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Farkash A, Gordon A, Mohr R, Sela O, Pevni D, Ziv-Baran T, Grupper A, Kfir JE, Ben-Gal Y. Single versus bilateral internal thoracic artery grafting in patients with impaired renal function. PLoS One 2024; 19:e0297194. [PMID: 38354161 PMCID: PMC10866522 DOI: 10.1371/journal.pone.0297194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/31/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE The optimal strategy for surgical revascularization in patients with impaired renal function is inconclusive. We compared early and late outcomes between bilateral internal thoracic artery (BITA) and single ITA (SITA) grafting in patients with renal dysfunction. METHODS This is a retrospective analysis of all the patients with multivessel disease and impaired renal function (estimated glomerular filtration rate <60mL/min/1.73m2) who underwent isolated coronary artery bypass graft (CABG) in our center during 1996-2011, utilizing either BITA or SITA revascularization. RESULTS Of the 5301 patients with multivessel disease who underwent surgical revascularization during the study period, 391 were with impaired renal function: 212 (54.2%) underwent BITA, 179 (45.8%) underwent SITA. Patients who underwent BITA were less likely to have comorbidities. Statistically significant differences were not observed between the BITA and SITA groups in 30-day mortality (5.6% vs. 9.0%, p = 0.2) and in rates of early stroke, myocardial infarction, and sternal infection (4.5% vs. 6.1%, p = 0.467; 1.7% vs. 2.8%, p = 0.517; and 2.2% vs. 5.7%, p = 0.088, respectively). Long-term survival of the BITA group was better: median 8.36 vs. 4.14 years, p<0.001. In multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.704, 95% CI: 0.556-0.89, p = 0.003). In analysis of a matched cohort (134 pairs), early outcomes did not differ between the groups; however, in multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.35 (95%CI 0.18-0.68), p = 0.002). CONCLUSIONS BITA revascularization did not impact early outcome in patients with CRF, but demonstrated a significant protective effect on long-term survival in the unmatched and matched cohorts.
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Affiliation(s)
- Ariel Farkash
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Gordon
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orr Sela
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dmitri Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Grupper
- Department of Nephrology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan E. Kfir
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ben-Gal Y, Gordon A, Teich N, Sela O, Kramer A, Ziv-Baran T, Mohr R, Pevni D. Saphenous Vein versus Arterial Graft to the Right System in Left-sided Arterial Revascularization. Ann Thorac Surg 2021; 114:2280-2287. [PMID: 34843693 DOI: 10.1016/j.athoracsur.2021.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/18/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To investigate clinical outcomes of various arterial grafts (AGs) vs. saphenous vein grafts (VGs) to the right coronary system in patients who received left-side bilateral internal thoracic artery revascularization. METHODS We compared short- and long-term outcomes of all the patients operated in our center during 1996-2011, who received left-sided bilateral internal thoracic artery (left anterior descending and left circumflex) grafting and either a VG or an AG to the right coronary system. RESULTS Of 1691 patients, 983 received a VG and 708 received an AG to the right coronary system: 387 gastroepiploic arteries and 321 internal thoracic artery grafts. The median follow-up was 15.7 ± 0.32 years. For the VG and AG groups, early mortality (1.6% for VG and 1.3% for AG, p=0.55) and other early adverse outcomes did not differ. Long-term (up to 20 years) survival was similar (34.1 +/- 3.4% for VG vs. 36.0 +/-2% for AG, p=0.86). In multivariable analysis, VG to the right coronary artery was not found to be a predictor of inferior survival (hazard ratio: 0.99 95%CI 0.836-1.194, p=0.99). Comparing two propensity matched groups of 349 pairs with a VG or an AG, and accounting for the severity of the right coronary lesion, did not demonstrate differences in early outcome or late survival between the groups. CONCLUSIONS Early outcomes and long-term survival were comparable among patients who received left-sided bilateral internal thoracic artery revascularization, between various graft types to the right coronary system.
