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Guo FW, Chen H, Dong YL, Shang JN, Ruan LT, Yan Y, Song Y. The Value of Left Internal Mammary Artery Flow Velocity in Predicting the Prognosis of Patients After Coronary Artery Bypass Grafting. Cardiol Res 2023; 14:396-402. [PMID: 37936630 PMCID: PMC10627374 DOI: 10.14740/cr1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Background The purpose of this study was to explore the value of the left internal mammary artery flow velocity (LIMAV) measured by ultrasound before coronary artery bypass grafting (CABG) in predicting the prognosis of patients after left internal mammary artery (LIMA) bypass grafting. Methods One hundred and four patients who underwent CABG with LIMA as the bridge vessel in the cardiovascular surgery department of our hospital between May 2018 and June 2019 were selected. All patients underwent transthoracic Doppler ultrasonography to measure LIMAV preoperatively. Intraoperatively, mean graft flow (MGF) and pulsatility index (PI) of the LIMA bridge were measured using transit time flow measurement (TTFM). The primary endpoint event in this study was cardiac death within 18 months after surgery. Results The Cox survival analysis showed that the MGF, the LIMAV and left ventricular ejection fraction (LVEF) were risk factors for death after CABG. The cut-offs of MGF, LIMAV and LVEF for the prediction of death after CABG were ≤ 14 mL/min (area under the curve (AUC): 0.830; sensitivity: 100%; specificity: 65.6%), ≤ 60 cm/s (AUC: 0.759; sensitivity: 65.5%; specificity: 85.3%), and ≤ 44% (AUC: 0.724; sensitivity: 50%; specificity: 88.5%), respectively. Compared with the use of MGF, MGF + LIMAV, combination of the MGF + LIMAV + LVEF (AUC: 0.929; sensitivity: 100%; specificity: 81.1%) resulted in a stronger predictive value (MGF vs. MGF + LIMAV + LVEF: P = 0.02). Conclusion LIMAV measured by preoperative transthoracic ultrasound combined with intraoperative MGF and LVEF may have a greater value in predicting patients' risk of cardiac death after CABG.
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Affiliation(s)
- Feng Wei Guo
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Hong Chen
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Ya Ling Dong
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Jia Nan Shang
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Li Tao Ruan
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Yang Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Yan Song
- Department of Ultrasound, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
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Stefil M, Dixon M, Benedetto U, Gaudino M, Lees B, Gray A, Gerry S, Taggart D, Flather M. Coronary artery bypass grafting using bilateral internal thoracic arteries in patients with diabetes and obesity: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2023; 47:101235. [PMID: 37576079 PMCID: PMC10422672 DOI: 10.1016/j.ijcha.2023.101235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/06/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023]
Abstract
Background Patients with diabetes and obesity are at higher risk of adverse long-term outcomes following coronary artery bypass grafting. The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA), but BITA is not routinely used due to lack of clear evidence of efficacy and concerns over sternal wound complications. Methods Medline, Embase and the Cochrane Library were searched for studies comparing the efficacy and safety of BITA and SITA grafting in patients with diabetes and obesity. Meta-analysis of mortality and sternal wound complications was performed. Results We identified eight observational and ten propensity matched studies, and one RCT, comparing BITA and SITA which included patients with diabetes (n = 19,589); two propensity matched studies and one RCT which included patients with obesity (n = 6,972); mean follow up was 10.5 and 11.3 years respectively. Meta-analysis demonstrated a mortality reduction for BITA compared to SITA in patients with diabetes (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70-0.90; p = 0.0003). In patients with obesity there was a non-significant reduction in mortality in the BITA group (RR 0.73, 95% CI 0.47-1.12; p = 0.15). There was a significantly higher rate of sternal wound complications following BITA observed in patients with diabetes (RR 1.53, 95% CI 1.23-1.90; p = 0.0001) and obesity (RR 2.24, 95% CI 1.63-3.07; p < 0.00001). Conclusions BITA is associated with better long-term survival in patients with diabetes. The effects of BITA grafting in patients with obesity are uncertain. BITA is associated with higher rates of sternal wound complications compared to SITA in both patients with diabetes and obesity.
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Affiliation(s)
- Maria Stefil
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Matthew Dixon
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norfolk and Norwich University Hospital, Norwich, United Kingdom
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Rodgers-Fischl PM, Makdisi G. Internal Thoracic Artery and Vascular Adaptations. Ann Thorac Surg 2021; 113:695. [PMID: 34102180 DOI: 10.1016/j.athoracsur.2021.05.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Peter M Rodgers-Fischl
- Division of Cardiothoracic Surgery, University of Kentucky Medical Center, 800 Rose Street MN 150 Lexington, KY 40536-0298.
| | - George Makdisi
- Division of Cardiothoracic Surgery, University of South Florida, Tampa, FL, USA
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Kanzaki T, Numata S, Yamazaki S, Ikemoto K, Hohri Y, Yaku H, Itatani K, Nakajma S, Takahashi A. Computational fluid dynamics of internal mammary artery-left anterior descending artery anastomoses. Interact Cardiovasc Thorac Surg 2020; 31:611-617. [PMID: 33137825 DOI: 10.1093/icvts/ivaa183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/01/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to elucidate the remodelling of the internal mammary artery (IMA)-left anterior descending artery anastomosis and compare 2 different anastomosis techniques (end-to-side versus side-to-side) using computational fluid dynamics. METHODS This study included 9 patients. Computed tomography (CT) angiography was performed immediately after coronary artery bypass grafting (CABG) and at 3-6 months later. The computational fluid dynamics models were made using the CT data. The pulsatile 3-dimensional blood flow was achieved with the finite volume method to evaluate the postoperative morphological and haemodynamic changes at the anastomosis in each patient. Flow velocity distribution, wall shear stress (WSS) and its fluctuation oscillatory shear index were measured. RESULTS No early or mid-term graft occlusion was observed in the study series. In the side-to-side anastomosis, pouch formation at the distal end of IMA caused a vortex flow with low WSS immediately after CABG. However, at 3-6 months after surgery, this pouch disappeared. As a result, the laminar straight flow with uniform WSS distribution was achieved inside the anastomosis. In the end-to-side anastomosis, the anastomosis shape was remodelled, resulting in a laminar flow pattern with uniform WSS distribution. A patchy high oscillatory shear index was detected at the IMA wall on the top of anastomosis in either anastomosis techniques immediately after the surgery, but it disappeared at 3-6 months after surgery. CONCLUSIONS Regardless of the anastomosis technique used, a successful remodelling of the IMA-left anterior descending artery anastomosis shape was achieved a few months after surgery, resulting in a straightforward flow streamline, with uniform WSS distribution and minimal oscillatory shear index.
