NGUYỄN HOÀNG ĐỊNH, MD PhD LÊ MINH KHÔI, MD, PhD University of Medicine and Pharmacy of HCM City University Medical Center SYNTAX • RCT study included 1800 pts: CABG vs PCI • MACCE at 12 months From: CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting J Am Coll Cardiol 2015;66(13):1417-1427 doi:10.1016/j.jacc.2015.07.060 Figure Legend: Survival After Percutaneous and Surgical CAD Treatment Modalities Comparisons of unadjusted 9-year all-cause mortality (A) and unplanned reintervention-free (B) survival shown for all coronary revascularization groups: 2,207 bare-metal stent (BMS) percutaneous coronary intervention (PCI) (age 66.6 ± 11.9 years); 2,381 drug-eluting stent (DES)-PCI (age 65.9 ± 11.7 years); 2,289 single-arterial (SA) coronary artery bypass graft (CABG) (age 69.3 ± 9.0 years); and 1,525 multiarterial (MA)-CABG (age 58.3 ± 8.7 years) The p values were derived by log-rank test CAD = coronary artery disease Date of download: 10/4/2015 Copyright © The American College of Cardiology All rights reserved From: CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting Optimal Revascularization of Multivessel CAD: Comparison of 9Year Propensity Matched All-Cause Mortality Survival Data for Both PCI Treatment Cohorts Each cohort is separately compared to single-arterial (SA) and multiarterial (MA) coronary artery bypass graft (CABG) surgery: (A) bare-metal stent (BMS) percutaneous coronary intervention (PCI) versus SA-CABG; (B) BMS-PCI versus MA-CABG; (C) drug-eluting stent (DES)-PCI versus SA-CABG; and (D) DES-PCI versus MA-CABG The p values were derived by log-rank test CAD = coronary artery disease J Am Coll Cardiol 2015;66(13):1417-1427 doi:10.1016/j.jacc.2015.07.060 Date of download: 10/4/2015 Copyright © The American College of Cardiology All rights reserved IMA vs SVG vs RA • Morphology: IMA has thin smooth muscle media + tight internal elastic lamina • Physiology: IMA produces more NO than RA and SVG • Increased EDRFs produced by IMAs results in superior graft patency and additional protects native coronary artery circulation Thomas F Luscher, New Eng J Med 1998, Circ 2007 ber mortality of Dùng Không ĐMNT dùng Risk trái ĐMNT ratio 2,25 3,2 6,5 2.03 8797 1,6 3,7 2,31 432 3,2 10,5 3,26 Yea patie (STS) Grover (VACS) Dabal (COAP) Nguyen H Dinh nts 199 38.57 199 14.17 0.25 Edwards r TMH 200 201 0.00 Authors DMNTT 0.75 Inhospital 0.50 Num 1.00 LIMA to LAD 20 40 60 ONE MAMMARY ARTERY IS GOOD, IS TWO BETTER? • Lytle 2004: survival rate of BITA group is higher than LITA group after – 20 years of follow-up Lytle, B W., Blackstone, E H., Sabik, J F., Houghtaling, P., Loop, F D., Cosgrove, D M (2004) Ann Thorac Surg, 78(6), 2005-2012; discussion 2012-2004 ONE MAMMARY ARTERY IS GOOD, IS TWO BETTER? META ANALYSIS • Taggart 2001: BITA significantly improved survival rate HR=0,81 • Taggart, D P., D'Amico, R., Altman, D G (2001) Lancet, 358(9285), 870-875 Effects of bilateral internal mammary artery grafting on long-term survival Gijong Yi et al Circulation 2014;130:539-545 Copyright © American Heart Association, Inc All rights reserved BIMA skeletonisation • Preparation: • Harvest, divide distally and clip • Wrab in papaverine swab + increase BP to 150 for 5mins • No need to inject • Artery • Longer • Wider • See full length • Easier composites • Easier sequential BIMA skeletonisation: when not to use • Diabetes especially if insulin dependent AND obese • Bad lungs (prolonged ventilation) • Patients on steroids and immunosuppressives • Elderly? Figure A, Representative SPECT Image of postoperative sternal perfusion in a patient who received a left skeletonized and a right nonskeletonized ITA Differences in sternal perfusion are discernible in the manubrium and middle third of the sternum Munir Boodhwani et al Circulation 2006;114:766-773 Copyright © American Heart Association, Inc All rights reserved RISK FACTORS OF DSWI • BIMA harvesting (RR 2.18) • Medically treated diabetes (RR 1.73) • Female sex (RR 1.8) • Higher BMI (7% increased risk per kg/m2) • Previous MI (RR 1.58) • Peripheral arterial diseases (RR 1.73) • Raza S, Sabik III JF et al Surgical revascularization techniques that minimize surgicak risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus J Thorac Cardiovasc Surg 2014;148:1257-66 HOW TO AVOID DSWI IN BIMA GRAFTING • Patient selection • Skeletonized IMAs harvesting • Sternal closure techniques • Topical antibiotic: vancomycin, gentamycin? ITAs HARVESTING AND IABP SUPPORT Vohra: IABP help facilitate ITAs harvesting, decrease renal failure and hospital stay in unstable angina, low EF and left main patients • Vohra, H A (2006) J Card Surg, 21(1), 1-5 Summary and conclusions CABG using BITA T-graft is safe with long-term survival benefits and should be encouraged in daily practice • Strong angiographic evidence of >90% long-term patency of both IMAs • Meta-analyses and large registries show benefit of BIMA • ART trial phase 1: BIMA does not increase year mortality, risk of stroke, MI, revascularization Summary and conclusions Composite arterial graft with no-touch technique reduces risk of stroke Use of BIMA slightly increase risk of SWI, can reduce risk with skeletonization technique Thank you for your kind attention!