Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients

Meta-analysis of BITA versus SITA grafting in diabetic patients: evidence from propensity score-matched studies

BACKGROUND

It has been demonstrated that the use of bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) improves long-term survival in comparison to the use of a single internal thoracic artery (SITA) graft. However, the optimal transplantation technique for diabetic patients remains undetermined. The purpose of this meta-analysis was to compare the effectiveness and safety of BITA and SITA CABG in diabetic patients.

METHODS

A comprehensive search of Google Scholar, Science Direct, and PubMed was conducted for studies with propensity score-matched comparing between BITA and SITA grafting in diabetic patients. The main goal was to know mid- to long-term mortality, and the supplementary results included incidence of deep sternal wound infection, 30-day mortality, and incidence of reoperation due to hemorrhage.

RESULTS

The meta-analysis included 11 studies involving 3762 diabetic patients with matched propensity scores. Compared to SITA grafting, BITA grafting was associated with a significant reduction in long-term mortality (HR 0.78; 95% CI 0.67-0.91), P = 0.03, I2 = 54%. There were no significant differences between the two groups in terms of 30-day mortality, reoperation for bleeding, cerebrovascular accident, or renal failure.

CONCLUSIONS

BITA grafting appears to provide better overall survival than SITA grafting in patients with diabetes. However, using BITA grafting is associated with a greater risk of deep sternal wound infection. These findings may help guide the choice of grafting technique in diabetic patients undergoing CABG.

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BACKGROUND

Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG.

METHODS

All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit.

RESULTS

A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG.

CONCLUSIONS

Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BACKGROUND

To compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).

METHODS

Among 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.

RESULTS

After adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504-0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499-0.902; p = 0.008).

CONCLUSIONS

Bilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification

BACKGROUND

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken.

OBJECTIVE

This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF).

METHODS

Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA).

RESULTS

Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm).

CONCLUSIONS

By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

Strategies to Minimize Sternal and Leg Wound Complications after Coronary Artery Bypass Grafting Using No-Touch Saphenous Vein Grafts

PURPOSE

The aims of the present study were to examine sternal and saphenous vein (SV) harvest site wound complication rates, and to assess the strategies to minimize the sternal and leg wound complications after coronary artery bypass grafting using a no-touch (NT) SV.

METHODS

Patients who underwent coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) and/or NT SV grafts from March 2021 to June 2023 (N = 166) at a newly opened cardiac surgical program were included. We obeyed the current guidelines for the prevention of sternal wound infection. In addition, unilateral ITA was used in most of the patients and the sternal wound was meticulously closed using multiple sternal wires (≥7) and ZipFix. For the NT SV harvesting, the LigaSure device was used to minimize thermal injury, and the wound was meticulously closed.

RESULTS

Sternal wound infections developed in 3/166 (1.8%) patients; all three patients showed superficial sternal wound infections. Leg wound complications were present in 2/153 (1.3%) patients, who recovered after secondary intention healing.

CONCLUSION

Sternal wound complications after CABG could be minimized by the unilateral ITA usage, meticulous closure of the sternal wound in addition to compliance with the current guidelines. Wound complications after NT SV harvest may also be minimized by preoperative evaluation, careful harvesting, and meticulous wound closure.

Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries

BACKGROUND

Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event".

METHODS

We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy.

RESULTS

This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis.

CONCLUSIONS

We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

Bilateral versus single internal mammary artery in diabetic patients: systematic review and meta-analysis

OBJECTIVES

Data on bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) on diabetics were analyzed; This is the only meta-analysis, the last 7 years.

METHODS

Medline through PubMed/EMBASE/CINHAL and the Cochrane Central Register of Controlled Trials; 179 articles were studied; 19 studies deemed suitable and were included in the analysis.

RESULTS

The mortality was 2.41% for BIMA versus 1.71% for SIMA (odds ratio [OR] =  0.95; 95% confidence interval [CI]: 0.74-1.22). Postoperative reopening for bleeding was higher at 3.75% for BIMA versus 2.91% for SIMA (OR =  1.49; 95% CI: 1.15-1.93). The incidence of MI was 0.87% for BIMA versus 0.83% for SIMA (OR =  0.73; 95% CI: 0.37-1.44). Deep sternal wound infection was 3.02% for BIMA and 1.95% for SIMA (OR =  1.57; 95% CI: 1.26-1.95). When skeletonized, the incidence of DSWI was 2.5% for BIMA versus 2.41% for SIMA. There was a significant difference at 5-year survival favoring the BIMA, 85.15% BIMA versus 80.77% SIMA (OR =  1.79; 95% CI: 1.60-2.01). The 10-year overall survival was 74.04% BIMA versus 61.57% SIMA (OR =  1.79; 95% CI: 1.61-1.98). The 15-year survival was 47.08% for BIMA versus 37.06% for SIMA (OR =  1.69; 95% CI: 1.52-1.88).