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Affiliation(s)
- Tomohito Kanzaki
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Yamazaki
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Koki Ikemoto
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunsuke Nakajma
- Department of Cardiology, Sakurakai Takahashi Hospital, Hyogo, Japan
| | - Akihiko Takahashi
- Department of Cardiology, Sakurakai Takahashi Hospital, Hyogo, Japan
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Niclauss L, Masci PG, Pavon AG, Rodrigues D, Schwitter J. Blood flow assessment by transit time flow measurement and its prognostic impact in coronary bypass surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:356-368. [DOI: 10.23736/s0021-9509.20.11150-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Intimal regeneration after coronary endarterectomy and onlay grafting in coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 67:677-683. [PMID: 30790237 DOI: 10.1007/s11748-019-01083-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Coronary onlay grafting, with or without endarterectomy, has been widely used for the treatment of diffuse lesions. Recent studies have demonstrated excellent long-term patency and favorable remodeling of onlay anastomosis; however, the underlying mechanisms remain unknown. Here, we describe the mechanism of intimal regeneration based on postmortem pathological evaluation of a patient who had undergone onlay grafting with coronary endarterectomy. METHODS The onlay anastomosis was analyzed using a combination of immunohistological stainings, namely, H&E, vimentin, α-SMA, factor VIII, and Ki-67, to identify the source and mechanism of intimal regeneration after onlay grafting with endarterectomy. RESULTS Our results suggest that the regenerated endothelium derives from the smooth muscle cells of the endarterectomized media of the coronary artery and that it circumferentially covers the internal lumen of the arterial graft. CONCLUSIONS Intimal regeneration, derived from the smooth muscle cells of the endarterectomized coronary artery that proliferate toward the graft lumen, may be a key mechanism that underlies the observed favorable remodeling after onlay grafting during coronary endarterectomy.
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Jung Y, Ahn BH, Kim GS, Jeong IS, Lee KS, Song SY, Na KJ, Oh SG. Change in luminal diameter of the left internal thoracic artery anastomosed to the totally occluded left anterior descending coronary artery. J Cardiothorac Surg 2016; 11:157. [PMID: 27894348 PMCID: PMC5126870 DOI: 10.1186/s13019-016-0554-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 11/24/2016] [Indexed: 12/05/2022] Open
Abstract
Background Coronary artery bypass grafting (CABG) with a composite Y-graft made of the left internal thoracic artery (LITA) and another arterial graft has a risk for hypoperfusion. Changes over time in the diameter of the LITA anastomosed to the left anterior descending coronary artery (LAD) are not known. Methods Data were collected for 71 patients who had undergone coronary angiography (CAG) immediately and at 1 year following off-pump CABG with a composite Y-graft made of the LITA and either the radial artery or the right gastroepiploic artery. These patients were divided into 2 groups depending on the degree of LAD stenosis. Group 1 (n = 28) consisted of patients with complete occlusion of the LAD. Group 2 (n = 43) consisted of patients with <90% stenosis of the LAD. The clinical state and luminal diameter of the LITA on immediate postoperative and postoperative 1-year CAG were compared and analyzed. Results On the immediate postoperative CAG, mean LITA diameter of Group 1 was larger than that of Group 2 (2.09 ± 0.53 vs. 1.61 ± 0.33 mm, P = 0.01). Mean LITA diameter 1 year following CABG was also larger in Group 1 than in Group 2 (2.49 ± 0.31 vs. 2.10 ± 0.45 mm, P = 0.005). Both groups showed significant increases in the LITA diameters at postoperative 1 year. Conclusions The LITA used as a composite Y-graft underwent remodeling, resulting in a larger diameter, to supply adequate myocardial blood. The degree of change in luminal diameter varied according to the severity of the LAD stenosis.
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Affiliation(s)
- Yochun Jung
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea
| | - Byoung Hee Ahn
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea
| | - Gwan Sic Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea
| | - Kyo Seon Lee
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Sang Gi Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 501-757, South Korea.
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8
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Nakajima T, Tachibana K, Takagi N, Ito T, Kawaharada N. Histomorphologic superiority of internal thoracic arteries over right gastroepiploic arteries for coronary bypass. J Thorac Cardiovasc Surg 2016; 151:1704-8. [PMID: 26971376 DOI: 10.1016/j.jtcvs.2016.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/15/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In this study, we compared the histologic and morphometric properties of both internal thoracic arteries and the right gastroepiploic artery (GEA) in patients undergoing coronary artery bypass grafting (CABG). METHODS We microscopically examined transverse sections of segments of both internal thoracic arteries and the right GEA obtained from 83 consecutive patients who underwent CABG. RESULTS There were no significant differences between the internal thoracic arteries. Significant differences were found between the left and right internal thoracic arteries and GEA in the intimal width (21.8, 21.5, and 71.7 μm, respectively; P < .01), intima-to-media ratio (0.286, 0.256, and 0.749, respectively; P < .01), and media width (148.5, 157.5, and 164.8 μm, respectively; P = .43). No atherosclerotic lesions, medial calcification, or intimal thickening were seen in the internal thoracic arteries; however, atherosclerotic lesions were seen in the GEA. The intima of the GEA was thicker than that of the internal thoracic arteries. Intimal thickening of the GEA, but not the internal thoracic arteries, was positively correlated with risk of arteriosclerosis. In patients with diabetes mellitus, dietary/drug therapy and insulin therapy were associated with GEA intimal thickness (P = .02 and .01, respectively). CONCLUSIONS The internal thoracic arteries have equivalent histologic and morphometric properties that differ from those of the GEA only in intimal width. The former had no intimal thickening, and is thus preferable to the GEA for CABG.
