization in multi-vessels patients, associated with excellent postoperative outcome that should be part of the coronary surgical armamentarium.

Should the internal thoracic artery be skeletonized?

Traditionally, the internal thoracic artery is harvested as a pedicle. In contemporary cardiac surgical practice, however, certain surgeons practice the internal thoracic artery-skeletonization technique. A systematic review of clinical studies reporting on the use of skeletonized internal thoracic arteries (SKT-ITA) has not yet been performed. The primary aim of this review article is to examine comprehensively the entire body of evidence regarding the use of SKT-ITA. In particular, we aimed to analyze the effects of skeletonization on sternal blood supply, wall damage and blood flow in the harvested vessel, postoperative graft patency, and clinical outcome. Advantages and disadvantages of the skeletonization technique are highlighted and discussed.

Failure of internal thoracic artery grafts: conclusions from coronary angiography mid-term follow-up

BACKGROUND

The objective of this study was to identify causes of the failures of internal thoracic artery bypass grafts according to operative technique, the internal thoracic artery used, and the coronary artery grafted.

METHODS

This retrospective study concerns 302 follow-up angiographies performed in patients treated with 512 internal thoracic artery bypass grafts: 115 single grafts, 78 sequential grafts, and 109 grafts with two internal thoracic arteries (61 Y grafts). Postoperative angiography was performed after a mean period of 17.3 +/- 4.1 months.

RESULTS

Failures consisted of 11 (2%) occluded grafts and 19 (4%) nonfunctioning grafts (threadlike internal thoracic artery). There was no difference in patency among the various types of left anterior descending artery bypass grafts anastomosed with the left internal thoracic artery. The failure rate was higher with the right internal thoracic artery (13%) than with the left internal thoracic artery (4%; p < 0.05). The failure rate of the left anterior descending artery bypass grafts (3%) was lower than that for the branches of circumflex artery bypass grafts (13%; p < 0.05). The 19 cases of nonfunctioning grafts did not include significant anastomotic stenosis: 14 were related to competitive blood flow, 4 to a poor recipient coronary arterial bed, and 1 to significant distal coronary stenosis.

CONCLUSIONS

At least two thirds of failures of bypass grafts could have been avoided by more objective analysis of the coronary stenosis on preoperative coronary angiography and better mastery of the surgical technique.

Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study

BACKGROUND

We investigated whether off-pump coronary artery bypass (OPCAB) surgery should be the procedure of choice in total arterial myocardial revascularization with composite grafts.

METHODS

We prospectively enrolled 176 patients undergoing total arterial myocardial revascularization and assigned them at random to one of two groups: group 1 was composed of 88 patients undergoing coronary surgery with cardiopulmonary bypass (CPB); group 2 consisted of 88 patients receiving the OPCAB procedure. We excluded from this study patients with significant risk factors for CPB-related morbidity. Composite arterial grafts in Y-T shape were realized in three different configurations according to patients' characteristics, coronary anatomy, and target stenosis.

RESULTS

There were no significant differences between the two groups in terms of preoperative characteristics and risk factors (Euroscore: group 1 = 6.1 +/- 3.5, group 2 = 6.6 +/- 3.8). Mean number of anastomoses was similar in both groups (group 1 = 2.8 +/- 0.8, group 2 = 2.7 +/- 0.5) whereas mean mechanical ventilation time (group 1 = 23 +/- 9 hours, group 2 = 9 +/- 4 hours), intensive care unit stay (group 1 = 43 +/- 6 hours, group 2 = 22 +/- 8 hours), and postoperative stay (group 1 = 7 +/- 3 days, group 2 = 5 +/- 2 days) were significantly reduced in group 2. Early mortality was 2.3% in group 1 and 3.4% in group 2 (p = not significant). Major postoperative complications occurred similarly in the two groups (atrial fibrillation: group 1 = 35.2%, group 2 = 21.6%; myocardial infarction: group 1 = 2.2%, group 2 = 1.1%; stroke: group 1 = 2.2%, group 2 = 0%; abdominal infarction: group 1 = 3.4%, group 2 = 0%). At follow-up (mean, 15 +/- 12 months) no significant differences were observed in terms of survival free of any cardiac-related event (group 1 = 94.3%, group 2 = 96.5%; p = not significant).