CONCLUSIONS

Postoperative bleeding was higher in BIMA group. Bilateral internal mammary artery in diabetic patients should be carried out in a skeletonize fashion, to reduce DSWI. There is a survival benefit of using BIMA in diabetics within 5 years of surgery; it remains significant up to 15 years.

Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts

INTRODUCTION

The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts.

METHODS

We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group.

RESULTS

Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent.

CONCLUSIONS

Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

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.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

Off-Pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Octogenarians

BACKGROUND

We compared postoperative outcomes in octogenarians who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).Methods and Results: Among 1,532 patients who underwent isolated coronary artery bypass grafting between 2002 and 2021, 173 octogenarians were analyzed retrospectively. After inverse probability of treatment weighting, we found no statistically significant difference regarding patients' preoperative characteristics. No patient experienced deep sternal wound infection. More patients in the single than bilateral ITA group died within 30 days after surgery (5.0% vs. 0%, respectively; P=0.003). The mean follow-up duration was 4.2 years. At 5 years, the freedom from overall death following bilateral versus single ITA grafting was 78.2% and 53.7%, respectively (log-rank test, P=0.003), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 67.9% and 44.8% respectively (log-rank test, P=0.002). In multivariable Cox models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio [HR] 0.555; 95% confidence interval [CI] 0.342-0.903; P=0.018) and MACCE (HR 0.586; 95% CI 0.376-0.913; P=0.018).

CONCLUSIONS

Compared with single ITA grafting, off-pump skeletonized bilateral ITA grafting is associated with lower rates of overall death and MACCE in octogenarians undergoing CABG and does not increase the risk of deep sternal wound infection.

Diagnostic radiology methods for assessing coronary artery bypass graft viability

The review describes available modern radiological methods which are currently applied for a detailed and comprehensive anatomical and functional assessment of the viability of various coronary artery bypass grafts. In addition, it presents some aspects of the implementation of these methods and clinical interpretation of the results.

Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients

OBJECTIVE

To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG).

METHODS

We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality.

RESULTS

Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality.

CONCLUSION

Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.

Minimally Invasive Coronary Artery Bypass Grafting with Ultrasonically Skeletonized Internal Thoracic Artery

Objective

This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors’ initial experience.

Methods

From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting.

Results

The patients’ mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality.

Conclusions

Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.

Refinement of Coronary Artery Bypass Grafting at Juntendo University Hospital

Surgical treatment of ischemic heart disease began in 1945. After 1970, coronary artery bypass grafting (CABG) with cardiopulmonary bypass was developed along with coronary angiography. Juntendo University has been treating ischemic heart disease since 1980, and is actively performing off-pump CABG (OPCAB) since 2002. Besides the age of patients undergoing surgery, complications such as chronic hemodialysis, cerebrovascular disease, and malignancies make it challenging to reduce postoperative complications using OPCAB as graft preservation. OPCAB is technically challenging, and the CORONARY trial did not reveal its superiority over conventional CABG. Furthermore, high revascularization rates and technical differences among surgeons are important concerns. While not widely accepted in Europe and the United States, OPCAB comprises 65% of all stand-alone CABG in Japan. Japan reported a 2.5% hospital mortality rate in 2018, while the US reported 2.2% (according to the American Association of Thoracic Surgeons). In contrast, Juntendo University Hospital has maintained a 1% hospital mortality rate since 1984. To reduce the incidence of remote stroke in CABG patients, Juntendo has been using stroke-free management since 2010. Postoperative atrial fibrillation is 4-5 times more likely to recur than normal sinus rhythm after a 5-year course. In our study, 20% of patients suffered from chronic atrial fibrillation after ten years. Furthermore, left atrial appendage closure or amputation significantly reduces stroke in patients who undergo CABG and develop postoperative atrial fibrillation. Thus, OPCAB is a minimally invasive procedure with fewer complications; prevention of cardiogenic cerebral infarction can help improve remote outcomes.