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Affiliation(s)
- Yanai Ben-Gal
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Amit Gordon
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Teich
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orr Sela
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Kramer
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Ziv-Baran
- Dept. of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rephael Mohr
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dmitry Pevni
- Dept. of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Fertouk M, Gordon A, Pevni D, Ziv-Baran T, Sela O, Mohr R, Farkash A, Kramer A, Teich N, Nesher N, Ben-Gal Y. Early and late outcomes of single versus bilateral internal thoracic artery revascularization for patients in critical condition. PLoS One 2021; 16:e0255740. [PMID: 34352035 PMCID: PMC8341519 DOI: 10.1371/journal.pone.0255740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients. METHODS We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996-2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation. RESULTS During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p<0.001). No statistically significant differences were observed between the SITA and BITA groups in 30-day mortality; and in rates of early CVA, MI and sternal infections (13.0% vs. 8.5%, p = 0.148; 4.1% vs. 6.0%, p = 0.49; 6.7% vs. 4.5%, p = 0.32 and 2.1% vs. 2.5%, p>0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57-15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56-15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23-0.76, p = 0.004). CONCLUSIONS This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.
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Affiliation(s)
- Michal Fertouk
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amit Gordon
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orr Sela
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Farkash
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Teich
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nachum Nesher
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- * E-mail: ,
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Is the Use of BITA vs SITA Grafting Safe and Beneficial in Octogenarians? Ann Thorac Surg 2021; 111:1998-2003. [DOI: 10.1016/j.athoracsur.2020.07.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 06/07/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
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Ben-Gal Y, Gordon A, Ziv-Baran T, Farkash A, Mohr R, Kramer A, Teich N, Pevni D. Late Outcomes of In Situ Versus Composite Bilateral Internal Thoracic Artery Revascularization. Ann Thorac Surg 2020; 112:1441-1446. [PMID: 33378695 DOI: 10.1016/j.athoracsur.2020.11.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/23/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND We compared 2 configurations for revascularization of the internal thoracic arteries to the anterior and lateral walls. In the "in situ" configuration, an in situ right internal thoracic artery supplies the left anterior descending territory, and an in situ left internal thoracic artery is grafted to the left circumflex territory. In the "composite" configuration, an in situ left internal thoracic artery is grafted to the left anterior descending artery and a free right internal thoracic artery is attached end-to-side to the left internal thoracic artery and supplies the lateral wall. METHODS We compared outcomes of all the patients treated in our center by the described strategies during 1996 through 2011. RESULTS Of 2951 patients, 1220 underwent composite grafting and 1731 underwent in situ grafting; the median follow-up was 15.1 years (interquartile range, 11.2-18.6 years). Early mortality (2.2% vs 2.0%, P = .787) and other early adverse outcomes did not differ significantly between the groups. Long-term (15-year) survival was marginally significant in favor of the in situ group (53.5% vs 49.5%, P = .05); this difference disappeared after 20 years. Configuration strategy was not a predictor for better 15-year survival in multivariable analysis (hazard ratio, 0.97; 95% confidence interval, 0.85-1.09; P = .568). An additional analysis compared matched groups of 995 patients each who underwent the 2 configuration strategies and found no differences in early outcome or late survival between the groups. CONCLUSIONS This study demonstrated the safety and effectiveness of 2 strategies for bilateral internal thoracic artery revascularization to the left side, with comparable early outcomes and long-term survival.
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Affiliation(s)
- Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Amit Gordon
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ariel Farkash
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Nadav Teich
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Farkash A, Pevni D, Mohr R, Kramer A, Ziv-Baran T, Paz Y, Nesher N, Ben-Gal Y. Single versus bilateral internal thoracic artery grafting in patients with low ejection fraction. Medicine (Baltimore) 2020; 99:e22842. [PMID: 33126324 PMCID: PMC7598827 DOI: 10.1097/md.0000000000022842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Coronary artery bypass grafting (CABG) is the standard of care for the treatment of complex coronary artery disease. However, the optimal surgical treatment for patients with reduced left ventricular function with low ejection fraction (EF) is inconclusive. In our center, left-sided coronary grafting with bilateral internal thoracic artery (BITA) is generally the preferred method for surgical revascularization, also for patients with low EF. We compared early and long-term outcomes between BITA grafting and single internal thoracic artery (SITA) grafting in patients with low EF.We evaluated short- and long-term outcomes of all patients who underwent surgical revascularization in our center during 1996 to 2011, according to EF ≥30% and <30%. Univariate and multivariate analyses were performed. In addition, patients who underwent BITA and SITA grafting were matched using propensity score matching.In total, 5337 patients with multivessel disease underwent surgical revascularization during the study period. Of them, 394 had low EF. Among these, 188 underwent SITA revascularization and 206 BITA grafting. Those who underwent SITA were more likely to have comorbidities such as chronic obstructive pulmonary disease, diabetes, congestive heart failure, chronic renal failure, and a critical preoperative condition including preoperative intra-aortic balloon pump insertion.Statistically significant differences were not observed between the SITA and BITA groups in 30-day mortality (8.5% vs 6.8%, P = .55), sternal wound infection (2.7% vs 1.0%, P = .27), stroke (3.7% vs 6.3%, P = .24), and perioperative myocardial infarction (5.9% vs 2.9%, P = .15). Long-term survival (median follow up of 14 years, interquartile range, 11.2-18.9) was also similar between the groups. Propensity score matching (129 matched pairs) yielded similar early and long-term outcomes for the groups.This study did not demonstrate any clinical benefit for BITA compared with SITA revascularization in individuals with low EF.