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Affiliation(s)
- Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Kazutoshi Tachibana
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuyuki Takagi
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiro Ito
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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Change of luminal diameter of skeletonized and non-skeletonized radial artery graft at early and late postoperative period. Heart Vessels 2015; 31:474-81. [PMID: 25656931 PMCID: PMC4820472 DOI: 10.1007/s00380-015-0639-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 01/23/2015] [Indexed: 11/21/2022]
Abstract
The radial artery is increasingly used as a second arterial conduit for myocardial revascularization. However, the radial artery is susceptible to vasospasm, which is thought to be the principal cause of graft
failure. The radial artery is harvested as a skeletonized or a non-skeletonized graft, but the effect of different harvesting technique remains unknown. In this study, we compared the early- and mid-term angiographic findings to elucidate its influence on the graft luminal diameter. We harvested 39 radial arteries either as a skeletonized (n = 18) or a non-skeletonized graft (n = 21) using an ultrasonic scalpel. We constructed a composite straight graft by combining a right internal thoracic artery and a radial artery. All the radial artery grafts were sequentially anastomosed to coronary arteries. We measured the diameters of the radial arteries before the operation, within 1 month and 1 year after the operation. At early postoperative period, graft diameter was significantly larger in skeletonized grafts. Graft diameter at the point before the first and the second anastomosis was similar in skeletonized grafts, although that was significantly smaller before the second anastomosis in non-skeletonized grafts. However, 1 year after the operation, the graft diameter was comparable and equally reduced after the first anastomosis in both groups. Skeletonization with an ultrasonic scalpel increases the luminal diameter of the radial artery graft at early postoperative period, which, however, reduces possibly as adaptation to graft flow 1 year after the operation.
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10
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Davierwala PM, Mohr FW. Bilateral internal mammary artery grafting: rationale and evidence. Int J Surg 2015; 16:133-9. [PMID: 25612853 DOI: 10.1016/j.ijsu.2015.01.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/13/2015] [Accepted: 01/15/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
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11
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Vitulli P, Frati G, Benedetto U. Bilateral internal mammary artery grafting in obese: outcomes, concerns and controversies. Int J Surg 2015; 16:158-62. [PMID: 25598215 DOI: 10.1016/j.ijsu.2015.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/06/2015] [Accepted: 01/13/2015] [Indexed: 01/22/2023]
Abstract
Obese patients are generally considered unsuitable to receive bilateral internal mammary arteries (BIMA) during coronary artery bypass grafting (CABG) due to the perceived vulnerability to sternal wound infection and lack of evidence supporting long-term survival benefit. However, no consistent evidence currently discourages the use of BIMA in obese patients. The present review questions the common perception that obesity unacceptably increases the risk of sternal wound complications in patients receiving BIMA grafting. Moreover, the use of skeletonization harvesting technique is expected to further minimize such a risk. Our institutional experience confirmed that BIMA grafting is a safe strategy which does not increase operative mortality and does not significantly affect the incidence of sternal wound complications. On the other hand, a long term benefit in terms of overall survival and freedom from repeat revascularization from the use of BIMA was found.
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Affiliation(s)
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
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12
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Al-Sabti HA, Al Kindi A, Al-Rasadi K, Banerjee Y, Al-Hashmi K, Al-Hinai A. Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft. J Saudi Heart Assoc 2014; 25:247-54. [PMID: 24198449 DOI: 10.1016/j.jsha.2013.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 05/31/2013] [Accepted: 06/08/2013] [Indexed: 10/26/2022] Open
Abstract
Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.
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Sajja LR, Mannam G. Internal thoracic artery: anatomical and biological characteristics revisited. Asian Cardiovasc Thorac Ann 2014; 23:88-99. [PMID: 24585304 DOI: 10.1177/0218492314523629] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The left internal thoracic artery has become the conduit of choice for coronary artery bypass grafting, due to its superior patency rates at 10 or more years with little or no evidence of atherosclerotic changes. Recent evidence indicates that a second internal thoracic artery graft provides improved results relative to overall survival and major cardiac and cerebrovascular event-free survival, and reduces the need for repeat revascularization. However, the routine use of bilateral internal thoracic arteries is limited due to a perceived higher incidence of deep sternal wound infection. The surgical anatomy, collateral blood supply to the sternum, and biological characteristics of internal thoracic artery conduits are reviewed.
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Affiliation(s)
| | - Gopichand Mannam
- Division of Cardiothoracic Surgery, Star Hospitals, Hyderabad, India
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14
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Barner HB. Conduits for coronary bypass: strategies. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:319-27. [PMID: 24175266 PMCID: PMC3810553 DOI: 10.5090/kjtcs.2013.46.5.319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 09/05/2013] [Accepted: 09/05/2013] [Indexed: 01/02/2023]
Abstract
Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.
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Affiliation(s)
- Hendrick B Barner
- Division of Cardiothoracic Surgery, St. Louis University Hospital, USA
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15
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Otsuka F, Yahagi K, Sakakura K, Virmani R. Why is the mammary artery so special and what protects it from atherosclerosis? Ann Cardiothorac Surg 2013; 2:519-26. [PMID: 23977631 DOI: 10.3978/j.issn.2225-319x.2013.07.06] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 07/09/2013] [Indexed: 12/19/2022]
Abstract
The internal mammary artery (IMA) grafts have been associated with long-term patency and improved survival as compared to saphenous vein grafts (SVGs). Early failure of IMA is attributed to poor surgical technique and less with thrombosis. Similarly, bypass surgery especially with the use of IMA has also been shown to be superior at 1-year as well as over five years compared to percutaneous procedures, including the use of drug-eluting stents for the treatment of coronary artery disease. The superiority of IMAs over SVGs can be attributed to its striking resistance to the development of atherosclerosis. Structurally its endothelial layer shows fewer fenestrations, lower intercellular junction permeability, greater anti-thrombotic molecules such as heparin sulfate and tissue plasminogen activator, and higher endothelial nitric oxide production, which are some of the unique ways that make the IMA impervious to the transfer of lipoproteins, which are responsible for the development of atherosclerosis. A better comprehension of the molecular resistance to the generation of adhesion molecules that are involved in the transfer of inflammatory cells into the arterial wall that also induce smooth muscle cell proliferation is needed. This basic understanding is crucial to championing the use of IMA as the first line of defense for the treatment of coronary artery disease.