Up-to-Date, Skeletonized or Pedicle Bilateral Internal Mammary Artery; Does It Matter?

PURPOSE

In this article, we reported on the up-to-date literature regarding skeletonized bilateral internal mammary artery (BIMA) flow and the effect on sternal perfusion. We also reviewed the pros and cons of the skeletonization technique versus the conventional pedicle technique for harvesting the BIMA.

METHODS

We performed an up-to-date review using the PubMed database, with a specific focus on the contemporary published literature.

RESULTS

BIMA skeletonization can preserve the sternal microcirculation, minimize tissue damage, and maintain blood supply to the chest wall at the tissue level. This effect is also apparent in diabetics. Deep sternal wound infection (DSWI) rates are significantly less with skeletonization versus the conventional pedicle technique and are comparable to single internal mammary artery harvesting.

CONCLUSIONS

Contemporary large-scale studies demonstrate that skeletonization of the BIMA increases conduit length, provides superior flow, reduces the incidence of DSWIs, and improves late survival. Hopefully, this review will increase awareness of the compelling evidence in favor of using skeletonized internal mammary arteries and stimulate increased uptake of BIMA revascularization surgery.

Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.

Multiple versus single arterial grafting in the elderly: a meta-analysis of randomized controlled trials and propensity score studies

INTRODUCTION

The benefit of adding a second arterial conduit is still controversial, mainly in specific subgroups. We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and early results in elderly patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG).

EVIDENCE ACQUISITION

MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960-April 2020). Survival at a ≥ 1-year follow-up and early outcomes were evaluated. Outcomes were collected from matched samples or PS adjusted analysis: hazard ratio (HR) along with their variance, frequencies or odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events).

EVIDENCE SYNTHESIS

Eleven PS cohorts and 1 RCT comprising > 18,800 patients older than 70 (>6200 MAG and >12,500 SAG) were included in this meta-analysis. MAG was associated with lower long-term mortality (pooled HR: 0.81, 95%CI: 0.72-0.91, p<0.01, I2=64%) in the absence of higher risk of early mortality (pooled OR: 0.74, 95%CI: 0.44 to 1.25, p=0.27, I2=0%). In a meta-regression, MAG survival advantage was more pronounced in studies with a higher MAG usage rate (β = -0.0052, p=0.021).

CONCLUSIONS

Current evidence suggests that advanced age should not limit MAG's use considering its benefits in long-term survival. Of note, an individualized patient selection for this approach is warranted.

Bilateral Internal Thoracic Artery Grafting in Hemodialysis Patients

BACKGROUND

We compared postoperative outcomes in hemodialysis (HD) patients who underwent isolated coronary artery bypass grafting (CABG) for multivessel disease using either bilateral or single skeletonized internal thoracic artery.Methods and Results:Among 1,486 patients who underwent isolated CABG between 2002 and 2020, 145 HD patients were retrospectively analyzed. After inverse probability of treatment weighting, there were no significant differences in the preoperative characteristics. No significant differences in 30-day mortality (P=0.551) or postoperative deep sternal wound infection (P=0.778) were observed. However, the bilateral internal thoracic artery grafting group had a lower postoperative stroke rate (0% vs. 4.0%, P=0.019). No significant differences in freedom from all-cause death (P=0.760) and cardiac death (P=0.863) were found. In the multivariate Cox proportional hazards models, bilateral internal thoracic artery grafting was not associated with all-cause death (P=0.246) or cardiac death (P=0.435).

CONCLUSIONS

Bilateral internal thoracic artery grafting in HD patients did not improve mid-term outcomes, but it was also not associated with worse postoperative outcomes. Use of the bilateral internal thoracic artery may be an important option in patients with limited conduits to prevent postoperative complications.

Radial Artery vs Bilateral Mammary Composite Y Coronary Artery Grafting: 15-Year Outcomes

BACKGROUND

Total arterial coronary revascularization for three coronary territory disease can be achieved with a second arterial conduit joined to the left internal mammary artery as a Y graft, by using either a radial artery (RAY) or a second mammary artery (BIMAY).