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Affiliation(s)
- Ariel Farkash
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Dmitri Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
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Bilateral internal thoracic artery grafting in patients with left main disease: a single-center experience. Coron Artery Dis 2020; 31:464-471. [PMID: 32271239 DOI: 10.1097/mca.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compared early and long-term outcomes between bilateral internal thoracic artery (BITA) grafting and single internal thoracic artery (SITA) grafting in patients with LM disease. METHODS We evaluated the outcomes of all patients with LM disease who underwent revascularization in our center during 1996-2011. Variables that were adjusted for in a multivariate analysis and in propensity matching included age, sex, comorbid diseases, repeat operation, the number of diseased vessels, other conduits used, the use of sequential grafting, the number of grafts constructed, and the operative era (1996-2000 vs. 2001-2011). RESULTS In total, 949 patients with LM disease underwent BITA grafting and 564 underwent SITA grafting during the study period. SITA patients were more often female and more likely to have comorbidities such as chronic obstructive pulmonary disease, ejection fraction <30%, recent myocardial infarction, diabetes, congestive heart failure, chronic renal failure, and peripheral vascular disease, and to have undergone an emergency operation. We found no statistically significant difference between the SITA and BITA groups in 30-day mortality (4.8% vs. 3.3%, P = 0.136), sternal wound infection (2.0% vs. 2.4%, P = 0.548), and stroke (3.2% vs. 4.4%, P = 0.234). BITA patients had improved long-term survival (70.1% vs. 52.0% p<0.001), median follow-up of 15 years. In multivariate analysis, after propensity score matching (477 matched pairs), this finding was not statistically significant (P = 0.135). CONCLUSION This study did not demonstrate a clear benefit of BITA grafts among patients with LM disease.
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Abstract
BACKGROUND The use of two bilateral internal thoracic artery grafting (BITA) was shown to lead to survival benefit. However, operators are reluctant to use BITA with peripheral vascular disease (PVD) because of concerns of increased rates of sternal wound infection and lack of studies supporting survival benefit compared with single internal thoracic artery (SITA) grafting. The aim of this study is to compare outcome BITA grafting versus of SITA and vein grafts in PVD patients. PATIENTS AND METHODS Six hundred and twenty-one PVD patients who underwent BITA between 1996 and 2011 were compared with 372 patients who underwent SITA. RESULTS SITA patients were older and more likely more likely to have comorbidities (female, insulin-dependent diabetes, chronic obstructive lung disease, congestive heart failure, previous coronary artery bypass grafting, renal insufficiency, cerebrovascular disease, and emergency operation). Operative mortality (5.1 vs. 4.5%, in the SITA and BITA, respectively, P=0.758), rate of sternal wound infection (5.1 vs. 3.9%, P=0.421), and strokes (4.8 vs. 7.4%, P=0.141) were not significantly different between groups. BITA patients did not have significantly better 10-year survival (52.6 vs. 45.9%, P=0.087) and after propensity score matching (302 well-matched pairs), BITA was not associated with improved survival (hazard ratio: 0.902; 95% confidence interval: 0.742-1.283; P=0.784) (Cox model). CONCLUSION The routine use of BITA versus SITA in PVD patients does not improve long-term survival. Selective use of BITA in lower risk patients might unmask the benefits of BITA.
