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Dashwood MR, Celik Z, Topal G. Reducing vasospasm of vein and arterial conduits used in coronary artery bypass surgery: are solutions the solution or is preserved perivascular fat the answer? Front Physiol 2025; 16:1539102. [PMID: 39958693 PMCID: PMC11825516 DOI: 10.3389/fphys.2025.1539102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Accepted: 01/16/2025] [Indexed: 02/18/2025] Open
Abstract
The three main conduits used for myocardial revascularization in patients with coronary artery disease (CAD) are the internal thoracic artery (ITA), radial artery (RA) and saphenous vein (SV). In coronary artery bypass grafting (CABG) conduits may be harvested with perivascular adipose tissue (PVAT) intact (pedicled) or removed (skeletonized). Various studies have shown that the patency rate of these bypass grafts may be affected by the preservation or removal of PVAT. Vasospasm is often encountered at harvesting, a condition that has both immediate and long term effects on graft performance. During surgery a variety of antispastic solutions are routinely used on conduits that have anti-contractile and/or vasorelaxant actions. Spasm may be abolished or reduced when PVAT is left intact at harvesting and this is particularly the case for the SV. The protective properties of PVAT are multifactorial, ranging from its mechanical properties in supporting the graft after implantation to the beneficial effect of adipocyte-derived factors. This review aims to outline the possible mechanisms through which preserved PVAT could alleviate vasospasm and improve conduit performance in CABG. Moreover, since preservation of PVAT reduces spasm at and after surgery this review also considers whether antispastic solutions are needed if conduits are harvested with PVAT intact.
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Affiliation(s)
- Michael R. Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
| | - Zeynep Celik
- Department of Pharmacology, Istanbul University Faculty of Pharmacy, Istanbul, Türkiye
| | - Gokce Topal
- Department of Pharmacology, Istanbul University Faculty of Pharmacy, Istanbul, Türkiye
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2
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Dimagli A, Gemelli M, Kumar N, Mitra M, Sinha S, Fudulu D, Harik L, Cancelli G, Soletti G, Olaria RP, Bonaros N, Gaudino M, Angelini GD. A systematic review and meta-analysis of internal thoracic artery harvesting techniques: Skeletonized vs pedicled. Int J Cardiol 2024; 395:131577. [PMID: 37956758 DOI: 10.1016/j.ijcard.2023.131577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES The aim of this meta-analysis was to compare clinical and angiographic outcomes of skeletonized versus pedicled internal thoracic artery for coronary artery bypass grafting. METHODS A comprehensive search on Ovid MEDLINE, Ovid EMBASE and Scopus was performed from inception to December 2022. The primary outcome was follow-up mortality and graft failure. Secondary outcomes were repeat revascularization, cardiovascular death and operative mortality, myocardial infarction, stroke, and sternal wound complications (SWCs). Pooled estimate for follow-up outcomes was summarized as incidence rate ratio (IRR) and 95% confidence interval (CI) while short-term outcomes were pooled as odds ratio (OR) and 95% CI. For all outcomes, inverse variance weighting was used for pooling. RESULTS Twenty-eight studies, including 7 randomized trials and 21 observational studies, for a total of 5664 patients in the skeletonized group and 7434 in the pedicled group, were included in the analysis. At a mean weighted follow-up of 4.8 years, there was no difference in mortality between the two groups (IRR 1.14; 95% CI 0.59-2.20). However, the skeletonized group had a higher incidence of graft failure compared to the pedicled group (IRR 1.87, 95% CI 1.33-2.63) but a lower risk of SWCs (OR 0.42; 95% CI 0.30-0.60). There was no difference in short-term outcomes. CONCLUSIONS Compared to the pedicled harvesting technique, skeletonization of the internal thoracic artery is associated with higher rate of graft failure and lower risk of SWCs without mortality difference.
