Bilateral mammary artery revascularization - Nguyễn Hoàng Định

 results in superior 
graft patency and additional protects native coronary 
artery circulation. 
Thomas F. Luscher, New Eng J Med 1998, Circ 2007 
LIMA to LAD 
Authors 
Yea
r 
Num
ber 
of 
patie
nts 
Inhospital 
mortality 
Risk 
ratio 
Dùng 
ĐMNT 
trái 
Không 
dùng 
ĐMNT 
Edwards 
(STS) 
199
4 
38.57
8 2 4 2,25 
Grover 
(VACS) 
199
4 
14.17
2 3,2 6,5 2.03 
Dabal 
(COAP) 
200
3 8797 1,6 3,7 2,31 
Nguyen H 
Dinh 
201
0 432 3,2 10,5 3,26 
TMH
DMNTT
0
.0
0
0
.2
5
0
.5
0
0
.7
5
1
.0
0
0 20 40 60
ONE MAMMARY ARTERY IS GOOD, 
IS TWO BETTER? 
• Lytle 2004: survival rate of 
BITA group is higher than 
LITA group after 7 – 20 
years of follow-up. 
Lytle, B. W., Blackstone, E. H., Sabik, J. F., Houghtaling, P., Loop, F. D., Cosgrove, D. M. (2004). Ann 
Thorac Surg, 78(6), 2005-2012; discussion 2012-2004. 
 • Taggart 2001: BITA 
significantly improved 
survival rate HR=0,81 
ONE MAMMARY ARTERY IS GOOD, 
IS TWO BETTER? META ANALYSIS 
• Taggart, D. P., D'Amico, R., Altman, D. G. (2001). Lancet, 358(9285), 870-875. 
Effects of bilateral internal mammary artery grafting on long-term survival. 
Gijong Yi et al. Circulation. 2014;130:539-545 
Copyright © American Heart Association, Inc. All rights reserved. 
Randomized Trial to Compare Bilateral Versus Single Internal 
Mammary Coronary Artery Bypass Grafting (CABG): 
One Year Results of the Arterial Revascularisation Trial (ART) 
DP Taggart, DG Altman, AM Gray, B Lees, F Nugara, LM Yu, H Campbell, M Flather, on 
behalf of the ART Investigators 
John Radcliffe Hospital Oxford, University of Oxford, Royal Brompton & Harefield NHS Foundation Trust London 
and Imperial College London 
ESC Hot Line 2010, Stockholm 
On Line publication in EHJ 
LONG-TERM SURVIVAL BENEFIT 
ART (ARTERIAL REVASCULARISATION TRIAL) 
• The only RCT study available involved 28 centers in 7 
countries 
• 3102 patients, LITA vs BITA groups 
• Ten-year results expected 
• 2010: Results at one year: BITA does not increase 
inhospital morbidity and mortality. 
• 2018: 10-year survival 
Taggart, D. P., Altman, D. G., Gray, A. M., Lees, B., Nugara, 
F., Yu, L. M., et al. (2010), "Randomized trial to compare 
bilateral vs. single internal mammary coronary artery bypass 
grafting: 1-year results of the Arterial Revascularisation Trial 
(ART)". Eur Heart J, 31(20), 2470-2481. 
ART Summary and Conclusions 
o Shows that routine use of BIMA is feasible in CABG patients 
o Testament to safety of contemporary CABG with 1 or 2 IMA 
• 30 day mortality 1.2%; 1 year mortality 2.5% 
o Use of BIMA does not increase 
• 30 day or 1 year mortality 
• duration of post op stay 
• risk of stroke, MI, revascularization 
o Use of BIMA results in a slight increase in the risk of sternal wound 
reconstruction by 1.3% 
o ART is funded for 10 years to determine if BIMA reduce mortality 
and need for repeat revascularization (expected completion 2018) 
• Class IIa: When anatomically and clinically suitable, use 
of a second IMA to graft the left circumflex or right 
coronary artery (when critically stenosed and perfusing LV 
myocardium) is reasonable to improve the likelihood of 
survival and to decrease reintervention (LOE: B) 
• Class IIa: Bilateral IMA grafting should be considered in 
patients < 70 years of age (LOE: B) 
• Class IIa: Routine skeletonized IMA dissection should be 
considered (LOE: B) 
• Class I: Skeletonized IMA dissection is recommended in 
patients with diabetes or when bilateral IMAs are 
harvested (LOE: B) 
WHY LESS SURGEONS PERFORM BIMA GRAFTING? 
