Total coronary revascularization with the internal thoracic arteries T graft

1. Total coronary revascularization with the internal thoracic arteries T graft B. El Nakadi, Y. De Bruyne, M. Joris C.H.U. de Charleroi, Belgium

2. Total coronary revascularization with the internal thoracic arteries T graft • 1960 : RITA RCA • 1965 : LITA LAD • 1973 : RITA + LITA in situ • 80’s : LITA on LAD improves long-term survival

3. Total coronary revascularization with the internal thoracic arteries T graft sITA > < bITA grafting

4. Total coronary revascularization with the internal thoracic arteries T graft • Complications of bITA grafting

5. Total coronary revascularization with the internal thoracic arteries T graft • Sternal infection risk factors • Univariate analysis : • bITA grafting • Obesity • Diabetes • Prolonged mechanical ventilation • Multivariate regressive analysis : • bITA grafting p=0.0001 • Obesity p=0.0014 • Prolonged ventilation p=0.0018 Kouchoukos. Ann. Thorac. surg. 1990

6. Total coronary revascularization with the internal thoracic arteries T graft • ITAs have proved to be the best bypass graft but have an inadequate length to bypass Cx pl and RC arteries to achieve a complete revascularization.

7. Total coronary revascularization with the internal thoracic arteries T graft

8. Total coronary revascularization with the internal thoracic arteries T graft

9. Total coronary revascularization with the internal thoracic arteries T graft • Material:( jan. 94 sept.97 ) • 106 patients , 1E/10G • Age: 51 ys (35-69) • Redo: 8 % • Diabetes: 21% • Obesity: 38 %

10. Total coronary revascularization with the internal thoracic arteries T graft • Material: • NYHA: II: 49 % III: 13 % IV: 22 % • Stress test: 58 patients. 90 % • EF: 0.60 (0.22-0.85) +

11. Total coronary revascularization with the internal thoracic arteries T graft

12. Total coronary revascularization with the internal thoracic arteries T graft • Operative data: • Anastomoses: 4.25 (3-6) 3 (2-4) redo patients. • Aortic cross clamping: 94 ñ 18 min. • IABP: 1 (EF:0.25) • Exploration for bleeding: 0

13. Total coronary revascularization with the internal thoracic arteries T graft • Morbidity: • Transient s-t elevation: 12 (11 %) • Q wave infarction: 3 (3 %) • Sternal infection: 1 (1%) • Mortality: 0

14. Total coronary revascularization with the internal thoracic arteries T graft • Follow-up(105 patients) • 26 ñ 13 months • Survival: 99 % • Stress test: 90 % • Recurrent angina: 7 NYHA II (7 %) • infarct: 0 • Sternal instability: 2 % rewiring -

15. Total coronary revascularization with the internal thoracic arteries T graft • Is the blood supply sufficient? • clinical results . • Experimental studies. • What about subclavian artery atherosclerosis? • before surgery free LITA + in situ RITA. • after surgery - Extraanatomic bypass. -Angioplasty.

16. Total coronary revascularization with the internal thoracic arteries T graft • Follow-up: • Symptoms, stress test, thallium test. • Graft evaluation: • Duplex(supraclavicular fossa) :qualitative flow information in 95 % of cases. • Spiral CT scan : graft patency sensitivity 85 %& specificity 100% • Angiography.

17. Total coronary revascularization with the internal thoracic arteries T graft • Has the potential to increase event-free survival and reduce the need for reoperation in patients with three-vessel disease. • Can be performed with a low mortality and morbidity in a selected population, even in patients requiring reoperation.