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Ag-Rejuan Y, Pevni D, Nesher N, Kramer A, Paz Y, Mohr R, Malamud D, Ben-Gal Y. Left anterior descending artery revascularization with the right internal thoracic artery T-graft: the 'reverse composite' configuration. Interact Cardiovasc Thorac Surg 2019; 29:830-835. [PMID: 31384952 DOI: 10.1093/icvts/ivz193] [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: 01/23/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The use of bilateral internal thoracic artery graft for myocardial revascularization has improved the long-term survival and decreased the rate of repeat interventions in patients. A key technical factor for complete arterial revascularization is sufficient length of the internal thoracic artery (ITA) graft. The purpose of this study was to compare early and long-term outcomes of 'standard composite' grafting and 'reverse composite' grafting. In the former, the left ITA (LITA) is connected to the left anterior descending artery, and the right ITA is connected end-to-side to the LITA for revascularization of the left circumflex artery. In 'reverse composite' grafting, the LITA is connected to the left circumflex artery, and the right ITA is connected end-to-side to the LITA, for revascularization of the left anterior descending artery. METHODS We compared the outcomes of 1365 patients who underwent coronary artery bypass grafting in Tel-Aviv Sourasky Medical Centre, using bilateral ITA as standard composite versus 'reverse composite' grafts, between January 1996 and December 2011. A propensity score matching analysis compared 132 pairs of patients who underwent bilateral ITA by the 2 modes. RESULTS Twelve hundred and thirty patients underwent standard 'composite' grafts and 135 underwent 'reverse composite' grafts. Early mortality and early adverse effects did not differ significantly between the groups. After matching, the difference in late mortality between the groups was not statistically significant. CONCLUSIONS This study suggests that revascularization of the left anterior descending with the right ITA, arising from an in situ LITA, is safe and provides early outcomes and long-term survival that are not significantly different from those of the standard composite grafting technique. However, there was evidence of better survival in the standard composite group.
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Affiliation(s)
- Yael Ag-Rejuan
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dmitry Pevni
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nachum Nesher
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dorel Malamud
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pevni D, Mohr R, Kramer A, Paz Y, Nesher N, Ben-Gal Y. Are two internal thoracic grafts better than one? An analysis of 5301 cases. Eur J Cardiothorac Surg 2019; 56:935-941. [DOI: 10.1093/ejcts/ezz094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
OBJECTIVES
Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease.
METHODS
Patients in our institution who underwent BITA grafting during 1996–2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan–Meier analysis was performed, both for the entire cohort and for the matched cohort.
RESULTS
SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan–Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001).
CONCLUSIONS
Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization.
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Affiliation(s)
- Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nachum Nesher
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pevni D, Nesher N, Kramer A, Paz Y, Farkash A, Ben-Gal Y. Does bilateral versus single thoracic artery grafting provide survival benefit in female patients? Interact Cardiovasc Thorac Surg 2019; 28:860-867. [DOI: 10.1093/icvts/ivy367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/23/2018] [Accepted: 12/27/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dmitry Pevni
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Farkash
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Sourasky Medical Center, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011. PLoS One 2018; 13:e0201227. [PMID: 30102699 PMCID: PMC6089414 DOI: 10.1371/journal.pone.0201227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/11/2018] [Indexed: 11/19/2022] Open
Abstract
Objectives Bilateral internal thoracic artery (ITA) grafting is associated with improved survival. However, potential survival benefit of using two ITA`s in patients with chronic lung disease (CLD) is questionable due to their increased risk of sternal wound infection (SWI) compared to operations incorporating single ITA (SITA). The purpose of this study is to compare early and long-term outcome of bilateral internal thoracic artery (BITA) grafting to that of grafting with single internal thoracic grafts and vein grafts or radial artery (SITA) in CLD patients with multi-vessels coronary disease. Methods One hundred and forty eight CLD patients who underwent BITA between 1996 and 2011 were compared with 239 who underwent SITA at the same period. Results SITA patients were more often female, more likely to have insulin treated diabetes (DM), DM with end organ damage, neurologic dysfunction and unstable angina. Despite of the difference in preoperative characteristics, early mortality (5.4% vs. 5.4%, in the SITA and BITA respectively, p = 0 < .999) and occurrences of SWI (6.3% vs 9.5%, p = 0.320) and strokes (3.8% vs 5.4%,p = 0.611) were not significantly different between groups. BITA patients did not have better Kaplan-Meier 10 year survival (52.8% vs. 42.6%, p = 0.088) and after matching, BITA and SITA had similar adjusted survival (HR 0.983[95%CI 0.755–1.280] p = 0.901) (cox model). Conclusion Our study results suggest that in patients with CLD, the choice of BITA grafting technique did not provide survival benefit compared to SITA with other conduits.