North America: 4.4% (2011 STS database) 
United Kingdom and Australia: <10% 
• Lack of RCT? 
• Longer operating time. Increased technical demands. 
Work load pressure? 
• Potential increased risk of wound complications? 
• The intense scrutiny of immediate outcomes following 
CABG surgery forces surgeons to choose operation less 
beneficial in long term but less risky in short term. 
Patient characteristics 
UMC Heart Center 2008-2014 
N=151 pts 
Age 54 ± 8.0 History of stroke 9 (6%) 
Sex 116 (78%) PCI 10 (6.6%) 
Diabetes 35 (23.2%) LM disease 53 (35.1%) 
Hypertension 102 (76.5%) N. of disease vessels 2.9 
Smoking 91 (60.3%) EF 64.8 ± 8.6 
Lipidemia disorders 90 (59.6) Hypokenisia 31 (20.5%) 
COPD 1 (0.7%) Clopidogrel 79 (52,3%) 
Chronic renal failure 4 (2.6%) Unstable angina 100 (66.2%) 
Ancient MI 28 (18.5%) EuroSCORE II 2.96 ± 2.38 
CCS classification 
• N=151 
CCS I, 1% 
CCS II, 45% 
CCS III, 53% 
CCS IV, 1% 
CCS I CCS II CCS III CCS IV
Operative characteristics 
Onpump 
(n=59) 
OPCAB 
(n=92) 
Total 
(n=151) 
Urgency 
Planned 52 87 139 
Urgent 1 3 8 
Emergent 6 2 4 
IABP 
Preop 5 1 6 
CPB weaning 6 0 6 
Post-op 1 0 1 
Op. time 411 ± 85 356 ± 60 
CPB time 115 ± 42 
Cross-clamp 74 ± 35 
BITA combination strategies 
SHORT-TERM OUTCOMES 
IMA 
Conduits 
Target vessels No. of grafts 
LIMA 
LAD 121 
Ramus 10 
Diagonal 52 
OM 33 
Total 216 
RIMA 
LAD 35 
Ramus 10 
Diagonal 9 
Cx 1 
OM 114 
PDA 64 
PLA 10 
RCA 5 
Total 248 
Left coronary artery 385 
Right coronary artery 79 
Total 464 
IMA graft per patient 3.07 
Early outcomes 
Ventilating time 16 g (13,22) 
ICU stay 3 ngày (3,4) 
Chest reopen 
 Bleeding 
 DSWI 
6 (4%) 
5 
1 
Neurologic complications 9 (6%) 
Stroke 0 
Renal failure 4 (2,6%) 
SWI 1 (0.7%) 
AMI 5 (3,3%) 
Mortality 
 Sepsis 
 AMI 
3 (2%) 
1 
2 
MR (adjusted) 2%/2,96% = 0,68 
Follow-up 
• 142 pts (6 lost of follow-up) 
• 3 months - 6 years, mean 40 months. 
• Mortality: 2 (1 lung cancer, 1 gangrenous cholecystitis) 
• No reintervention. 