CONCLUSIONS

Off-pump coronary artery surgery could be successfully used for total arterial grafting without compromising the completeness of revascularization. Avoidance of CPB significantly decreased mechanical ventilation support and length of intensive care unit and postoperative stay; however in the absence of risk factors for cardiopulmonary bypass, off-pump coronary artery surgery did not improve early and midterm clinical outcome.

Long-term patency of the right internal mammary artery used as a coronary bypass conduit and the effect of the recipient vessel

This study reviewed our experience with the long-term patency of the right internal mammary coronary artery (RIMA) bypass graft in 58 patients over 1 year. Thirty-one percent (n = 18) of patients had obstructive lesions in the RIMA. In vessels with any lesion, the percent stenosis was 85.5% (range 30% to 100%). Eleven of 38 patients (28%) with right-sided recipient vessels had significant stenosis, whereas 21% of left-sided recipient vessels had significant stenosis of the RIMA. When compared with left internal mammary artery grafting, the long-term patency of the RIMA was lower than expected and warrants larger prospective studies.

Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians

BACKGROUND

Despite well-established benefits of arterial (ART) grafting, surgeons have been reluctant to use this conduit in octogenarians. This study explores the influence of arterial revascularization on operative and long-term outcomes of coronary artery bypass grafting surgery.

METHODS

A retrospective analysis was conducted of 987 consecutive patients 80 years of age or older who underwent isolated coronary artery bypass grafting between January 1989 and November 2000. Patients with saphenous vein graft only (SVG; n = 574) were compared with those receiving arterial and saphenous vein grafts (ART+SVG; n = 413). Mean follow-up for SVG patients was 3.8 years (range, 4 months to 12.6 years) and 98.6% complete, and mean follow-up was 3.1 years for ART+SVG patients (range, 2 months to 11.2 years) and 97.3% complete.

RESULTS

Patients with SVG had a significantly higher (p = 0.009) operative mortality (11.1% versus 6.3%) and significantly longer postoperative length of stay (12.9 versus 10.7 days; p = 0.002) than ART+SVG recipients. More ART+SVG than SVG patients were free of all postoperative complications (290 of 413; 70.2% versus 372 of 574; 64.8%; p = 0.086). Multivariable analysis identified SVG as an independent predictor of operative mortality (p = 0.014) and late mortality (p = 0.040). When patients were matched by equivalent propensity scores to receive SVG only, operative mortality was higher for SVG patients in four of the five quintiles. At 10 years, 97.0% +/- 1.2% of SVG and 92.9% +/- 3.7% of ART+SVG current survivors were free of all late major adverse cardiac events (p = 0.565), and 95.5% of SVG patients and 97.5% of ART+SVG patients were in Canadian class 1 or 2 (p = 0.162). On the SF-36 quality-of-life assessment, ART+SVG patients scored significantly higher than both SVG patients and age-adjusted normal subjects. Physical health summary component scores were 36.8 +/- 11.0 for SVG and 41.0 +/- 10.3 for ART+SVG (p = 0.001). Mental health summary scores were comparable for the two groups.

CONCLUSIONS

Arterial grafting confers an operative survival benefit, and an enhanced long-term quality of life in elderly patients.

Safety and usefulness of composite grafts for total arterial myocardial revascularization: a prospective randomized evaluation

OBJECTIVES

To evaluate the results of total arterial revascularization with composite grafts compared with the results of conventional coronary surgery, we enrolled 200 consecutive patient undergoing myocardial revascularization.

METHODS

Patients were randomly assigned to 2 groups of 100 patients each: group 1 underwent total arterial revascularization, and group 2 received left internal thoracic artery on left anterior descending artery grafts plus additional saphenous vein grafts. The groups were comparable in terms of continuous and discrete variables and preoperative risk factors.