METHODS

Patients undergoing total arterial revascularization for three coronary territory disease were identified from two cardiac surgical databases (in Sydney and Melbourne, Australia) using Society of Thoracic Surgeons-based definitions. BIMAY-treated patients underwent surgery between 1994 and 2009, mostly using an age-limited protocol, whereas RAY-treated patients underwent surgery between 1996 and 2003 without age limits. All-cause mortality data were acquired from the national death registry, and survival was estimated by the Kaplan-Meier method. Propensity score matching was performed using 13 variables. Given the age imbalance between the groups, the primary comparison was performed for age 66 years or younger.

RESULTS

Overall, 1896 patients underwent RAY procedures, and 720 patients underwent BIMAY operations. Older age at surgery was the strongest independent predictor of mortality, with a hazard ratio of 2.06, and a 95% confidence interval of 1.93, 2.22 (P < .001). After propensity score matching, we identified 299 pairs of patients 66 years of age or younger with no preoperative or operative differences and similar ages at surgery: RAY 56.4 ± 7.0 years of age vs BIMAY 56.4 ± 6.8 years of age (P = .96). The RAY group had 4.0 ± 0.9 grafts, and the BIMAY group had 3.9 ± 0.9 grafts (P = .814). All-cause mortality was not different, with the proportion surviving at 15 years at 74.9% for the RAY group vs 76.2% for the BIMAY group (P = .211).

CONCLUSIONS

Survival was not different between the RAY and BIMAY groups for total arterial revascularization of three coronary territory bypass grafting.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature

Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.

•

Bilateral internal thoracic artery grafting is superior to single internal thoracic artery grafting in terms of outcomes.

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Bilateral internal thoracic artery grafting is underused, especially in diabetic patients.

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The risk of DSWI in skeletonized BITA grafting in diabetic patients is almost similar to SITA grafting.

•

Skeletonized BITA grafting should be encouraged in selected diabetic patients.

Incidence, types and outcomes of sternal wound infections after cardiac surgery in Saudi Arabia. A retrospective medical chart review

Objectives:

To determine the incidence, types, risk factors, identify organisms, and assess outcomes of surgical wound infections (SWIs) after cardiac surgery at a tertiary hospital in Riyadh, Saudi Arabia.

Methods:

This historical cohort study reviewed the chart of patients who underwent cardiac surgery at King Khalid University Hospital, Riyadh, Saudi Arabia between January 2009 and December 2014. The proforma contained personal data, comorbidities, type of surgery, microbiological analysis, and management outcomes.

Results:

A total of 1241 patients were enrolled in the study comprising 1,032 (83.2%) men and 209 (16.8%) women. Forty (3.2%) patients developed SWI, of which 32 (2.5%) were superficial and 8 (0.7%) were deep. Gender, obesity, diabetes mellitus, non-use of statins, and coronary artery bypass graft (CABG) surgery were not significant predictors of infection in the study. Methicillin-susceptible Staphylococcus aureus was isolated predominantly in 45%, followed by Klebsiella and Pseudomonas species. Methicillin-resistant Staphylococcus aureus, Enterococcus faecium, and extended β-lactamase-producing gram-negative organisms were pathogens isolated in last 3 years of the review. Simple and vacuum assisted closure therapies led to complete resolution in 32 (80%) patients, while 8 (20%) developed sternal osteomyelitis. All patients survived except one with a deep SWI who died of uncontrolled sepsis.

Conclusion:

Despite the low incidence of postoperative SWIs, the risk of sternal osteomyelitis development persists. Meticulous choice of CABG components and appropriate postoperative management, especially detecting early signs of SWI could contribute to lower its incidence and complications.

A Novel Subxiphoid Approach for Bilateral Internal Thoracic Artery Harvesting

OBJECTIVE

Bilateral internal thoracic artery (BITA) bypass can enable more complete arterial revascularization procedures. Minimally invasive cardiac surgery (MICS) can offer significant patient benefits. New minimally invasive technology for sternal retraction and tissue manipulation is needed to enable ergonomic and reliable minimally invasive ITA harvesting. The goal of this research was to develop technology and techniques, along with experimental testing and training models, for a sternal-sparing approach to in situ BITA harvesting through a small subxiphoid access site.

METHODS

This study focused on optimizing custom equipment and methods for subxiphoid BITA harvesting initially in a porcine model (19 pig carcasses, 36 ITAs) and subsequently in 7 cadavers (14 ITAs).