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Loberman D, Pevni D, Mohr R, Paz Y, Nesher N, Midlij MK, Ben-Gal Y. Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients After Recent Myocardial Infarction? J Am Heart Assoc 2017; 6:JAHA.117.005951. [PMID: 28733432 PMCID: PMC5586304 DOI: 10.1161/jaha.117.005951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI. Methods and Results In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3‐vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, P=0.01), and sternal infections and strokes were similar. Median follow‐up was 15.21 years (range: 0–21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, P<0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; P=0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; P=0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; P=0.009; Cox model). Conclusions This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection.
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Affiliation(s)
- Dan Loberman
- Division of Cardiac Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Dmitry Pevni
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamad Khaled Midlij
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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One or Two Internal Thoracic Grafts? Long-Term Follow-Up of 957 Off-Pump Coronary Bypass Surgeries. Ann Thorac Surg 2017; 104:70-77. [DOI: 10.1016/j.athoracsur.2016.10.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 09/12/2016] [Accepted: 10/24/2016] [Indexed: 11/20/2022]
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Pevni D, Ben-Gal Y, Mohr R, Teich N, Raviv Z, Kramer A, Paz Y, Medalion B, Nesher N. Comparison of radial and bilateral internal thoracic artery grafting in patients with peripheral vascular disease†. Interact Cardiovasc Thorac Surg 2017; 24:911-917. [PMID: 28329325 DOI: 10.1093/icvts/ivw449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 12/18/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The composite T-graft with radial artery (RA) attached end-to-side to the left internal thoracic artery (ITA) provides arterial myocardial revascularization without the increased risk of deep sternal wound infection associated with harvesting 2 ITAs. However, many surgeons are reluctant to use RA in patients with peripheral vascular disease (PVD) due to concerns regarding the quality of the conduit in this subset of patients. The purpose of this study is to compare early- and long-term outcomes of arterial grafting with bilateral ITAs (BITA) to that of single ITA and RA in patients with PVD. METHODS Between 1999 and 2010, 619 consecutive patients with PVD (500 BITAs and 119 single ITA and RA) underwent myocardial revascularization in our institution. RESULTS Occurrence of following risk factors as female sex, age 70+, diabetes, unstable angina, emergency operation, cerebrovascular disease and chronic obstructive pulmonary disease was higher in the RA-ITA group. The RA-ITA group also had a higher logistic EuroSCORE (22.1 vs 13.3). Operative mortality and occurrence of deep sternal wound infection of the two groups was similar (4.2% vs 5.0% and 2.5% vs 4.0% for the radial and bilateral ITA, respectively). Median follow-up was 9.75 years. Unadjusted Kaplan-Meier 10-year survival of the two groups was similar (44.1% vs 49.6%, P = 0.7). After propensity score matching (100 pairs), assignment to BITA was not associated with better adjusted survival (hazard ratio 0.593, 95% confidence interval 0.265-1.327, P = 0.20, Cox model). CONCLUSIONS In patients with PVD, complete arterial revascularization with left ITA and RA can be justified with regards to survival.
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Affiliation(s)
- Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Teich
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Raviv
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin Medalion
- Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients With Diabetes Mellitus? Ann Thorac Surg 2017; 103:551-558. [DOI: 10.1016/j.athoracsur.2016.06.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 11/19/2022]
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Pevni D, Mohr R, Paz Y, Kramer A, Ben-Gal Y, Nesher N, Medalion B. Long-term outcome of revascularization with composite T-grafts: Is bilateral mammary grafting better than single mammary and radial artery grafting? J Thorac Cardiovasc Surg 2015; 151:1311-9. [PMID: 26794927 DOI: 10.1016/j.jtcvs.2015.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 11/20/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Bilateral internal mammary artery (BIMA) grafting is associated with improved survival. However, many surgeons are reluctant to use this technique, owing to the potentially increased risk of sternal infection. The composite T-graft with radial artery (RA) attached end-to-side to the left internal mammary artery (IMA) provides complete arterial revascularization without increased risk of sternal infection. The purpose of this study is to compare outcomes of these 2 strategies. METHODS Patients who underwent BIMA grafting using the composite T-graft technique, between 1996 and 2010 (n = 1329), were compared with 389 patients who underwent composite grafting with a single IMA + RA during the same time period. RESULTS Patients undergoing single IMA grafting were older, more often women, and more likely to have diabetes, peripheral vascular disease, and COPD, and to need an emergency operation. Congestive heart failure, left main disease, and recent myocardial infarction were more prevalent with bilateral grafting. Propensity-score matching was used to account for differences between groups in preoperative patient characteristics. The 268 matched pairs had similar characteristics. The median follow-up time was 14.19 (95% confidence interval 13.43-14.95) years. Operative mortality and Kaplan-Meier 10-year survival of the 2 matched groups were similar (3.4% vs 3.7%, and 61.6% vs 64%, for the groups treated with BIMA and single IMA, respectively). Cox-adjusted survival was similar (P = .514). Age, chronic renal failure, and performance of <3 bypass grafts were independent predictors of decreased survival. CONCLUSIONS This study suggests that long-term outcomes of arterial revascularization with a composite T-graft constructed using left IMA and RA are not inferior to outcomes after BIMA grafting.