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Barner HB. Conduits for Coronary Bypass: Arteries Other Than the Internal Thoracic Artery's. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:165-77. [PMID: 23772403 PMCID: PMC3680601 DOI: 10.5090/kjtcs.2013.46.3.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 05/06/2013] [Accepted: 05/06/2013] [Indexed: 11/16/2022]
Abstract
This is the third in a series on coronary artery bypass which reviews three alternative arterial conduits. The radial artery has become the most widely used of the three and accumulating experience demonstrates better patency at 10 years versus saphenous vein. Drawbacks are a long incision on the forearm, the propensity for spasm and persistent sensory disturbance in about 10%. The first is answered by endoscopic harvest which may yield a shorter conduit but reduces sensory nerve injury. Spasm is managed pharmacologically and by less harvest trauma. The gastroepiploic artery is used in situ and free and although the abdominal cavity is entered complications are minimal and patency compares favorably with the radial artery. Use of the inferior epigastric artery remains minimal and its similar length often requires composite use but limited patency data are supportive. Other arteries have had rare use and this is unlikely to change because the three presented here have significant advantages and acceptance.
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Affiliation(s)
- Hendrick B Barner
- Division of Cardiothoracic Surgery, St. Louis University Hospital, USA
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Barner HB. Conduits for coronary bypass: internal thoracic artery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:351-67. [PMID: 23275918 PMCID: PMC3530720 DOI: 10.5090/kjtcs.2012.45.6.351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 11/11/2012] [Accepted: 11/12/2012] [Indexed: 11/19/2022]
Abstract
This second report in the series on coronary artery bypass presents the authors experience and personal views on the internal thoracic artery (ITA) which date to 1966. There has been a very gradual evolution in the acceptance of this conduit which was initially compared with the saphenous vein and viewed as an improbable alternative to it. As is common with concepts and techniques which are 'outside the box' there was skepticism and criticism of this new conduit which was more difficult and time consuming to harvest for the surgeon who had to do it all. It was viewed as small, fragile, spastic and its flow capacity was questioned. Only a few surgeons employed it because of these issues and some of them would frequently graft it to the diagonal artery as it was thought not to supply adequate flow for the left anterior descending unless it was small. After a decade, angiographic data revealed superior patency to vein grafts. Even this evidence and survival benefit reported a few years later did not convince many surgeons that their concerns about limitations justified its use. Thus widespread adaption of the ITA as the conduit of choice for the anterior descending required another decade and bilateral use is only now expanding to more than 5% of patients in the US and somewhat faster in other countries.
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Affiliation(s)
- Hendrick B Barner
- Division of Cardiothoracic Surgery, St. Louis University Hospital, USA
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Absence of deterioration of vascular function of the donor limb at late follow-up after radial artery harvesting. J Thorac Cardiovasc Surg 2011; 142:298-301. [DOI: 10.1016/j.jtcvs.2010.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/14/2010] [Accepted: 10/05/2010] [Indexed: 11/22/2022]
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Abstract
The internal thoracic artery (ITA) has become the gold standard graft material for modern coronary artery bypass grafting (CABG) because of its excellent long-term patency. The use of ITA grafts has also prolonged the postoperative survival of patients when applied to the left anterior descending artery or used bilaterally as 2 grafts for the left coronary system. Moreover, recent large-scale randomized clinical trials comparing the survival rates between CABG and percutaneous coronary intervention (PCI) with stents have shown that CABG is more effective for improving the survival of patients with severe coronary artery disease and/or in those with diabetes mellitus. The fundamental principle underlying these clinical benefits of CABG is the excellent endothelial function of the ITA, which provides physiological and metabolic effects that are beneficial not only for the graft itself, but also for the recipient coronary system. The production of nitric oxide and prostanoids by the ITA endothelium and their beneficial effects on the downstream coronary artery should therefore be taken into consideration when debating the merits of CABG vs. PCI.