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Affiliation(s)
- Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA; Bristol Heart Institute, University of Bristol, Bristol, UK.
| | - Marco Gemelli
- Bristol Heart Institute, University of Bristol, Bristol, UK; Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular, and Public Health Sciences, University of Padua, Padova, Italy
| | - Niraj Kumar
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Matthias Mitra
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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3
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Robu M, Rădulescu B, Margarint I, Știru O, Antoniac I, Gheorghiță D, Voica C, Nica C, Cacoveanu M, Iliuță L, Iliescu VA, Moldovan H. Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries. J Cardiovasc Dev Dis 2023; 10:457. [PMID: 37998515 PMCID: PMC10672728 DOI: 10.3390/jcdd10110457] [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: 10/14/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". METHODS We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. RESULTS This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. CONCLUSIONS We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.
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Affiliation(s)
- Mircea Robu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania;
| | - Bogdan Rădulescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania;
| | - Irina Margarint
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
| | - Ovidiu Știru
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania;
| | - Iulian Antoniac
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 060042 Bucharest, Romania; (I.A.); (D.G.)
- Academy of Romanian Scientists, 54, Spl. Independentei, 050711 Bucharest, Romania
| | - Daniela Gheorghiță
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 060042 Bucharest, Romania; (I.A.); (D.G.)
| | - Cristian Voica
- Department of Cardiovascular Surgery, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania; (C.V.); (C.N.); (M.C.)
| | - Claudia Nica
- Department of Cardiovascular Surgery, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania; (C.V.); (C.N.); (M.C.)
| | - Mihai Cacoveanu
- Department of Cardiovascular Surgery, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania; (C.V.); (C.N.); (M.C.)
| | - Luminița Iliuță
- Department of Cardiovascular Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania;
| | - Vlad Anton Iliescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania;
| | - Horațiu Moldovan
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (I.M.); (O.Ș.); (V.A.I.); (H.M.)
- Academy of Romanian Scientists, 54, Spl. Independentei, 050711 Bucharest, Romania
- Department of Cardiovascular Surgery, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania; (C.V.); (C.N.); (M.C.)
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4
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Nie C, Deng Y, Lu Y. Effect of skeletonisation and pedicled bilateral internal mammary artery grafting in coronary artery bypass surgery on post-operative wound infection: A meta-analysis. Int Wound J 2023; 21:e14424. [PMID: 37818829 PMCID: PMC10828717 DOI: 10.1111/iwj.14424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
The results showed that different internal thoracic artery (ITA) was associated with the rate of postoperative wound infection and the severity of pain following coronary artery bypass grafting (CABG). In order to ascertain if there was any genuine difference in the rate of postoperative infection and severity of the pain, we conducted a meta-analysis to evaluate if there was any actual difference in the wound complication that had been identified with the ITA method. Through EMBASE, Cochrane Library and Pubmed, and so forth, we systematically reviewed the results by August 2023, which compared the impact of skeletonised versus pedicled internal mammary artery (IMA) on wound complications following CABG. The trial data have been pooled and analysed in order to determine if a randomisation or fixed-effect model should be applied. The meta-analysis of data was performed with Revman 5.3 software. The results of this meta-study included 252 related articles from four main databases, and nine articles were chosen to be extracted and analysed. A total of 3320 patients were treated with coronary artery transplantation. Based on current data analysis, we have shown that the rate of postoperative wound infections is reduced by the use of the skeletonised internal mammary artery (SIMA) (OR, 1.84; 95% CI, 1.13, 3.01; p = 0.01). But the results showed that there were no statistically significant differences in the post-operation pain score of the patients (MD, 0.09; 95% CI, -0.58, 0.76; p = 0.79). Furthermore, the duration of the operation was not significantly different between the SIMA and pedicled internal mammary artery (PIMA) (MD, 3.30; 95% CI, -3.13, 9.73; p = 0.31). Overall, the SIMA decreased the rate of postoperative wound infection in CABG patients than the PIMA.
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Affiliation(s)
- Caihong Nie
- Traditional Chinese Medicine University of GuangzhouGuangzhouChina
| | - Yunping Deng
- Zhongnan University of Economics and LawWuhanChina
| | - Yongmei Lu
- Traditional Chinese Medicine University of GuangzhouGuangzhouChina
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5
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). J Thorac Cardiovasc Surg 2023; 166:1099-1114. [PMID: 37542480 DOI: 10.1016/j.jtcvs.2023.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 04/20/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY.