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Affiliation(s)
- Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel.
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
| | - Benjamin Medalion
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Tel Aviv, Israel
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Medalion B, Mohr R, Ben-Gal Y, Nesher N, Kramer A, Eliyahu S, Pevni D. Arterial coronary artery bypass grafting is safe and effective in elderly patients. J Thorac Cardiovasc Surg 2015; 150:607-12. [DOI: 10.1016/j.jtcvs.2015.06.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/09/2015] [Accepted: 06/13/2015] [Indexed: 10/23/2022]
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Hemo E, Mohr R, Uretzky G, Katz G, Popovits N, Pevni D, Medalion B. Long-term outcomes of patients with diabetes receiving bilateral internal thoracic artery grafts. J Thorac Cardiovasc Surg 2013; 146:586-92. [DOI: 10.1016/j.jtcvs.2012.04.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/22/2012] [Accepted: 04/06/2012] [Indexed: 11/28/2022]
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Ali E, Saso S, Ashrafian H, Athanasiou T. Does a skeletonized or pedicled left internal thoracic artery give the best graft patency?☆. Interact Cardiovasc Thorac Surg 2010; 10:97-104. [DOI: 10.1510/icvts.2009.221242] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Pevni D, Uretzky G, Mohr A, Braunstein R, Kramer A, Paz Y, Shapira I, Mohr R. Routine Use of Bilateral Skeletonized Internal Thoracic Artery Grafting. Circulation 2008; 118:705-12. [PMID: 18663087 DOI: 10.1161/circulationaha.107.756676] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Skeletonized harvesting of the internal thoracic artery (ITA) decreases the severity of sternal devascularization, thus reducing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting.
Methods and Results—
Between 1996 and 2001, 1515 consecutive patients underwent skeletonized bilateral ITA grafting. Of the 1179 male and 336 female patients, 641 (42.3%) were >70 years of age, and 519 (34.2%) had diabetes mellitus. Operative mortality was 2.8%. Early postoperative morbidity included sternal infection (1.6%), cerebrovascular accident (3%), and perioperative myocardial infarction (1%). Multiple regression analysis showed chronic obstructive pulmonary disease (odds ratio, 11.3; 95% confidence interval [CI], 4.45 to 28.55), repeat operation (odds ratio, 12.7; 95% CI, 3.25 to 49.56), and diabetes mellitus (non–insulin dependent: odds ratio, 4.64; 95% CI, 1.85 to 11.59; insulin dependent: odds ratio, 6.9; 95% CI, 1.35 to 35.27) to be associated with increased risk of sternal infection. Follow-up (between 5 and 12 years) revealed 305 late deaths. Kaplan-Meier 10-year survival rates for patients <65, 65 to 74, and >75 years of age were 87%, 75%, and 52%, respectively. Cox regression analysis revealed increased overall mortality (early and late) in patients with peripheral vascular disease (hazard ratio [HR], 1.8; 95% CI, 1.39 to 2.33), patients >75 years of age (HR, 7.23; 95% CI, 4.16 to 12.55), those undergoing repeat operations (HR, 2.22; 95% CI, 1.27 to 3.89), patients with preoperative congestive heart failure (HR, 1.64; 95% CI, 1.29 to 3.75), and those with chronic renal failure (HR, 1.52; 95% CI, 1.11 to 2.01). Operations performed without cardiopulmonary bypass were associated with better postoperative survival (HR, 0.66; 95% CI, 0.49 to 0.87).
Conclusions—
Bilateral ITA grafting is associated with low morbidity and good long-term results. Use of skeletonized bilateral ITA is appropriate for the elderly and most patients with diabetes; however, it is not recommended for repeat operations or for patients with chronic obstructive pulmonary disease.