CCS 
No pain 90 
1 42 
2 10 
3 0 
NYHA 
I 126 
II 14 
III 2 
IV 0 
Angiographic control by MSCT 
46 pts, 164 grafts, 24 months post-op 
Grafts Target 
vessels 
Patent String 
sign 
Obstructi
ve 
Stenotic Patency 
rates 
LIMA 
Diagonal 
LAD 
69/70 
23/23 
46/47 
0 1/70 
0 
1/47 
0 98,6% 
RIMA 
Ramus 
OM 
PDA 
RCA 
75/94 
3/4 
42/51 
22/29 
2/3 
4/94 
1/4 
0 
3/29 
0 
14/94 
0 
9/51 
3/29 
1/3 
1/94 
0 
0 
1/29 
0 
84% 
ĐMV trái 117/129 1/129 11/129 0 90,1% 
ĐMV phải 27/35 3/35 4/35 1/35 77,1% 
Total 144/164 4/164 15/164 1/164 90,3% 
Early and mid-term outcomes 
• Inhospital mortality 2%, RAMR: 0,68 
• AMI 3,3%, ARF 2,6%, SWI 0,7% 
• Patency rate 24 months: LIMA-LAD 98,6%, overall 90,3% 
• 2/142 mortality at follow-up (non-cardiac) 
• No patient with CCS > 2 
• No reintervention 
Author Year Method Method LCA system RCA system 
Barra 1995 Angiography 1 year 96.4% 80% 
Calafiore 2000 Angiography 2 week 
3 year 
96.4% 
98.8% 
A.Azmoun 2007 Angiography Before 
discharge 
98.9% 90% functional 
D Glineur 2008, 
2009 
Angiography 6 mo 97.2% 97% 
74.7% functional 
D Glineur 2011 Angiography 3 year 68% functional 
HY Hwang 2011 Angiography BD 
1 year 
5 year 
99.5% 
95.9% 
92.3% 
Nakajima 2011 Angiography 2 week 
10 year 
98% 
79,9% (symptomatic pts) 
FACTORS RELATED TO FLOW COMPETITION 
Nakajima H., et al. (2011). Eur J Cardiothorac Surg 40:399-404 
Nakajima 2011 
• 852 pts/3263 
anastomoses 
• T-graft arterial 
conduits 
• 10 year follow-
up 
TTFM: FLOW COMPETITON RIMA TO RCA 
 Before RCA ligation After RCA ligation 
HOW TO AVOID FLOW COMPETITION 
• Sequential anastomoses (side-to-side) should be used 
only if target vessels are significantly stenotic (≥ 70%). 
• The last anastomosis (end-to-side) is preferably on the 
most severely stenotic vessel (90 – 100% stenotic is 
ideal). 
Martin Misfeld, JCTS 2011 
BIMA skeletonisation 
• Preparation: 
• Harvest, divide distally and clip 
• Wrab in papaverine swab + increase BP to 150 for 5mins 
• No need to inject 
• Artery 
• Longer 
• Wider 
• See full length 
• Easier composites 
• Easier sequential 
BIMA skeletonisation: when not to use 
• Diabetes especially if insulin dependent AND obese 
• Bad lungs (prolonged ventilation) 
• Patients on steroids and immunosuppressives 
• Elderly? 
Figure 3. A, Representative SPECT Image of postoperative sternal perfusion in a patient who 
received a left skeletonized and a right nonskeletonized ITA. Differences in sternal perfusion are 
discernible in the manubrium and middle third of the sternum. 
Munir Boodhwani et al. Circulation. 2006;114:766-773 
Copyright © American Heart Association, Inc. All rights reserved. 
RISK FACTORS OF DSWI 
• BIMA harvesting (RR 2.18) 
• Medically treated diabetes (RR 1.73) 
• Female sex (RR 1.8) 
• Higher BMI (7% increased risk per kg/m2) 
• Previous MI (RR 1.58) 
• Peripheral arterial diseases (RR 1.73) 
• Raza S, Sabik III JF et al. Surgical revascularization techniques that minimize surgicak risk 
and maximize late survival after coronary artery bypass grafting in patients with diabetes 
mellitus. J Thorac Cardiovasc Surg 2014;148:1257-66 
HOW TO AVOID DSWI IN BIMA GRAFTING 
• Patient selection 
• Skeletonized IMAs harvesting 
• Sternal closure techniques 
• Topical antibiotic: vancomycin, gentamycin? 
ITAs HARVESTING AND IABP SUPPORT 
Vohra: IABP 
help facilitate 
ITAs harvesting, 
decrease renal 
failure and 
hospital stay in 
unstable angina, 
low EF and left 
main patients. 
• Vohra, H. A. (2006). J Card Surg, 21(1), 1-5. 
Summary and conclusions 
1. CABG using BITA T-graft is safe with long-term survival 
benefits and should be encouraged in daily practice. 
• Strong angiographic evidence of >90% long-term patency of 
both IMAs. 
• Meta-analyses and large registries show benefit of BIMA 
• ART trial phase 1: BIMA does not increase 1 year mortality, 
risk of stroke, MI, revascularization 
Summary and conclusions 
2. Composite arterial graft with no-touch technique 
reduces risk of stroke 
3. Use of BIMA slightly increase risk of SWI, can reduce 
risk with skeletonization technique 
Thank you for your kind attention!