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Affiliation(s)
- Soichiro Kitamura
- National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
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Manabe S, Fukui T, Tabata M, Shimokawa T, Morita S, Takanashi S. Arterial graft deterioration one year after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2010; 140:1306-11. [DOI: 10.1016/j.jtcvs.2010.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 11/26/2009] [Accepted: 01/01/2010] [Indexed: 11/27/2022]
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Plass A. Invited Commentary. Ann Thorac Surg 2009; 88:57-8. [DOI: 10.1016/j.athoracsur.2009.04.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 04/17/2009] [Accepted: 04/21/2009] [Indexed: 11/25/2022]
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Remodeling of Reconstructed Left Anterior Descending Coronary Arteries With Internal Thoracic Artery Grafts. Ann Thorac Surg 2009; 88:54-7. [DOI: 10.1016/j.athoracsur.2009.03.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Revised: 03/10/2009] [Accepted: 03/10/2009] [Indexed: 11/21/2022]
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Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah AS, Habib RH. Late results of conventional versus all-arterial revascularization based on internal thoracic and radial artery grafting. Ann Thorac Surg 2009; 87:19-26.e2. [PMID: 19101262 DOI: 10.1016/j.athoracsur.2008.09.050] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 09/16/2008] [Accepted: 09/19/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Use of one or more arterial grafts to revascularize two-vessel and three-vessel coronary artery disease has been shown to improve coronary artery bypass graft surgery (CABG) survival. Yet, the presumed long-term survival benefits of all-arterial CABG have not been quantified. METHODS We compared propensity-adjusted 12-year survival in two contemporaneous multivessel primary CABG cohorts with all patients receiving 2 or more grafts: (1) all-arterial cohort (n = 612; 297 three-vessel disease [49%]); and (2) single internal thoracic artery (ITA) plus saphenous vein (SV) cohort (n = 4,131; 3,187 three-vessel disease [77%]). RESULTS Early (30-day) deaths were similar for the all-arterial and ITA/SV cohorts (8 [1.30%] versus 69 [1.67%]) whereas late mortality was substantially greater for the ITA/SV cohort (85 [13.9%] versus 1,216 [29.4%]; p < 0.0001). The risk-adjusted 12-year survival was significantly better for all-arterial (with a risk ratio [RR] = 0.60; 95% confidence interval [CI]: 0.48 to 0.75; p < 0.001), but this benefit was true only for three-vessel disease (RR = 0.58; 95% CI: 0.43 to 0.78; p < 0.001) and not for two-vessel disease (RR = 0.97; 95% CI: 0.66 to 1.43; p = 0.89). The all-arterial survival benefit was also true for varying risk subcohorts: no diabetes mellitus (RR = 0.50; 95% CI: 0.37 to 0.69), diabetes mellitus (RR = 0.77; 95% CI: 0.56 to 1.07), ejection fraction 40% or greater (RR = 0.60; 95% CI: 0.45 to 0.78), and ejection fraction less than 40% (RR = 0.62; 95% CI: 0.40 to 0.98). Lastly, the multivariate analysis indicated a strong long-term effect of completeness of revascularization, particularly for all-arterial patients, so that compared with patients with two grafts, survival was significantly better when three grafts (RR = 0.54; 95% CI: 0.33 to 0.87) or four grafts (RR = 0.40; 95% CI: 0.21 to 0.76) were completed. CONCLUSIONS All-arterial revascularization is associated with significantly better 12-year survival compared with the standard single ITA with saphenous vein CABG operation, in particular for triple-vessel disease patients. The completeness of revascularization of the underlying coronary disease is critical for maximizing the long-term benefits of arterial-only grafting.
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Affiliation(s)
- Anoar Zacharias
- Yvonne Viens, SGM, Research Institute, Saint Vincent Mercy Medical Center, Toledo, Ohio 43608, USA
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Abstract
In the past decade, the use of the radial artery as a coronary artery bypass graft has been revitalized. However, there has been controversy regarding harvest techniques, antispasm protocols, and selection of target vessels. It is widely accepted that the patency of radial-artery grafts depends on the severity of native-vessel stenosis. Thus, radial artery grafts should be preferentially used for target vessels with high-grade (>75% stenosis) lesions. In this review article, we analyzed the current status of radial artery grafts as a coronary bypass conduit based on our personal experience and recently published literature data.
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Walpoth BH, Schmid M, Schwab A, Bosshard A, Eckstein F, Carrel T, Hess OM. Vascular adaptation of the internal thoracic artery graft early and late after bypass surgery. J Thorac Cardiovasc Surg 2008; 136:876-83. [DOI: 10.1016/j.jtcvs.2008.05.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 04/18/2008] [Accepted: 05/19/2008] [Indexed: 11/15/2022]
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Remodeling of the radial artery anastomosed to the internal thoracic artery as a composite straight graft. J Thorac Cardiovasc Surg 2007; 134:1136-42. [DOI: 10.1016/j.jtcvs.2007.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 07/20/2007] [Accepted: 07/26/2007] [Indexed: 11/21/2022]
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27
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Taniguchi M, Akasaka T, Saito Y, Kaji S, Kawamoto T, Sukmawan R, Yoshitani H, Neishi Y, Ohe T, Tanemoto K, Yoshida K. Improvement of flow capacity of the left internal thoracic artery graft assessed by using a pressure wire. J Thorac Cardiovasc Surg 2007; 134:1012-6. [PMID: 17903522 DOI: 10.1016/j.jtcvs.2007.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 04/11/2007] [Accepted: 05/11/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We sought to evaluate improvement of flow capacity in a left internal thoracic artery graft by means of pressure measurement. METHODS Eighteen patients who received a left internal thoracic artery graft to the left anterior descending coronary artery were studied. Angiography and pressure measurement at the proximal and distal portions of the left internal thoracic artery graft during maximal hyperemia with a pressure guide wire were performed at 1 month (early study) and 6 months (late study) after surgical intervention. RESULTS There are no significant differences between the early and late studies in resting mean aortic pressure, left ventricular end-diastolic pressure, left ventricular ejection fraction, and percentage diameter stenosis of the recipient left anterior descending coronary artery. There was no stenosis in the anastomosis site of the left internal thoracic artery graft and the distal left anterior descending coronary artery, as determined by means of angiography, in the early and late studies. The mean diameter of the distal left internal thoracic artery graft was significantly increased in the late study (1.6 +/- 0.2 vs. 1.8 +/- 0.2 mm, P = .011). There was a significant difference between the early and late studies in the pressure gradient through the graft (15 +/- 4 vs 13 +/- 3 mm Hg, P = .036). The ratio of distal to proximal pressure within the left internal thoracic artery graft in the late study was significantly increased from that in the early study (0.80 +/- 0.04 to 0.84 +/- 0.03, P = .0003). CONCLUSIONS The pressure ratio within the left internal thoracic artery graft became higher as the left internal thoracic artery graft adapted itself to the myocardial circulation. This finding might relate to decreasing the resistance of the left internal thoracic artery graft.
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Affiliation(s)
- Manabu Taniguchi
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan.
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Barry M, Touati G, Chardon K, Laude M, Libert JP, Sevestre H. Histologic study of coronary, radial, ulnar, epigastric and internal thoracic arteries: application to coronary artery bypass grafts. Surg Radiol Anat 2007; 29:297-302. [PMID: 17505775 DOI: 10.1007/s00276-007-0214-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 04/19/2007] [Indexed: 11/26/2022]
Abstract
The biometry and the histology of coronary, radial, ulnar, epigastric and internal thoracic arteries were studied in order to investigate the cause of their occlusions in coronary bypass grafts and to improve the results of these bypass grafts. These various arteries were removed from 40 anatomical specimens (27 males and 13 females). We found a correlation between the internal calibers of the ulnar and coronary arteries in males. Intimal changes and the presence of atheromatous plaque were observed in coronary, radial and ulnar arteries, but never in the internal thoracic artery. Like coronary arteries and their branches, radial, ulnar and epigastric arteries are muscular arteries and ageing results in thickening of the intima, which becomes fibrotic with migration of myocytes from the media and duplication of the internal elastic lamina. The media becomes fibrous, hypertrophic or atrophic. In contrast, the internal thoracic artery is an elastic artery, like the aorta. Ageing is characterized by loss, over a variable extent, of one or several elastic laminae of the media and more marked intimal thickening. Although anatomically, the caliber of radial, ulnar, and epigastric arteries remains adapted to that of coronary arteries, the long-term patency of radial, ulnar and epigastric arteries used as grafts is related to their histological characteristics.