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Affiliation(s)
- D. Pevni
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G. Uretzky
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A. Mohr
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R. Braunstein
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A. Kramer
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y. Paz
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I. Shapira
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R. Mohr
- From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pevni D, Hertz I, Medalion B, Kramer A, Paz Y, Uretzky G, Mohr R. Angiographic evidence for reduced graft patency due to competitive flow in composite arterial T-grafts. J Thorac Cardiovasc Surg 2007; 133:1220-5. [PMID: 17467433 DOI: 10.1016/j.jtcvs.2006.07.060] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 07/07/2006] [Accepted: 07/17/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Composite arterial grafting causes splitting of internal thoracic artery flow to various myocardial regions. The amount of flow supplying each region depends on the severity of coronary stenosis. Competitive flow in the native coronary artery can cause occlusion or severe narrowing of the internal thoracic artery supplying this coronary vessel. METHODS Two hundred three consecutive postoperative coronary angiographies of 163 patients who underwent bilateral internal thoracic artery grafting using the composite-T-graft technique were analyzed. Angiographies were done in symptomatic patients or in patients with positive thallium scan between 2 and 102 months after surgery and were compared with preoperative angiograms. RESULTS In 123 patients, both internal thoracic arteries were patent. The remaining 40 control patients had at least 1 nonfunctioning internal thoracic artery. A lower stenosis rate in the left anterior and circumflex arteries was associated with higher occlusion rate of the left internal thoracic artery (P < .005) and the right internal thoracic artery (P < .005), respectively. In 19 angiograms of 18 patients, graft failure could be related to competitive flow. This included 7 patients with disease of the left main artery and a preoperative stenosis degree ranging between 50% and 80%, 8 patients with moderate stenosis (70% or less) of the circumflex artery, and 3 with moderate stenosis of the left anterior descending artery. Three of the patients with disease of the left main artery, 2 of the patients with competitive flow in the circumflex artery, and all patients in the subgroup with left anterior descending arterial disease underwent percutaneous or surgical reintervention. CONCLUSION The composite T-graft technique of bilateral internal thoracic artery grafting should be reserved for patients with severe (70% or more) left anterior descending and circumflex arterial stenosis.
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Affiliation(s)
- Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Ryu SW, Ahn BH, Choo SJ, Na KJ, Ahn YK, Jeong MH, Kim SH. Skeletonized gastroepiploic artery as a composite graft for total arterial revascularization. Ann Thorac Surg 2006; 80:118-23. [PMID: 15975352 DOI: 10.1016/j.athoracsur.2005.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2004] [Revised: 01/26/2005] [Accepted: 02/01/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the purported advantages of using a gastroepiploic artery graft during coronary artery bypass, insufficient potential flow capacity and vasospasm remain major concerns. We assessed the efficacy and results of using a skeletonized composite gastroepiploic artery graft in situations in which bilateral internal thoracic and radial arteries could not be used. METHODS Between January 2000 and August 2002, 37 patients (25 men, 12 women; mean age, 59.9 years) underwent grafting with composite grafts using a skeletonized left internal thoracic artery plus the gastroepiploic artery. Coronary angiograms were performed in the immediate (median, 14 days, 36 patients) and early (median, 348 days, 32 patients) postoperative periods. Off-pump coronary artery bypass grafting was performed in all but 2 patients. RESULTS There were no deaths. The respective postoperative patencies of the left internal thoracic artery and gastroepiploic artery were 36 of 37 (97.2%) and 73 of 75 (97.3%) at the immediate period, and 34 of 34 and 62 of 67 (92.5%) at the early period. During follow-up, only 1 patient required percutaneous intracoronary intervention for gastroepiploic artery occlusion. CONCLUSIONS Skeletonized composite gastroepiploic artery grafts showed satisfactory clinical and angiographic results in situations in which bilateral internal thoracic and radial arteries could not be used. Although it needs longer follow-up, these early results demonstrated that the gastroepiploic artery may be a useful option in some situations of total arterial revascularization, used either as an in situ or as a composite graft.