RESULTS

Fifty consecutive ITAs were successfully harvested using this remote access approach. The last 20 ITA specimens harvested from the porcine model were explanted and measured; the average length of the free ITA grafts was 12.8 ± 0.9 cm (range 10.8 to 14.2 cm) with a mean time of 23.3 ± 5.2 minutes (range 13 to 25 minutes) for each harvest.

CONCLUSIONS

Early results demonstrate that both ITAs can be reliably harvested in a skeletonized fashion in situ through sternal-sparing, small subxiphoid access in 2 experimental models. This innovative approach warrants further exploration toward facilitating complete arterial revascularization and the further adoption of minimally invasive coronary artery bypass graft surgery.

The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

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 < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups.

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.

Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections

BACKGROUND

Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.

RESULTS

We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.

CONCLUSIONS

The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.

Multi-arterial and total-arterial coronary revascularization: Past, present, and future perspective

BACKGROUND AND AIM OF THE STUDY

Although abundant biological, clinical, and scientific evidence exists on the superiority of multi-arterial (MAR) and total-arterial revascularization (TAR) over the conventional strategy with a single internal thoracic artery, only 10% of patients undergoing coronary artery bypass grafting (CABG) in the United States receives a second arterial conduit, and only 5% of patients receives TAR.

METHODS AND RESULTS

In January 2020, the authors performed comprehensive search to identify studies that evaluated MAR and TAR strategies through the MEDLINE database.

CONCLUSIONS

In this paper, the authors reviewed the literature on the historical and current evidence in favor of MAR and TAR, thus underlying why current CABG practice needs qualitative improvement.

Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus: A Scientific Statement From the American Heart Association

Although cardiologists have long treated patients with coronary artery disease (CAD) and concomitant type 2 diabetes mellitus (T2DM), T2DM has traditionally been considered just a comorbidity that affected the development and progression of the disease. Over the past decade, a number of factors have shifted that have forced the cardiology community to reconsider the role of T2DM in CAD. First, in addition to being associated with increased cardiovascular risk, T2DM has the potential to affect a number of treatment choices for CAD. In this document, we discuss the role that T2DM has in the selection of testing for CAD, in medical management (both secondary prevention strategies and treatment of stable angina), and in the selection of revascularization strategy. Second, although glycemic control has been recommended as a part of comprehensive risk factor management in patients with CAD, there is mounting evidence that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes. In this document, we discuss the role of glycemic management (both in intensity of control and choice of medications) in cardiovascular outcomes. It is becoming clear that the cardiologist needs both to consider T2DM in cardiovascular treatment decisions and potentially to help guide the selection of glucose-lowering medications. Our statement provides a comprehensive summary of effective, patient-centered management of CAD in patients with T2DM, with emphasis on the emerging evidence. Given the increasing prevalence of T2DM and the accumulating evidence of the need to consider T2DM in treatment decisions, this knowledge will become ever more important to optimize our patients' cardiovascular outcomes.

Does Bilateral Internal Mammary Artery Grafting Better Suit Patients With Diabetes? - Two Different Ways to Explore Outcomes

BACKGROUND

This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.Methods and Results:Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001).

CONCLUSIONS

Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Coronary artery bypass surgery in type 2 diabetic patients: predictors of mortality and morbidity

Background

Coronary artery bypass grafting has been widely admitted in the therapeutic arsenal of coronary artery disease in diabetics with low morbi-mortality. However, it requires special management which may be challenging in low-volume centers especially in African countries. We aimed to analyze the outcome of coronary artery bypass graft in our diabetic population and define predictors of adverse events.

Patients and methods

We retrospectively enrolled 529 consecutive diabetic patients (type 2) who underwent on-pump coronary artery bypass grafting at our institution between January 2000 and June 2018. The mean age was 61.1 ± 8.3 years with 4.04 as sex ratio (M/F) and 2.95 as mean EuroSCORE II. History of acute myocardial infarction, left main coronary artery stenosis, and three-vessel disease was present in respectively 58%, 26.1%, and 72.2% of patients. The average number of bypass was 2.4 ± 0.8. Duration of cardiopulmonary bypass and aortic cross-clamping were respectively 124.8 ± 43.5 and 79.7 ± 32.9 min.