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Affiliation(s)
- M Barry
- Laboratoire d'Anatomie, Faculté de Médecine, Amiens, France.
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Abstract
Since its inception in the 1960s, coronary artery bypass graft (CABG) evolved as one of the most common, best documented, and most effective of all major surgical treatments for ischemic heart disease. Despite its widespread use, however, the outcome is not always completely satisfactory. The objective of this review is to highlight the physical determinants of biomechanical design of CABG so that future procedures would have prolonged patency and better outcome. Our central axiom postulates the existence of a mechanical homeostatic state of the blood vessel, i.e., the variation in vessel wall stresses and strains are relatively small under physiological conditions. Any perturbation of mechanical homeostasis leads to growth and remodeling. In this sense, stenosis and failure of a graft may be viewed as an adaptation process gone awry. We outline the principles of engineering design and discuss the biofluid and biosolid mechanics principles that may have the greatest bearing on mechanical homeostasis and the long-term outcome of CABG.
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Affiliation(s)
- Ghassan S Kassab
- Department of Biomedical Engineering, University of California, Irvine, California 92697-2715, USA.
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Mekontso-Dessap A, Kirsch M, Guignambert C, Zadigue P, Adnot S, Loisance D, Eddahibi S. Vascular-wall remodeling of 3 human bypass vessels: organ culture and smooth muscle cell properties. J Thorac Cardiovasc Surg 2006; 131:651-8. [PMID: 16515919 DOI: 10.1016/j.jtcvs.2005.08.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2005] [Revised: 08/19/2005] [Accepted: 08/26/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Late graft occlusions after coronary artery bypass grafting have been ascribed to neointimal hyperplasia. Given the pivotal role of smooth muscle cells in the pathogenesis of neointimal hyperplasia and the phenotypic heterogeneity of smooth muscle cells across vessels, we hypothesized that differences in long-term graft patency are at least partly related to differences in smooth muscle cell properties. The aim of the present study was to compare the vascular-wall remodeling of human internal thoracic artery, radial artery, and saphenous vein bypass conduits. METHODS We evaluated the intimal thickening of the human graft segments in organ cultures (histopathology, morphometric, and immunofluorescence analyses) and assessed the properties of cultured smooth muscle cells isolated from these vessels in terms of cell proliferation (tritiated thymidine incorporation), migration (modified Boyden chamber), and collagen synthesis (tritiated proline incorporation). RESULTS The total vessel-wall growth index and the intimal growth index were significantly higher for saphenous vein rings than for radial artery and internal thoracic artery rings. Immunofluorescence analyses showed predominant involvement of smooth muscle cells in neointimal growth induced by organ culture of saphenous vein rings. Cell proliferation was significantly higher in saphenous vein smooth muscle cells than in radial artery smooth muscle cells and significantly higher in radial artery smooth muscle cells than in internal thoracic artery smooth muscle cells. Migration of smooth muscle cells from saphenous vein grafts was significantly greater than from internal thoracic artery or radial artery grafts. Collagen synthesis was similar in smooth muscle cells from internal thoracic artery, radial artery, and saphenous vein grafts. CONCLUSIONS Ex vivo vascular-wall remodeling and smooth muscle cell intrinsic growth and migratory properties are dissimilar between arterial and venous grafts and might shed light on reported angiographic patency rates of these grafts.
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Affiliation(s)
- Armand Mekontso-Dessap
- Institut National de la Santé et de la Recherche Médicale, Faculté de Médecine de Créteil, Créteil, France.
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Kitamura S. Does the internal thoracic artery graft have self-reparative ability? J Thorac Cardiovasc Surg 2006; 130:1494-5. [PMID: 16307988 DOI: 10.1016/j.jtcvs.2005.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 08/22/2005] [Indexed: 10/25/2022]
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Barner HB, Sundt TM, Choong CK. Valve replacement after T-grafting: "beating heart surgery". Ann Thorac Surg 2006; 81:756-7. [PMID: 16427902 DOI: 10.1016/j.athoracsur.2004.11.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2004] [Revised: 11/19/2004] [Accepted: 11/22/2004] [Indexed: 11/24/2022]
Abstract
Patent internal thoracic and radial artery T-graft will adequately perfuse the heart during reoperation. Five of 1,023 patients with prior T-grafting had aortic (3) or mitral valve redo operations in which the heart was allowed to beat (after an initial dose of cardioplegia) during the operation without clamping the patent T-graft. Rapid resumption of cardiac function after one dose of cardioplegia and no intraoperative or postoperative evidence of myocardial infarction indicated adequacy of perfusion without apparent myocardial injury. This approach avoids injury to the T-graft from dissection and clamping, saves time, and simplifies the operation.
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Affiliation(s)
- Hendrick B Barner
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.
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Manabe S, Sunamori M. Radial Artery Graft for Coronary Artery Bypass Surgery: Biological Characteristics and Clinical Outcome. J Card Surg 2006; 21:102-14; 115. [PMID: 16426364 DOI: 10.1111/j.1540-8191.2006.00182.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The radial artery (RA) is gaining popularity as a bypass conduit for coronary artery bypass grafting, and its impact on clinical practice has been extensively explored. In the present article, we provide a review of postoperative hand circulation, vascular biological characteristics of the RA graft, the efficacy of vasodilator therapies, and mid-term clinical results of use of the RA graft. Fundamental studies revealed excellent vascular biological characteristics of the RA graft as a living arterial conduit, making it almost equivalent to the internal thoracic artery (ITA) graft. Clinical studies have yielded encouraging mid-term results. Most studies reported in favor of the RA graft over the saphenous vein graft with regard to patency rate, freedom from cardiac events, and survival. However, superiority of either the RA or right ITA graft has not been conclusively determined. The long-term results of RA grafts remain unknown, but at present, supplementary use of an RA graft with a left ITA graft appears feasible for CABG.
