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J Thorac Cardiovasc Surg 2007;134:233-235
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiovascular Surgery, Centro Cardiologico Monzino, University of Milan, Milan, Italy
b Division of Cardiovascular Surgery, L. Sacco Hospital, Milan, Italy.
Received for publication January 23, 2007; accepted for publication February 23, 2007. * Address for reprints: Fabio Barili, MD, Department of Cardiovascular Surgery - University of Milan, Centro Cardiologico Monzino IRCCS, Via Parea 4, 20138 Milan, Italy. (Email: fabarili{at}libero.it; fabio.barili{at}unimi.it).
Redo coronary artery bypass graft (redo CABG) procedures are a surgical challenge, especially when one or both internal thoracic arteries (ITAs) have been previously harvested. The lack of available ITA grafts at reoperation might jeopardize the long-term outcomes, because pedicle ITAs have shown longer patency than have other grafts.1,2
Early and midterm results after recycling of ITA grafts in coronary reoperations were demonstrated to be satisfactory.3–5 We report clinical and angiographic long-term follow-up of this procedure.
From January 1990 to December 2005, 9 patients (7 men and 2 women) underwent redo CABG, recycling the previously implanted ITAs. Patients were evaluated with regard to clinical, echocardiographic, and angiographic findings. They were prospectively followed up by direct visit, echocardiography, and stress test (Table 1). Between June 2006 and December 2006, a coronary angiographic follow-up was performed in all survivors (8 patients). Outcome variables included perioperative (30-day) mortality and morbidity, long-term survival, and ITA graft patency.
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The mean age of the population was 59.3 ± 13.3 years (range 38–76 years). The preoperative transthoracic echocardiographic ejection fraction was 50.2% ± 8.1%. Preoperative coronary angiography excluded proximal stenoses of the ITA grafts that were recycled as pedicle grafts.
The mean interval between operations was 27.7 ± 42.3 months (range 1–132 months). Five patients underwent early reoperation (<6 months) for stenosis at the anastomotic site. The remaining 4 patients had late reoperation owing to progression of native coronary disease.
The operation was performed on pump during cardioplegic arrest. The recycled grafts included 8 left and 2 right ITAs. One patient had both ITAs recycled. In 7 cases the left ITA had been previously anastomosed to the left anterior descending artery (LAD). In patient 3, it was transposed from an obtuse marginal branch to the LAD and the right gastroepiploic artery was anastomosed to the obtuse marginal branch. One young patient (No. 2) required the interposition of a short segment of saphenous vein between the left pedicle ITA and target LAD. The recycled right ITA was used to anastomose the right coronary artery distal to the previous anastomosis.
There were no operative or perioperative (30-day) deaths. The postoperative course was uneventful. Cumulative follow-up time was 1016.0 patient–months and was 100% complete. Complete follow-up ranged from 48 to 192 months (mean 112.8 ± 17.6 months, median 113 months).
At follow-up, 1 patient died of noncardiac causes 78 months after reoperation. The Kaplan–Meier overall survival estimate at 15 years was 83.3% ± 15.2%. The actuarial freedom from heart-related mortality was 100%.
There were 2 coronary angioplasty procedures at follow-up. Patient 2 underwent percutaneous transluminal coronary angioplasty and stenting on the anastomosis that was constructed to elongate the left ITA with an interposed saphenous vein graft, and patient 8 underwent angioplasty on the circumflex artery for the progression of coronary artery disease. The other patients had no recurrent angina and no abnormalities on stress testing. At long-term follow-up, coronary angiography showed patency of the recycled ITAs in all cases (Figure 1). Actuarial freedom from restenosis of recycled ITA graft at 15 years was 75.0% ± 21.7%.
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ITA is the graft of choice in terms of patency and durability, as it has been proven to improve long-term outcomes.1,2 These benefits could be helpful even in patients who undergo redo surgical myocardial revascularization, above all in younger patients who have a longer life expectancy.
The recycling of ITA grafts can be performed with excellent clinical results, although it introduces further technical difficulties to a challenging operation.3-5 In this limited experience, we reused previously placed ITA grafts with no perioperative deaths or complications. The long-term clinical and angiographic follow-up demonstrated that recycled ITAs maintain a high rate of patency even at long-term follow-up. Only 1 patient needed angioplasty of the graft, but the restenosis was located at the anastomosis between the ITA and the saphenous vein elongation.
The recycling of ITA grafts can be performed in only a selected redo CABG population,3 when the ITA is patent but stenotic in the perianastomotic area, when there is a stenosis in the coronary artery distal to the anastomosis, and when an interventional cardiologic approach is not feasible. Preoperative selective angiography of the used ITA is helpful to exclude proximal stenosis, to locate its relationship, and to provide anatomic details that may suggest this possible alternative approach during redo CABG surgery.
In conclusion, our limited experience confirmed that the recycling of ITA grafts in redo CABG can produce satisfactory outcomes in selected patients even at long-term follow-up.
References
This article has been cited by other articles:
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  B. El Oumeiri, D. Glineur, J. Price, M. Boodhwani, P. Yves Etienne, A. Poncelet, L. De Kerchove, S. Papadatos, P. Noirhomme, and G. El Khoury Recycling of Internal Thoracic Arteries in Reoperative Coronary Surgery: In-Hospital and Midterm Results Ann. Thorac. Surg., April 1, 2011; 91(4): 1165 - 1168. [Abstract] [Full Text] [PDF]
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