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Routine use of bilateral skeletonized internal mammary arteries for myocardial revascularization
J Gurevitch1, Y Paz, I Shapira
1Department of Thoracic and Cardiovascular Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel.
Insights
Routine use of bilateral skeletonized internal mammary artery grafting is safe and effective for complete arterial revascularization, even in elderly and diabetic patients undergoing coronary artery bypass grafting.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Complete arterial myocardial revascularization traditionally excluded certain patient groups.
- A novel technique utilizes a longer, skeletonized internal mammary artery for versatile revascularization without saphenous vein grafts.
Purpose of the Study:
- To evaluate the impact of routine double skeletonized internal mammary artery use in coronary artery bypass grafting.
- To assess safety and efficacy in a broad patient population, including elderly and diabetic individuals.
Main Methods:
- Prospective evaluation of 472 patients undergoing coronary artery bypass grafting (April 1996 - June 1997).
- Utilized double skeletonized internal mammary artery grafts in all patients.
- Average patient age 65, with 31% diabetic and 36% over 70 years old.
Main Results:
- Low operative mortality (1.7%), with significantly lower mortality in urgent/elective cases (0.7%) versus emergency (8.1%).
- Perioperative infarcts (0.6%) and strokes (1.3%) were infrequent.
- Two-year actuarial survival was 96.8%, with 92% angina-free survivors. Neither age nor diabetes predicted adverse events.
Conclusions:
- Bilateral skeletonized internal mammary artery grafting is a safe and effective alternative for myocardial revascularization.
- This technique is suitable for elderly and diabetic patients, challenging previous patient selection criteria.
Background:
Complete arterial myocardial revascularization without the use of saphenous veins grafts was primarily performed on selected patient populations such as the young and nondiabetic. In a recently developed surgical technique, the internal mammary artery is dissected gently as a longer skeletonized artery, providing greater versatility for complete arterial revascularization, without saphenous veins grafts.
Methods:
We prospectively evaluated the impact of the routine use of double skeletonized internal mammary artery in 472 patients who underwent coronary artery bypass grafting between April 1996 and June 1997. Their average age was 65 years (30 to 87 years), 383 (83%) were men, and 89 (17%) women. One hundred sixty-nine (36%) of the patients were older than 70 years, and 145 (31%) were diabetic. The average number of grafts was 3.2 per patient (two to six grafts).
Results:
Operative mortality was 1.7% (n = 8). The mortality of urgent and elective patients was 0.7% (3 of 410 patients), and that of emergency operations was 8.1% (5 of 62 patients; p < 0.01). There were three (0.6%) perioperative infarcts, and 6 patients (1.3%) sustained strokes. Sternal wound infection occurred in 8 patients (1.7%). Postoperative follow-up (1 to 25 months) was available in 462 patients (99%). Two-year actuarial survival was 96.8%, and 92% of the surviving patients are well and free of angina. Neither diabetes mellitus nor old age (>70 years) were significant independent predictors of any early or late untoward events. None of the 70 diabetic patients more than 65 years of age developed sternal wound infection. Chronic lung disease was found to be the only independent predictor for sternal infections.
Conclusions:
Routine use of bilateral skeletonized internal mammary artery is a safe replacement for the current myocardial revascularization technique even in the old and diabetic patients.