Research

Bilateral internal mammary arteries: evidence and technical considerations

by

Vallely MP, Edelman JJ, Wilson MK

Ann Cardiothorac Surg 2013 Jul;2(4):570-7

PMID: 23977638

Abstract

Bilateral internal mammary artery (BIMA) grafts are used for coronary revascularisation by only a minority of surgeons, despite a growing body of evidence suggesting improved survival when compared to use of only one internal mammary artery with additional saphenous vein grafts. Herein we review the evidence supporting revascularisation with BIMA and suggest reasons why the majority of surgeons use only one internal mammary artery. We discuss technical considerations, various graft combinations and the use of BIMA to facilitate anaortic off-pump coronary artery bypass (OPCAB).

Biomechanics and biocompatibility of the perfect conduit-can we build one?

by

Byrom MJ, Ng MK, Bannon PG

Ann Cardiothorac Surg 2013 Jul;2(4):435-43

PMID: 23977620

Abstract

No currently available conduit meets the criteria for an ideal coronary artery bypass graft. The perfect conduit would combine the availability and complication-free harvest of a synthetic vessel with the long-term patency performance of the internal mammary artery. However, current polymer conduits suffer from inelastic mechanical properties and especially poor surface biocompatibility, resulting in early loss of patency as a coronary graft. Approaches to manufacture an improved conduit using new polymers or polymer surfaces, acellular matrices, or cellular constructs have to date failed to achieve a commercially successful alternative. Elastin, by mimicking the native extracellular environment as well as providing elasticity, provides the ‘missing link’ in vascular conduit design and brings new hope for realization of the perfect conduit.

Systematic review of robotic-assisted, totally endoscopic coronary artery bypass grafting

by

Seco M, Edelman JJ, Yan TD, Wilson MK, Bannon PG, Vallely MP

Ann Cardiothorac Surg 2013 Jul;2(4):408-18

PMID: 23977616

Abstract

BACKGROUND: Advancements in surgical robotic technology over the last two decades have enabled coronary artery bypass grafting to be performed totally endoscopically, and have the potential to significantly change clinical practice in the future.

METHODS: A systematic review of studies reporting clinical outcomes of total endoscopic coronary artery bypass grafting (TECABG) was performed.

RESULTS: 14 appraised studies included 880 beating heart TECABGs, 360 arrested heart TECABGs, 633 one-vessel operations and 357 two-vessel operations. Patients were generally low-risk. There was a significant learning curve. The weighted means for short-term beating heart and arrested heart TECABG results respectively were: intraoperative exclusion rate of 5.7% and 1.9%, intraoperative conversion rate of 5.6% and 15.0%, all-cause mortality of 1.2% and 0.4%, stroke of 0.7% and 0.8%, myocardial infarction of 0.8% and 1.8%, new onset atrial fibrillation of 10.7% and 5.1% and post-operative reintervention rate of 2.6% and 2.3%. The overall rate of short term postoperative graft patency for beating heart and arrested heart TECABG was 98.3% and 96.4% respectively.

CONCLUSIONS: Appropriate patient selection was important in minimizing the risk of intraoperative and postoperative complications. Short-term outcomes of both beating and arrested heart TECABG were acceptable, but results so far have been heterogeneous. There were fewer studies reporting intermediate to long-term outcomes, but results were encouraging, and further investigation and development of the procedure is warranted.

A meta-analysis of randomized controlled trials on mid-term angiographic outcomes for radial artery versus saphenous vein in coronary artery bypass graft surgery

by

Cao C, Ang SC, Wolak K, Peeceeyen S, Bannon P, Yan TD

Ann Cardiothorac Surg 2013 Jul;2(4):401-7

PMID: 23977615

Abstract

BACKGROUND: Currently, saphenous vein (SV) and radial artery (RA) are the most commonly used conduits in combination with the left internal mammary artery for conventional coronary artery bypass graft surgery (CABG). The present meta-analysis aimed to assess the existing evidence from randomized controlled trials (RCTs) to compare the angiographic outcomes of these two conduits at mid-term follow-up.

METHODS: Four relevant and updated RCTs with follow-up beyond 3 years were identified using five electronic databases. Angiographic endpoints included complete occlusion, ‘string sign’, graft failure and complete patency.

RESULTS: The incidence of complete occlusion was significantly lower after using RA compared to SV [6.7% vs. 17.2%; odd ratio (OR), 0.36; 95% confidence interval (CI), 0.23-0.58; P<0.0001]. The angiographic 'string sign' was significantly more likely to be identified after using RA compared to SV (3.1% vs. 0%; OR, 5.65; 95% CI, 1.21-26.39; P=0.03). Graft failure was significantly lower after RA compared to SV (9.6% vs. 18.8%; OR, 0.47; 95% CI, 0.30-0.72; P=0.0005). Complete graft patency was found to be significantly higher after RA compared to SV (88.6% vs. 75.8%; OR, 3.19; 95% CI, 1.42-7.16; P=0.005).

CONCLUSIONS: Results of the present meta-analysis suggest that selected patients with severe, proximal stenosis may have superior angiographic outcomes at mid-term follow-up after using RA compared to SV for CABG. However, RA is associated with a significantly higher incidence of the ‘string sign’. Future studies should aim to collect additional data on symptomatic outcomes.

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