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | | | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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6
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert Systematic Review on the Choice of Conduits for Coronary Artery Bypass Grafting: Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2023; 116:659-674. [PMID: 37542509 DOI: 10.1016/j.athoracsur.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York.
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | - Kalie Kisson
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, New York
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, New York
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Thomas A Schwann
- Division of Cardiac Surgery, Baystate Health, Springfield, Massachusetts
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Moritz Wyler von Ballmoos
- Division of Cardiothoracic Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
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7
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). Eur J Cardiothorac Surg 2023; 64:ezad163. [PMID: 37535847 DOI: 10.1093/ejcts/ezad163] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023] Open
Abstract
PREAMBLE The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | - Kalie Kisson
- The Society of Thoracic Surgeons, Chicago, IL, USA
| | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY, USA
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thomas A Schwann
- Division of Cardiac Surgery, Baystate Health, Springfield, MA, USA
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Moritz Wyler von Ballmoos
- Division of Cardiothoracic Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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8
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Lamy A, Browne A, Sheth T, Zheng Z, Dagenais F, Noiseux N, Chen X, Bakeen FG, Brtko M, Stevens LM, Alboom M, Lee SF, Copland I, Salim Y, Eikelboom J. Skeletonized vs Pedicled Internal Mammary Artery Graft Harvesting in Coronary Artery Bypass Surgery: A Post Hoc Analysis From the COMPASS Trial. JAMA Cardiol 2021; 6:1042-1049. [PMID: 34132753 DOI: 10.1001/jamacardio.2021.1686] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The relative safety and patency of skeletonized vs pedicled internal mammary artery grafts in patients undergoing coronary artery bypass graft (CABG) surgery are unknown. Objective To investigate the association of skeletonized vs pedicled harvesting with internal mammary artery graft patency and clinical outcomes 1 year after CABG surgery. Design, Setting, and Participants This study was a post hoc analysis of the multicenter, randomized, double-blind, placebo-controlled Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial, which enrolled 27 395 patients from 602 centers in 33 countries from March 2013 through May 2016. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 grafts implanted and an estimated glomerular filtration rate of at least 30 mL/min. A total of 1002 of 1448 patients were randomized to the CABG arm of the COMPASS trial and underwent skeletonized (282 [28.1%]) or pedicled (720 [71.9%]) internal mammary artery harvesting. The patients had evaluable angiography results 1 year after surgery. Data were analyzed from October 11, 2019, to May 14, 2020. Interventions Patients underwent graft harvesting with either the pedicled technique or skeletonized technique. Main Outcomes and Measures The primary outcome was graft occlusion 1 year after CABG surgery, as assessed by computed tomography angiography. Results A total of 1002 patients underwent skeletonized (282 [28.1%]; mean [SD] age, 65.9 [8.1] years; 229 men [81.2%]; 194 White patients [68.8%]) or pedicled (720 [71.9%]; mean [SD] age, 64.8 [7.6] years; 603 men [83.8%]; 455 White patients [63.2%]) internal mammary artery harvesting. Rates of internal mammary artery graft occlusion 1 year after CABG surgery were higher in the skeletonized group than in the pedicled group (33 of 344 [9.6%] vs 30 of 764 [3.9%]; graft-level adjusted odds ratio, 2.41; 95% CI, 1.39-4.20; P = .002), including the left internal mammary artery to left anterior descending artery (21 of 289 [7.3%] vs 25 of 725 [3.4%]; graft-level adjusted odds ratio, 2.10; 95% CI, 1.14-3.88, P = .02). After a mean follow-up of 23 months, skeletonized graft harvesting was also associated with a higher rate of major adverse cardiovascular events (20 [7.1%] vs 15 [2.1%]; adjusted hazard ratio, 3.19; 95% CI, 1.53-6.67; P = .002) and repeated revascularization (14 [5.0%] vs 10 [1.4%]; adjusted hazard ratio, 2.75; 95% CI, 1.10-6.88; P = .03). Conclusions and Relevance This post hoc analysis of the COMPASS randomized clinical trial found that harvesting of the internal mammary artery during CABG surgery using a skeletonized technique was associated with a higher rate of graft occlusion and worse clinical outcomes than the traditional pedicled technique. Future randomized clinical trials are needed to establish the safety and patency of the skeletonized technique. Trial Registration ClinicalTrials.gov Identifier: NCT01776424.