Results

In-hospital mortality was 5.9% (n = 31) and the late mortality was 6.9% (n = 32). Duration of artificial ventilation, ICU stay, and postoperative stay were respectively 7 h, 44 h, and 13 days. Postoperative complications were myocardial infarction, superficial wound infection, mediastinitis, and low cardiac output syndrome in respectively 9.1%, 25.5%, 3.8%, and 12.7% of patients. Multivariable logistic regression analysis revealed that left ventricular ejection fraction < 40% (OR = 1.88; 95% CI 1.30–2.47; p = 0.03), poor perioperative glycemic control (OR = 1.53; 95% CI 1.12–2.38; p = 0.014), intra-aortic balloon pump insertion (OR = 2.29; 95% CI 1.47–3.10; p < 0.001), and postoperative cardiac complications (OR = 2.01; 95% CI 1.23–2.78; p < 0.001) were predictors of in-hospital mortality. Predictors of mediastinitis were obesity (OR = 5.86; 95% CI 1.43–23.95; p = 0.014), inotropic drugs use (OR = 8.14; 95% CI 1.57–42.34; p = 0.013), chest reopening for bleeding (OR = 4.01; 95% CI 0.62–25.85; p = 0.014), and blood transfusion (OR = 7.56; 95% CI 1.09–52.76; p = 0.041). Follow-up was 86.1% complete, with a mean follow-up of 63.5 ± 48.3 months (1–192 months), and cumulative survival at 5, 10, and 15 years was respectively 95.5 ± 1.1%, 86.3 ± 2.9%, and 76.9 ± 6.9%.

Conclusion

Even in low-volume centers in developing areas, coronary artery bypass surgery is an effective therapy for coronary artery disease in diabetic patients despite a relative high morbidity and mortality.

A comparative review of the outcomes of using arterial versus venous conduits in coronary artery bypass graft (CABG)

Nowadays one of the most frequent reasons of death in the world is coronary artery disease. CABG is a portion of a common revascularization mediation that is done to supervise CAD by applying vessels that are grafted to revascularize vessels distal from the blockage. Different sources of grafts are included veins (specifically saphenous) and arteries (include mammary and radial arteries). Multiple conduits are used to this end, but the most suitable is left internal mammary artery (LIMA) to the left anterior descending artery (LAD) as a golden standard. Saphenous vein grafts were the guiding approach applied by the vast majority of cardiac surgeons in the 1970s, even though all approaches were supported by doctors. Although the radial artery graft was introduced simultaneously, this approach due to its complications was not as prevalent. This article is aimed to define the pros and cons of applying each kind of grafts according to the results furnished by existent studies. It has also examined the benefits provided by total arterial coronary artery bypass graft against CABG including venous graft for patients with CAD from the perspective of surgeons.

Arterial Grafts for Coronary Bypass

Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years.

Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery?

PURPOSE OF REVIEW

The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG).

RECENT FINDINGS

The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG.On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective.

SUMMARY

Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications.

Five-year costs from a randomised comparison of bilateral and single internal thoracic artery grafts

BACKGROUND

The use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting (CABG) may improve survival compared with CABG using single internal thoracic arteries (SITA). We assessed the long-term costs of BITA compared with SITA.

METHODS

Between June 2004 and December 2007, 3102 patients from 28 hospitals in seven countries were randomised to CABG surgery using BITA (n=1548) or SITA (n=1554). Detailed resource use data were collected from the initial hospital episode and annually up to 5 years. The associated costs of this resource use were assessed from a UK perspective with 5 year totals calculated for each trial arm and pre-selected patient subgroups.

RESULTS

Total costs increased by approximately £1000 annually in each arm, with no significant annual difference between trial arms. Cumulative costs per patient at 5-year follow-up remained significantly higher in the BITA group (£18 629) compared with the SITA group (£17 480; mean cost difference £1149, 95% CI £330 to £1968, p=0.006) due to the higher costs of the initial procedure. There were no significant differences between the trial arms in the cost associated with healthcare contacts, medication use or serious adverse events.

CONCLUSIONS

Higher index costs for BITA were still present at 5-year follow-up mainly driven by the higher initial cost with no subsequent difference emerging between 1 year and 5 years of follow-up. The overall cost-effectiveness of the two procedures, to be assessed at the primary endpoint of the 10-year follow-up, will depend on composite differences in costs and quality-adjusted survival.

TRIAL REGISTRATION NUMBER

ISRCTN46552265.