RESULTS

There were no differences between group 1 and group 2 in terms of the number of grafted vessels (mean, 2.8 vs 2.9, respectively), crossclamping time (mean, 38 +/- 7 vs 40 +/- 6 min, respectively), intensive care unit stay (mean, 25 +/- 8 vs 24 +/- 7 hours, respectively), and hospital mortality (1% in both groups) nor were there any differences in postoperative complications. At the mean follow-up of 12 +/- 4 months, patients receiving total arterial revascularization (group 1) showed a better outcome in terms of angina recurrence (group 1 vs group 2: 2 vs 13 patients, P =.007), need of percutaneous transluminal coronary angioplasty reintervention (group 1 vs group 2: 0 vs 8 patients, P =.0012), and actuarial freedom from cardiac events (group 1 vs group 2: 96% vs 67%, P =.006). Angiography carried out in 72% in group 1 and in 68% in group 2 demonstrated a patency rate of 99% of saphenous vein grafts in group 1 and 89% of saphenous grafts in group 2.

CONCLUSIONS

Total myocardial revascularization with composite arterial grafts provided superior clinical results and improved patient outcome, even in the short term to midterm. Arterial conduit-related benefits were clearly evident with respect to recurrence of angina and a higher graft patency rate.

Off-pump total arterial myocardial revascularization according to the right Y-graft configuration

OBJECTIVES

The aims of this study were as follows: 1) to evaluate the early outcome of the off-pump total arterial myocardial revascularization according to the right y-graft (lambda-graft) configuration and 2) to compare baseline flow and maximum flow between patients undergoing on-pump and off-pump right y-graft (RYG) construction.

METHODS

Between December 1998 and January 2001, 47 patients (Group I) and 20 patients (Group II) with three vessel disease underwent on-pump and off-pump coronary artery bypass graft (CABG) respectively according to the RYG configuration. The mean age was 55.5 +/- 4.7 years and 55 +/- 6.4 years in Groups I and II, respectively. The RYG was constructed employing both internal mammary arteries (IMAs) only, in 21 and 8 patients in Groups I and II, respectively, presenting proximal-middle third stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA). The modified RYG configuration employing both IMAs and radial artery (RA) was performed in 26 and 12 patients in Groups I and II, respectively, presenting middle-distal third stenosis of the LAD and distal stenosis of the RCA or posterior descending artery stenosis. Postoperatively all patients underwent transthoracic echo color-Doppler (TTECD) contrast enhanced (by Levovist) before and after adenosine provocative testat one week and three months after operation.

RESULTS

There were no hospital deaths. The mean mechanical ventilation was significantly different in Group I versus Group II patients, 18 +/- 4.4 hours versus 13 +/- 5.7 hours, respectively (p = 0.041). The mean intensive care unit stay was 1.5 +/- 0.6 days in Group I and 1 +/- 0.4 days in Group II (p = 0.033). There were no differences between Groups I and II regarding the IMA diameter, mean velocity, and mean flow. At follow-up time, 6 +/- 2.4 months after the surgical procedure, all patients were alive and free of angina. The coronary flow reserve (CFR) at LIMA main stem was significantly higher at three months when compared to the values at one week after the surgical procedure within the same group, (LIMA)CFR (three months) = 2.37 +/- 0.6 versus (LIMA)CFR (one week) = 2.07 +/- 0.4 (p = 0.005) in Group I and (LIMA)CFR (three months) = 2.4 +/- 0.4 versus (LIMA)CFR (one week) = 2.06 +/- 0.3 (p = 0.004) in Group II. Similarly, the CFR at RIMA main stem were significantly higher at three months when compared to the values at one week after the surgical procedure: (RIMA)CFR (three months) = 2.47 +/- 0.7 versus (RIMA)CFR (one week) = 2.1 +/- 0.5 (p = 0.004) in Group I and (RIMA)CFR (three months) = 2.48 +/- 0.5 versus (RIMA)CFR (one week) = 2.08 +/- 0.4 (p = 0.008) in Group II.

CONCLUSION

The flow dynamic data, almost identical between patients undergoing off-pump and on-pump total arterial myocardial revascularization (TAMR) according to the RYG configuration, demonstrate that this technique can be applied with excellent results without the employment of cardiopulmonary bypass in selected coronary artery disease patients.