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Affiliation(s)
- André Lamy
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Austin Browne
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, Beijing, China
| | - François Dagenais
- Department of Cardiac Surgery, Quebec Heart and Lung Institute affiliated with Laval University, Quebec City, Quebec, Canada
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital affiliated with Nanjing Medical University, Nanjing, China
| | - Faisal G Bakeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miroslav Brtko
- Department of Cardiac Surgery, Fakultní Nemocnice Hradec Králové, Hradec Králové, Královéhradecký, Czech Republic
| | - Louis-Mathieu Stevens
- Department of Cardiac Surgery, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
| | - Mariam Alboom
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ingrid Copland
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yusuf Salim
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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9
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Kusu-Orkar TE, Kermali M, Masharani K, Noshirwani A, MacCarthy-Ofosu B, Oguamanam N, Bin Saeid J, Muir AD, Harky A. Skeletonized or Pedicled Harvesting of Left Internal Mammary Artery: A Systematic Review and Meta-analysis. Semin Thorac Cardiovasc Surg 2020; 33:10-18. [PMID: 32979482 DOI: 10.1053/j.semtcvs.2020.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
We sought to compare clinical outcomes in skeletonized versus pedicled left internal mammary artery (LIMA) grafts in elective coronary artery bypass grafting through a systematic review and meta-analysis. A comprehensive electronic literature search of PubMed, Ovid, Embase, and Scopus was conducted from inception to January 2020. Only short-term (30 days) studies which compared both techniques have been included in our analysis. Primary outcomes were post anastomosis flow rate and sternal wound infection rate (SWI); secondary outcomes were conduit length, acute myocardial infarction and 30-day mortality. Thirteen articles with a total of 6222 patients met the inclusion criteria. Except for the prevalence of diabetes mellitus being significantly lower in the skeletonized cohort (odds ratio [OR] 0.77 95% confidence interval [CI] [0.61, 0.97], P = 0.03), there were no differences in the preoperative demographics between the 2 groups. The skeletonized LIMA conduit was significantly longer when compared to the pedicled conduit (weighted mean difference -2.64 cm 95% CI [-3.71, -1.56], P < 0.0001). SWI rates were not significantly different in the skeletonized versus pedicled LIMA group (OR 0.71 95% CI [0.47, 1.06], P = 0.10). New onset of acute myocardial infarction and 30-day mortality rate was similar in the 2 groups (OR 1.04 and 0.97, respectively, P > 0.05 in both). The postanastomoses flow rate was higher in skeletonized LIMA (Weighted Mean Difference -11.51 mL/min 95% CI [-20.54, -2.49], P < 0.01). Harvesting the LIMA using the skeletonized technique is associated with higher postanastomosis flow rates and longer conduit lengths; with no difference in SWI and mortality rates when compared to the pedicled technique. We suggest that this technique should be adopted, particularly for BITA harvesting. However, further research is needed to provide clearer indications for both methods.
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Affiliation(s)
| | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Kellan Masharani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Arish Noshirwani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Nina Oguamanam
- Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Jalal Bin Saeid
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Andrew D Muir
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
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10
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Urso S, Sadaba R, Tena MÁ, Bellot R, Ríos L, Martínez-Comendador JM, Abad C, Portela F. Arteria mamaria interna esqueletizada versus pediculada: una revisión sistemática. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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11
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Dolapoglu A, Beketaev I. Can Past Stenting and Blood Lipid Levels Affect the Graft Patency After Coronary Artery Bypass Surgery? J Card Surg 2015; 30:902. [PMID: 26031940 DOI: 10.1111/jocs.12578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ahmet Dolapoglu
- Cardiovascular Surgery Department, Texas Heart Institute, Houston, Texas
| | - Ilimbek Beketaev
- Center for Stem Cell Engineering, Texas Heart Institute, Houston, Texas
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