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Published on: March 27, 2018
Reusing the patent internal mammary artery as a conduit in redo coronary artery bypass surgery
Nnamdi Nwaejike1, Charlene Tennyson1, Roberto Mosca1
1Department of Cardiothoracic Surgery, University Hospitals of South Manchester, Manchester, UK.
Insights
Recycling internal mammary artery (IMA) grafts for repeat coronary artery bypass surgery (CABG) is a safe and effective option when feasible. Studies show good long-term outcomes, making it a viable choice for redo CABG procedures.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Redo coronary artery bypass grafting (CABG) presents unique challenges, particularly regarding graft availability.
- The internal mammary artery (IMA), also known as the internal thoracic artery (ITA), is a preferred arterial conduit for primary CABG due to its long-term patency.
- Reusing previously implanted IMA grafts in redo CABG has been explored as a potential solution for conduit scarcity.
Purpose of the Study:
- To evaluate the safety and efficacy of reusing or recycling internal mammary artery (IMA) grafts in patients undergoing redo coronary artery bypass grafting (CABG).
Main Methods:
- A systematic review of published literature was conducted to identify studies reporting on the use of previously implanted IMA/internal thoracic artery (ITA) grafts in redo CABG.
- Evidence from 10 selected papers, including retrospective series and case reports, was analyzed to assess outcomes.
Main Results:
- Multiple studies involving various numbers of patients (ranging from 4 to 60) demonstrated no operative or perioperative mortality in most cases when using recycled IMA/ITA grafts.
- Postoperative angiography in some series confirmed excellent patency and flow in redone IMA/ITA grafts.
- Reported outcomes included low rates of 30-day mortality (8.3%) and myocardial infarction (3%) in one large series, with no need for further revascularization in some patients.
Conclusions:
- The recycled internal mammary artery (IMA)/internal thoracic artery (ITA) is a safe and viable conduit for redo coronary artery bypass grafting (CABG) when it can be successfully harvested.
- While studies indicate good long-term outcomes, direct comparative data against first-time IMA harvest or other conduits is limited due to the predominantly retrospective nature of the evidence.
Abstract:
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with previous internal mammary artery/internal thoracic artery (ITA) grafts, can the internal mammary artery/ITA be reused/recycled in redo coronary artery bypass surgery? Fourteen papers were found using the reported search of which 10 represented the best evidence to answer the clinical question. There was variation in patient selection, the number of patients reported, outcome measures recorded, and methods and duration of follow-up. The results were mostly in favour of using a recycled ITA when it could be safely harvested. Most studies were retrospective. One large series of 60 patients who underwent redo coronary artery bypass grafting (CABG) using previously implanted ITAs had a mean time to reoperation of 117 ± 68 months. They reported no operative deaths; no patients required further or subsequent target vessel revascularization; 30-day mortality was 8.3% and myocardial infarction rate was 3%. Another two series of 16 and 12 patients underwent recycling of arterial grafts during coronary artery revascularization with no perioperative deaths in either. Postoperative angiography was performed in 10 patients in one of these studies, which showed excellent flow in all redone left internal thoracic artery (LITA) grafts. One study reported results from a prospective cohort of 9 patients who underwent redo coronary artery bypass grafting. Interval between operations was between 1 and 132 months. There was no perioperative mortality, but 1 patient required reintervention (to an interposition vein graft). A further study of 4 patients who underwent redo CABG using ITAs that were patent but with severe stenosis at the distal anastomosis had no mortality. Postoperative angiography showed patency of all grafts. There have also been 4 case reports on reusing the ITA/ITA in redo CABG with no damage to the reused LITA, no perioperative mortality and satisfactory follow-up at up to 29 months. Evidently, the recycled ITA can be used in redo coronary artery bypass grafting. Papers found were retrospective series or case reports. As such, there is no direct comparison in outcomes between the recycled ITA and first-time ITA harvest or any other conduit for CABG. In conclusion, we find that when it is possible to harvest a previously used ITA, studies have shown it to be a safe and viable conduit in redo CABG with good long-term outcomes.
