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Internal thoracic artery malperfusion: fast decision for an additional vein graft has impact on patient outcome
Parwis Massoudy1, Yi-Young Kim, Murat Cetin
1Clinic for Thorax and Cardiovascular Surgery, University Clinic of Essen, Essen, Germany. parwis.massoudy@uni-essen.de
Insights
Internal thoracic artery (ITA) malperfusion after coronary artery bypass grafting (CABG) can be lethal. Promptly performing an additional vein graft to the left anterior descending (LAD) artery in cases of ITA malperfusion improves patient survival.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Internal thoracic artery (ITA) malperfusion is a serious complication following coronary artery bypass grafting (CABG).
- This complication can be devastating and lead to mortality.
- Our institutional practice involves performing an additional vein graft to the distal left anterior descending (LAD) artery when ITA malperfusion occurs.
Purpose of the Study:
- To evaluate the outcomes of patients experiencing ITA malperfusion during CABG.
- To determine if an additional vein graft to the distal LAD impacts patient survival.
- To identify factors associated with improved outcomes in ITA malperfusion cases.
Main Methods:
- A retrospective review of 2877 CABG procedures performed between August 1999 and July 2002.
- Identification of 65 patients (2.3%) who experienced ITA malperfusion.
- All identified patients received an additional vein graft to the distal LAD; data on timing and outcomes were analyzed.
Main Results:
- Of 65 patients with ITA malperfusion, 54 (83%) survived and 11 (17%) died.
- Survivors (Group 1) had significantly shorter cross-clamp times (88 vs. 104 minutes) and time intervals between CPB termination and re-cross-clamping (23 vs. 46 minutes) compared to non-survivors (Group 2).
- Survivors exhibited significantly lower maximum postoperative troponin I levels (35 vs. 136 ng/mL), indicating less myocardial damage.
Conclusions:
- Survivors of ITA malperfusion demonstrated shorter cross-clamp times and reduced myocardial injury.
- Shorter time intervals from CPB termination to re-cross-clamping in survivors suggest prompt intervention is beneficial.
- A rapid decision to perform an additional vein graft for ITA malperfusion may positively influence postoperative patient outcomes.
Background:
Internal thoracic artery (ITA) malperfusion has been described as a potentially devastating and lethal complication of coronary artery bypass grafting (CABG). It is our practice to perform an additional vein graft to the distal left anterior descending (LAD) artery in such cases.
Methods:
From August 1999 to July 2002, 2877 CABG procedures were performed at our institution. In 65 patients (2.3%) ITA malperfusion was observed. All of them were treated with an additional vein graft to the distal LAD. All patient data were screened for the time interval between the occurrence of ITA malperfusion and the decision to perform an additional vein graft.
Results:
Of 65 patients with ITA malperfusion, 54 patients (83%) survived (group 1), 11 patients (17%) died (group 2). There was no difference in preoperative risk status between the groups. Cross clamp time was 88 +/- 4 minutes in group 1 and 104 +/- 11 minutes in group 2 (p = 0.04). Intraoperative ITA flow to LAD was 6 +/- 1 mL/min in group 1 and 10 +/- 5 mL/min in group 2 (p = 0.2). Time between release of cross clamp and second period of cross clamping was 50 +/- 5 minutes in group 1 and 75 +/- 11 minute group 2 (p = 0.02). Time between termination of cardiopulmonary bypass (CPB) and second period of cross clamping was 23 +/- 3 minutes in group 1 and 46 +/- 7 minutes in group 2 (p = 0.003). Vein graft flow to distal LAD was 54 +/- 4 mL/min in group 1 and 52 +/- 12 mL/min in group 2 (p = 0.5). Maximum postoperative troponin I was 35 +/- 11 ng/mL in group 1 and 136 +/- 32 in group 2 (p = 0.003).
Conclusions:
Survivors of ITA malperfusion had shorter cross clamp times and less myocardial damage as evidenced by lower postoperative troponin I levels. Time intervals between first and second cross clamp and between termination of CPB and second cross clamp were lower in survivors, thus indicating that a fast decision for an additional vein graft may influence postoperative patient outcome.
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