1
|
Stevens LM, Chartrand-Lefebvre C, Mansour S, Béland V, Soulez G, Forcillo J, Basile F, Prieto I, Noiseux N. Anterolateral territory coronary artery bypass grafting strategies: a non-inferiority randomized clinical trial: the AMI-PONT trial. Eur J Cardiothorac Surg 2023; 63:ezad060. [PMID: 36805638 PMCID: PMC10133400 DOI: 10.1093/ejcts/ezad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/09/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVES The main objective was to assess whether a composite coronary artery bypass grafting strategy including a saphenous vein graft bridge to distribute left internal mammary artery outflow provides non-inferior patency rates compared to conventional grafting surgery with separated left internal mammary artery to left anterior descending coronary graft and aorto-coronary saphenous vein grafts to other anterolateral targets. METHODS All patients underwent isolated grafting surgery with cardiopulmonary bypass and received ≥2 grafts/patients on the anterolateral territory. The graft patency (i.e. non-occluded) was assessed using multislice spiral computed tomography at 1 year. RESULTS From 2012 to 2021, 208 patients were randomized to a bridge (n = 105) or conventional grafting strategy (n = 103). Patient characteristics were comparable between groups. The anterolateral graft patency was non-inferior in the composite bridge compared to conventional grafting strategy at 1 year [risk difference 0.7% (90% confidence interval -4.8 to 6.2%)]. The graft patency to the left anterior descending coronary was no different between groups (P = 0.175). Intraoperatively, the bridge group required shorter vein length for anterolateral targets (P < 0.001) and exhibited greater Doppler flow in the mammary artery pedicle (P = 0.004). The composite outcome of death, myocardial infarction or target vessel reintervention at 30 days was no different (P = 0.164). CONCLUSIONS Anterolateral graft patency of the composite bridge grafting strategy is non-inferior to the conventional grafting strategy at 1 year. This novel grafting strategy is safe, efficient, associated with several advantages including better mammary artery flow and shorter vein requirement, and could be a valuable alternative to conventional grafting strategies. Ten-year clinical follow-up is underway. TRIAL REGISTRATION ClinicalTrials.gov: NCT01585285.
Collapse
Affiliation(s)
- Louis-Mathieu Stevens
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| | - Carl Chartrand-Lefebvre
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Samer Mansour
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Division of Cardiology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Gilles Soulez
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Jessica Forcillo
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| | - Fadi Basile
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Ignacio Prieto
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Nicolas Noiseux
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| |
Collapse
|
2
|
Lobo HG, Lobo JG, Pimentel MD, Silva BGB, de Souza CS, Montenegro ML, Leitão MCDA, Jamacuru FVF. Intraoperative Analysis of Flow Dynamics in Arteriovenous Composite Y Grafts. Braz J Cardiovasc Surg 2016; 31:351-357. [PMID: 27982343 PMCID: PMC5144566 DOI: 10.5935/1678-9741.20160053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 08/04/2016] [Indexed: 11/20/2022] Open
Abstract
Objective Composite graft of left internal thoracic artery and great saphenous vein in
revascularization of the left coronary system is a technique well described
in literature. The aim of this study is to analyze blood flow dynamics in
this configuration of composite graft especially in what concerns left
internal thoracic artery's adaptability and influence of great saphenous
vein segment on left internal thoracic artery's flow. Methods Revascularization of left coronary system with composite graft, with left
internal thoracic artery revascularizing the anterior interventricular
artery and a great saphenous vein segment, anastomosed to the left internal
thoracic artery, revascularizing another branch of the left coronary system,
was performed in 23 patients. Blood flow was evaluated by transit time
flowmetry in all segments of the composite graft (left internal thoracic
artery proximal segment, left internal thoracic artery distal segment and
great saphenous vein segment). Measures were performed in baseline condition
and after dobutamine-induced stress, without and with non-traumatic
temporary clamping of the distal segments of the composite graft. Results Pharmacological stress resulted in increase of blood flow values in the
analyzed segments (P<0.05). Non-traumatic temporary
clamping of great saphenous vein segment did not result in statistically
significant changes in the flow of left internal thoracic artery distal
segment, both in baseline condition and under pharmacological stress.