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Affiliation(s)
- Susumu Manabe
- Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-Ku, Tokyo 113-8519, Japan.
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Affleck DG, Barner HB, Bailey MS, Perry LA, Maniar H, Prasad SM, Damiano RJ. Flow dynamics of the internal thoracic and radial artery T-graft. Ann Thorac Surg 2005; 78:1290-4; discussion 1290-4. [PMID: 15464487 DOI: 10.1016/j.athoracsur.2004.03.113] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2004] [Indexed: 11/23/2022]
Abstract
BACKGROUND Complex use of arterial conduits has resurrected concerns about the adequacy of conduit flow. The T-graft is the extreme example of this trend. Our purpose was to identify the limitation of single source inflow and to compare flow capacity with completion coronary flow. METHODS Between February 1999 and November 2001, 372 patients underwent total arterial revascularization with the T-graft alone. Intraoperative flows were recorded for each limb of the T-graft before and after distal anastomoses in 204 patients. Independent predictors of T-graft flow were identified by multivariate analysis. RESULTS Free flow for the radial arterial (RA) limb was 161 +/- 81 mL/min, the internal thoracic artery (ITA) limb 137 +/- 57 mL/min (combined 298 +/- 101 mL/min) versus simultaneous limb flow of 226 +/- 84 mL/min giving a flow restriction of 24% +/- 14%. Completion coronary flow was 88 +/- 49 mL/min for the RA, 60 +/- 45 mL/min for the ITA, and 140 +/- 70 mL/min for both limbs simultaneously to give a flow reserve (vs simultaneous free flow) of 160% or 1.6. Independent predictors of completion RA limb flow are RA proximal diameter (p = 0.005), number of anastomoses (p = 0.018), and target stenosis (p = 0.005). CONCLUSIONS A flow reserve of 1.6 compares favorably with an ITA flow reserve of 1.8 at 1-month postoperatively and 1.8 for both the ITA T-graft and the ITA/RA T-graft at 1-week postoperatively as reported by others. Proximal RA diameter and competitive coronary flow influence completion T-graft flow. These data quantitate the limitation of single source inflow of the T-graft configuration and support its continued use.
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Affiliation(s)
- David G Affleck
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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36
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Ivascau C, Buklas D, Massetti M, Sabatier R, LePage O, Neri E, Babatasi G, Khayat A. Can An Early Peri-Anastomotic LITA Stenosis Be Reversible? Ann Thorac Surg 2005; 79:348-51. [PMID: 15620982 DOI: 10.1016/j.athoracsur.2003.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2003] [Indexed: 11/23/2022]
Abstract
Peri-anastomotic graft stenosis is a possible complication of coronary artery bypass graft operations. Early failure of myocardial revascularization may result from graft stenosis with inherent difficulties in perioperative diagnosis and subsequent management. We report the case of a 58-year-old man who experienced early preanastomotic left internal thoracic artery bypass stenosis that progressively resolved during a 2-year period without reoperation or interventional angioplasty. Although the mechanisms underlying graft stenosis remain unclear, this case emphasizes the role of repeated coronary angiography in the choice of treatment.
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Affiliation(s)
- Calin Ivascau
- Department of Thoracic and Cardiovascular Surgery, University Hospital Center, Caen, France
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Rodrigues AJ, Vicente WVA, Bassetto S, Filho AS. Anomalous origin of the left coronary artery from the pulmonary artery in an adult with systemic collateral circulation to the left coronary artery. Ann Thorac Surg 2004; 78:1082-4. [PMID: 15337058 DOI: 10.1016/s0003-4975(03)01421-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2003] [Indexed: 10/26/2022]
Abstract
A case of anomalous origin of the left coronary artery from the pulmonary artery in an adult with collateral circulation between the left coronary artery and systemic extracardiac vessels is reported. After evaluating the surgical options, my colleagues and I conclude that ligation of the left coronary artery and a left internal thoracic artery graft to the left anterior descending coronary artery is the preferable option for treating such patients.
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Affiliation(s)
- Alfredo J Rodrigues
- Division of Cardiothoracic Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
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Abstract
BACKGROUND The skeletonized radial artery harvesting technique has routinely been used in our institute. Its clinical outcome is acceptable; however, the graft patency rate at 1 year has not been reported. METHODS Between July 1, 2003, and October 31, 2002, 50 consecutive patients underwent isolated coronary artery bypass using skeletonized radial artery grafts in our hospital. There were no hospital deaths or perioperative myocardial infarctions. All patients completed follow-up by November 2003. Twenty of these patients (18 asymptomatic volunteers and 2 symptomatic patients) underwent coronary angiography at 1 year, and the results were analyzed. RESULTS At a mean (+/-SD) follow-up period of 1.2 +/- 0.2 years, there were no deaths. Two patients developed angina due to graft occlusion (1 in the radial artery and another in the gastroepiploic artery). Twenty-one radial artery grafts and 36 distal anastomoses with radial artery grafts were evaluated by angiography at 1 year (0.9 +/- 0.1 years). There was 1 radial artery graft occlusion affecting 1 distal anastomosis, giving a perfect graft patency rate of 95.2% (20/21) and a perfect anastomosis patency rate of 97.2% (35/36). The patient with the occluded radial artery graft had a history of peripheral vascular disease and diabetes. There were no graft stenoses or string signs. CONCLUSION At our limited follow-up, the results of using skeletonized radial artery grafts are excellent. Extensive skeletonization will not affect the graft patency rate or early graft spasm. Careful examinations of the radial artery grafts in patients with a history of peripheral artery disease and diabetes are mandated.
