Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

Background Bilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels. Methods A propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections. Results A total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577). Conclusions In-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

HOW TO RECYCLE A MISUSED LEFT INTERNAL THORACIC ARTERY: TIPS AND TRICKS

In this case report we describe how to recycle the Left Internal Thoracic Artery (LITA) when misused but not damaged. 8 years after a Left Anterior Small Thoracotomy followed by LAD stenting for STEMI in 1st post-operative day, a 67 years old woman had a NSTEMI with angiographic evidence of intra-stent re-stenosis with a perfectly patent LITA, harvested only from the 4th to the 6th intercostal space. During redo surgery, LITA was harvested as a pedicle from the anastomosis to the 4th intercostal space and primarily from the 1st to the 4th intercostal space. Special attention was paid at the level of the 4th intercostal space where the vessel was stuck to the sternum: a 15 blade was used being scissors or cautery too dangerous. At the end of harvesting, the LITA was full-length available for a new coronary anastomosis on LAD, distal to the previous one.

Pedicled versus skeletonized internal thoracic artery grafts: a randomized trial

Objective Concerns have been raised regarding whether skeletonization of the internal thoracic artery could damage the graft and thereby reduces its patency. The objective of this study was to compare patency rates at mid- and long-term follow-up between pedicled and skeletonized left internal thoracic artery grafts. Methods This randomized controlled trial included 109 patients undergoing coronary artery bypass surgery. The patients were assigned to receive either one pedicled or one skeletonized left internal thoracic artery graft to the left anterior descending artery. Follow-up was performed at 3 years with conventional angiography, and at 8 years with computed tomography angiography. Differences between patency rates were analyzed with Fisher’s exact test and a generalized linear model. Results The patency rates for pedicled and skeletonized left internal thoracic artery grafts were 46/48 (95.8%) versus 47/52 (90.4%), p = 0.44 at 3 years, and 40/43 (93.0%) versus 37/41 (90.2%), p = 0.71 at 8 years, respectively. The difference in patency rates for pedicled and skeletonized grafts was 5.4% (95% confidence interval: −4.2–14.5) at 3 years and 2.8% (95% confidence interval: −9.9–14.1) at 8 years. All failed grafts, except for one with a localized stenosis, were anastomosed to native coronary arteries with a stenosis less than 70%. Three patients suffered sternal wound infections (two in the pedicled group, one in the skeletonized group). Conclusions The skeletonization technique can be used without jeopardizing the patency of the left internal thoracic artery. The most important factor in graft failure was target artery stenosis below 70%.

Harvesting left internal thoracic artery via clamshell incision for coronary bypass and lung transplant

Concomitant lung transplantation and coronary artery bypass grafting operation became more prevalent over the last decade due to the advanced age of recipients. Median sternotomy approach is traditionally used when internal thoracic artery is utilized. Here we report a technique of harvesting the left internal thoracic artery via a clamshell incision for a combined coronary artery bypass and bilateral lung transplant operation in a 71-year-old male with terminal respiratory failure and coronary artery disease.