Similarly, non-traumatic temporary clamping of left internal thoracic artery
distal segment did not result in statistically significant changes in great
saphenous vein segment flow. Conclusion Composite grafts with left internal thoracic artery and great saphenous vein
for revascularization of left coronary system, resulted in blood flow
dynamics with physiological adaptability, both at rest and after
pharmacological stress, according to demand. Presence of great saphenous
vein segment did not alter physiological blood flow dynamics in distal
segment of left internal thoracic artery.
Collapse
Affiliation(s)
- Heraldo Guedis Lobo
- Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil; Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, CE, Brazil
| | - José Glauco Lobo
- Department of Surgery, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil
| | | | | | | | | | | | | |
Collapse
|
3
|
Portugal IBM, Ribeiro IDL, de Sousa-Rodrigues CF, Monte-Bispo RF, da Rocha AC. Distribution of saphenous vein valves and its practical importance. Braz J Cardiovasc Surg 2014; 29:564-8. [PMID: 25714210 PMCID: PMC4408819 DOI: 10.5935/1678-9741.20140038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 12/02/2013] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Among the veins used as a graft in myocardial revascularizations and ends, great saphenous vein is the most used. Knowing the presence and location of valves has great importance when evaluating the surgical anatomy of the great saphenous vein. Despite major surgical application and many works involving great saphenous vein, the number of valves present in it from the saphenous hiatus to the medial epicondyle of the femur is still described inaccurately. The objective of this study is to quantify the valves of the great saphenous vein from the saphenous hiatus to the medial epicondyle of the femur to determine the best portion of the great saphenous vein to perform revascularization surgeries. METHODS This is a cross sectional observational study in which it was analyzed great saphenous vein extracted from 30 cadavers. It was measured the length of the veins; (diameter) at its proximal, middle and distal, quantifying the number of valves in each one and the total number of valves at the great saphenous vein. RESULTS The frequency of valves in the great saphenous vein taken from the medial epicondyle of the femur to the saphenous hiatus was 4.82, ranging between 2 and 9. Moreover, there is a significant difference in the number of valves in the proximal and distal relative to the average. CONCLUSION the median and distal portions of the saphenous vein in the thigh, are the best options for the realization of bridges due to the fact that these portions have fewer valves which therefore would tend to decrease the risk of complications connected with the valves in these grafts.
Collapse
Affiliation(s)
| | - Igor de Lima Ribeiro
- Universidade Estadual de Ciências da Saúde de Alagoas
(UNCISAL), Maceió, AL, Brazil
| | | | | | | |
Collapse
|
4
|
Noiseux N, Chartrand-Lefebvre C, Mansour S, Stevens LM. Reply to Lobo Filho et al. Eur J Cardiothorac Surg 2014; 47:940-1. [PMID: 25035413 DOI: 10.1093/ejcts/ezu283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 06/12/2014] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nicolas Noiseux
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
| | - Carl Chartrand-Lefebvre
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Samer Mansour
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada Division of Cardiology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Louis-Mathieu Stevens
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
| |
Collapse
|
5
|
Lobo Filho JG, Lobo Filho HG, Pimentel MD, Montenegro ML. A novel composite coronary bypass graft strategy using the saphenous vein bridge: could the venous valves induce worse patency results? Eur J Cardiothorac Surg 2014; 47:940. [PMID: 25035416 DOI: 10.1093/ejcts/ezu282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/12/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- José Glauco Lobo Filho
- Department of Surgery, Walter Cantidio University Hospital of the Federal University of Ceará, Fortaleza, Brazil
| | | | | | | |
Collapse
|
6
|
Drouin A, Noiseux N, Chartrand-Lefebvre C, Soulez G, Mansour S, Tremblay JA, Basile F, Prieto I, Stevens LM. Composite versus conventional coronary artery bypass grafting strategy for the anterolateral territory: study protocol for a randomized controlled trial. Trials 2013; 14:270. [PMID: 23971858 PMCID: PMC3766263 DOI: 10.1186/1745-6215-14-270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/12/2013] [Indexed: 11/20/2022] Open