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Affiliation(s)
- Hitoshi Hirose
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan.
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Hagiwara H, Ito T, Kamiya H, Akita T, Usui A, Ueda Y. Mid-term structural change in the radial artery grafts after coronary artery bypass grafting. Ann Thorac Surg 2004; 77:805-10; discussion 810-1. [PMID: 14992876 DOI: 10.1016/j.athoracsur.2003.09.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND Currently, excellent patency rates of radial artery grafts for coronary artery bypass grafting in the early period have been reported. However, the long-term result of radial artery grafts remains unclear. We investigated the midterm structural change in radial artery grafts using intravascular ultrasound imaging (IVUS). METHODS IVUS studies were performed on 15 radial artery grafts in the early phase and 11 in the midterm phase (20.3 +/- 13.7 days and 37.6 +/- 7.2 months after surgery, respectively). The radial artery grafts were observed throughout the entire length and 10 cross-sectional images were selected from each graft for measurement of the thickness of the intima (IN) and intima-plus-media (IN + MD). Grafts having palpable arteriosclerosis at the time of harvesting were excluded. IN and IN + MD were compared between the early and midterm phases using repeated measures analysis of variance. The coefficient of variation of IN and IN + MD was calculated as an index of irregularity and compared between the phases. RESULTS IVUS revealed uniform and thin intima and media in the early and midterm groups and IVUS images were similar between the groups. There was no significant difference in both IN and IN + MD between the groups (IN, p = 0.83; IN + MD, p = 0.55). The median of coefficient of variation of IN and IN + MD was 8.5% and 8.1% in the early group and 8.7% and 9.3% in the midterm group. Again, there was no significant difference between the groups (IN, p = 0.87; IN + MD, p = 0.27). CONCLUSIONS The present study suggested that structural changes rarely developed in radial artery grafts over several years after surgery.
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Affiliation(s)
- Hiroaki Hagiwara
- Nagoya University Graduate School of Medicine, Department of Cardiothoracic Surgery, Japanese Red Cross Nagoya First Hospital, Aichi, Japan.
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Abstract
BACKGROUND Use of arterial grafts in coronary surgery is based on the excellent patency of the left internal thoracic artery (LITA) and an expectation that other arterial grafts-right internal thoracic artery (RITA) and radial artery (RA)-will give similar patencies, superior to saphenous vein. We examined patencies of arterial grafts in a practice with extensive use for more than 15 years. METHODS Consecutive postoperative angiograms of 2,127 arterial/coronary conduits were evaluated. Angiograms were performed for cardiac symptoms. Assessment was by two observers. String signs were considered as occlusions. RESULTS There were 2127 arterial conduits. Overall patencies were as follows: LITA, 96.4% (1296 of 1345); RITA, 88.3% (534 of 605); aortocoronary RA, 89.3% (158 of 177). The LITA patency to the left anterior descending artery was 97.1% (1131 of 1165); to the obtuse marginal artery it was 91.7% (165 of 180; p 0.01). The RITA pedicled graft patency was 86% (275 of 321) compared with free RITA, 91% (259 of 284; p = not significant). For RITA there was a hierarchy of patency for coronary territory grafted (left anterior descending artery best, right coronary/posterior descending artery worst) and for degree of coronary stenosis: if stenosis was less than 60%, patency was 65% (47 of 72); if stenosis was more than 60%, patency was 90.9% (485 of 533; p = 0.0001). Similarly for the radial artery there was higher patency with greater coronary stenosis. The LITA patency at 5 years was 98%, at 10 years it was 95%, and at 15 years it was 88%. The RITA patency at 5 years was 96%, at 10 years it was 81%, and at 15 years it was 65%. The radial artery patency at 1 year was 96% and at 4 years it was 89%. For 3,714 vein grafts also studied overall patency was 61% (2266 of 3214) with patencies of 95% at 5 years, 71% at 10 years, and 32% at 15 years. CONCLUSIONS Excellent long-term patencies of arterial grafts are noted, superior to those of vein grafts. Patencies were influenced by conduit, by distribution, and by coronary artery stenosis.
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Affiliation(s)
- James Tatoulis
- Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.
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Abstract
Knowledge of blood vessel mechanical properties is fundamental to the understanding of vascular function in health and disease. Analytic results can help physicians in the clinic, both in designing and in choosing appropriate therapies. Understanding the mechanical response of blood vessels to physiologic loads is necessary before ideal therapeutic solutions can be realized. For this reason, blood vessel constitutive models are needed. This article provides a critical review of recent blood vessel constitutive models, starting with a brief overview of the structure and function of arteries and veins, followed by a discussion of experimental techniques used in the characterization of material properties. Current models are classified by type, including pseudoelastic, randomly elastic, poroelastic, and viscoelastic. Comparisons are presented between the various models and existing experimental data. Applications of blood vessel constitutive models are also briefly presented, followed by the identification of future directions in research.
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Affiliation(s)
- Raymond P Vito
- Woodruff School of Mechanical Engineering, Atlanta, Georgia 30332-0405, USA.
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Barner HB. Coronary revascularization in the 21st century. Emphasis on contributions by Japanese surgeons. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2002; 50:541-53. [PMID: 12561100 DOI: 10.1007/bf02913172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The first three decades of coronary artery surgery have provided the foundation for the next century of this evolution. It is apparent that a multitude of events including the development of cardioplegia, improving surgical instrumentation, technological advances including endoscopic approaches and computer assisted robotics and biologic discoveries such as the role of the endothelium have provided the underpinnings for improved surgical outcomes. However, the single most important determinant of late results is the type of bypass conduit used for grafting. Thus, use of the left internal thoracic artery (ITA) grafted to the left anterior descending coronary is a more important determinant of survival than is any other factor (progression of coronary artery disease, increased age, poor left ventricular function, diabetes, female gender and off-pump operations). Use of two ITAs provides further benefit and it is likely that three or more arterial conduits will be shown to be advantageous in this regard in due time. Japanese cardiothoracic surgeons have made significant contributions to the continuing evolution of coronary bypass surgery and particularly to the advance of arterial conduits. This report will address those contributions to this evolution.
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