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Affiliation(s)
- Sang-Wan Ryu
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Seoul, South Korea
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Baskett RJF, Cafferty FH, Powell SJ, Kinsman R, Keogh BE, Nashef SAM. Total Arterial Revascularization is Safe: Multicenter Ten-Year Analysis of 71,470 Coronary Procedures. Ann Thorac Surg 2006; 81:1243-8. [PMID: 16564251 DOI: 10.1016/j.athoracsur.2005.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 11/30/2005] [Accepted: 12/01/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose of this study was to assess the use of arterial revascularization and to compare the in-hospital mortality with other CABG grafting strategies. METHODS A total of 71,470 CABG patients (1992-2001) in 27 centers in the United Kingdom were studied. The proportion of patients with arterial revascularization was compared. In-hospital mortality was compared for various grafting strategies: all-arterial (n = 5,401), all non-all-arterial patients (n = 66,069), one artery any number of veins (n = 49,801). The groups were compared for in-hospital mortality using multivariate logistic regression to assess the independent effect of the grafting strategies on mortality; logistic EuroSCORE-predicted mortality was compared to actual mortality, and all arterial and one artery and veins patients were compared with propensity score analysis. RESULTS There was a significant increase in the proportion of all-arterial patients over time (3.2% to 11.7%, p < 0.001) with evidence of variability across centers. Crude mortality for all-arterial patients was 2% vs 3% for all non-all-arterial patients (p < 0.001). In multivariate analysis, all-arterial was associated with a slight but insignificant increase in in-hospital mortality (odds ratio [OR] 1.13; [95% confidence interval {CI} 0.86-1.48], p = 0.36). There was a trend toward higher mortality in the all-arterial group when compared with the one artery and veins group (OR 1.19 [95% CI 0.91-1.56], p = 0.10). The one artery and veins group was the only group where actual mortality was significantly lower than predicted by EuroSCORE (p < 0.001). In propensity analysis the mortality was 1.51% for one artery and veins and 1.74% of all-arterial patients (p = 0.56). CONCLUSIONS The use of arterial grafting has increased over time, varies by center, and appears to be safe in terms of in-hospital mortality.
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Caputo M, Narayan P, Angelini GD. Conventional surgery with aortic cross-clamping. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2004.000828. [PMID: 24415522 DOI: 10.1510/mmcts.2004.000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This article provides a brief description of how to perform proximal and distal anastomosis on the arrested empty heart along with the grafting strategy and utilisation of different conduits in coronary artery revascularisation. Sequential grafting and indications of coronary artery revascularisation has also been described.
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Affiliation(s)
- Massimo Caputo
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
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Abstract
The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Alder Hey Hospital, Liverpool, United Kingdom.
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Pevni D, Uretzky G, Yosef P, Yanay BG, Shapira I, Nesher N, Braunshtein R, Mohr R. Revascularization of the Right Coronary Artery in Bilateral Internal Thoracic Artery Grafting. Ann Thorac Surg 2005; 79:564-9. [PMID: 15680836 DOI: 10.1016/j.athoracsur.2004.07.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2004] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bilateral internal thoracic artery (BITA) grafting with a composite T-graft enables right coronary artery (RCA) system revascularization with the distal end of the free right internal thoracic artery (RITA). This study compares this grafting technique to left-sided BITA grafting and RCA revascularization with the right gastroepiploic artery (RGEA) and saphenous vein grafts (SVG). METHODS From April 1996 to July 1999, 1000 consecutive patients underwent left-sided revascularization with BITA. In 231 patients RCA grafting was performed with free RITA, in 246 with RGEA, in 142 with SVG, and 381 did not receive any graft to the RCA (no-graft group). RESULTS Female gender, old age (> 70), emergency, and congestive heart failure were less prevalent in the RGEA group, and prior percutaneous transluminal coronary angioplasty was more prevalent in the no-graft group. Thirty-day mortality (3.6%, 4.9%, 2%, and 3.4% in the RITA, SVG, RGEA, and no-graft groups, respectively) and occurrence of perioperative complications (sternal infection, myocardial infarction, cerebrovascular accident, and bleeding) were similar. Overall, however, the trend was toward a higher complication rate in the RITA group (10.3%, 4.9%, 5.6%, and 7.3% respectively, p = 0.06). Midterm follow-up (40 to 78 months) showed similar 6-year survival (Kaplan-Meier) (88%, 87%, 89.5%, and 85.5%, respectively) and similar return of angina (10.8%, 6.3%, 10.6%, and 9.5%, respectively) in the four groups. CONCLUSIONS Early and midterm results in patients undergoing left-sided BITA grafting are not affected by the conduit used for RCA grafting.
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Affiliation(s)
- Dmitry Pevni
- Department of Thoracic and Cardiovascular Surgery, Tel-Aviv Sourasky, Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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