Abstract
Background In severe coronary artery disease, coronary artery bypass grafting (CABG) surgery is indicated to re-establish an adequate blood supply to the ischemic myocardium. Effectiveness of CABG surgery for symptom relief and mortality decrease should therefore depend on bypass graft patency. As bypass using a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis allows the best results in terms of graft patency, we designed a new surgical technique using a saphenous vein graft as a venous bridge to distribute the LIMA flow to the cardiac anterolateral territory. This novel strategy could extend the patency benefits associated to the LIMA. Other potential benefits of this technique include easier surgical technique, possibility to use saphenous vein grafts as vein patch angioplasty, shorter saphenous vein grafts requirement and reduced or eliminated manipulations of the ascendant aorta (and associated stroke risk). Methods/Design Between July 2012 and 2016, 200 patients undergoing a primary isolated CABG surgery using cardiopulmonary bypass with a LAD bypass graft and at least another target on the anterolateral territory will be randomized (1:1) according to 1) the new composite strategy and 2) the conventional strategy with a LIMA-to-LAD anastomosis and revascularization of the other anterolateral target(s) with a separated aorto-coronary saphenous vein graft. The primary objective of the trial is to assess whether the composite strategy allows non-inferior anterolateral graft patency index (proportion of non-occluded CABGs out of the total number of CABGs) compared to the conventional technique. The primary outcome is the anterolateral graft patency index, evaluated at one year by 256-slice computed tomography angiography. Ten years of clinical follow-up is planned to assess clinical outcomes including death, myocardial infarction and need for revascularization. Discussion This non-inferiority trial has the potential to advance the adult cardiac surgery field, given the potential benefits associated with the composite grafting strategy. Trial registration ClinicalTrials.gov: NCT01585285.
Collapse
Affiliation(s)
- Ariane Drouin
- Division of Cardiac Surgery, 3840, Saint-Urbain Street, Montreal, Quebec, H2W 1T8, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Tremblay JA, Stevens LM, Chartrand-Lefebvre C, Chandonnet M, Mansour S, Soulez G, Prieto I, Basile F, Noiseux N. A novel composite coronary bypass graft strategy: the saphenous vein bridge--a pilot study. Eur J Cardiothorac Surg 2013; 44:e302-7. [PMID: 23904134 DOI: 10.1093/ejcts/ezt388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this pilot study was to describe and assess the safety of a novel composite graft technique for coronary artery bypass grafting (CABG) surgery. A saphenous vein is grafted to the left anterior descending artery (LAD) and other anterolateral coronary arteries, creating a saphenous vein bridge (SVB) and the left internal mammary artery (LIMA) is anastomosed to the SVB, distributing the blood flow distally (LIMA-SVB). METHODS All patients who underwent CABG with the LIMA-SVB between 2005 and 2008 at our centre were enrolled in this study. Perioperative data were retrospectively collected from hospital charts, and the clinical follow-up was completed by telephone interview. Graft patency was assessed by computed tomography angiography (CTA) in patients with the longest follow-up time (n = 20). RESULTS A total of 256 patients (mean age: 67 ± 12 years; 79% male) received 4.0 ± 1.0 grafts, including 2.2 ± 0.4 distal grafts provided by the LIMA-SVB. Nine (3.5%) deaths and 4 (1.6%) myocardial infarctions (MIs) were noted in the perioperative period. With a median follow-up time of 36 months [inter-quartile range 31-44], 1 (0.5%) MI and 2 (1.0%) strokes were reported. At 51 months post-surgery [47-53], CTA demonstrated a LIMA pedicle (n = 20) and SVB (n = 42) patency rate of 100 and 93%, respectively. Specifically, the LIMA-SVB patency rate was 100% to the LAD and 85% to diagonal arteries. Aortocoronary vein grafts (n = 38) patency rate in the same patients was 87%. CONCLUSIONS Revascularization of the anterolateral territory using the LIMA-SVB is a promising approach considering its clinical safety and favourable patency rate results. A prospective randomized clinical trial is underway to compare this technique to conventional CABG.
Collapse
Affiliation(s)
- Jan-Alexis Tremblay
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|