Treatment of Anomalous Coronary Arteries-Surgical Revascularisation Using the Pure Internal Thoracic Artery Technique
Ramon L James1, Sudeep Das De1, Sanjeet Singh Avtaar Singh1
1Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow G81 4DH, UK.
Insights
Internal thoracic artery grafts offer a durable solution for anomalous aortic origin of coronary artery (AAOCA) surgery. Careful consideration of graft failure risk in non-flow-limiting disease cases is essential for successful outcomes.
Area of Science:
- Cardiovascular Surgery
- Congenital Heart Disease
- Vascular Grafting
Background:
- Anomalous aortic origin of coronary artery (AAOCA) is a rare congenital heart defect.
- Surgical correction is necessary to prevent adverse cardiac events.
- Internal thoracic artery (ITA) grafts are increasingly utilized in coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the efficacy and durability of CABG using pedicled Right Internal Thoracic Artery (RITA), Left Internal Thoracic Artery (LITA), or Pure Internal Thoracic Artery (PITA) techniques for AAOCA.
- To assess long-term outcomes and identify factors influencing graft patency.
Main Methods:
- Retrospective review of 14 patients undergoing surgery for AAOCA between 2013-2021.
- Data collected included patient demographics, coronary anomaly morphology, surgical technique, and perioperative/long-term outcomes.
- CABG performed using pedicled skeletonized RITA, LITA, or PITA grafts.
Main Results:
- No perioperative mortality observed in 14 patients (11 males, median age 62.5 years).
- Presentations included angina and acute coronary syndrome; varied AAOCA morphologies were observed.
- Median follow-up of 43 months showed one case of graft failure and two non-cardiac deaths.
Conclusions:
- Internal thoracic artery grafts provide a durable treatment for AAOCA.
- Graft failure risk in patients without flow-limiting disease requires careful consideration.
- Preoperative demonstration of ischemia may improve surgical outcomes and graft patency.
Objectives:
To evaluate the use of CABG utilising an isolated pedicled Right Internal Thoracic Artery (RITA) or Left Internal Thoracic Artery (LITA) or the Pure Internal Thoracic Artery (PITA) technique to treat anomalous aortic origin of coronary artery (AAOCA).
Methods:
A retrospective review of all patients at our institution over an 8-year period (2013-2021) who underwent surgery for AAOCA was performed. Data assessed included patient demographics, initial presentation, morphology of coronary anomaly, surgical procedure, cross-clamp time, cardiopulmonary bypass time, and long-term outcome.
Results:
A total of 14 patients underwent surgery, including 11 males (78.5%) with a median logistic EuroSCORE of 1.605 (IQR 1.34). The median age was 62.5 years (IQR 48.75). Presentation was angina (7 patients), acute coronary syndrome (5 patients), incidental findings in aortic valve pathology (2 patients). AAOCA morphology varied: RCA from left coronary sinus (6), RCA from left main stem (3), left coronary artery from the right coronary sinus (1), left main stem arising from right coronary sinus (2) and circumflex artery arising from the right coronary sinus (2). Overall, 7 patients had co-existing flow-limiting coronary artery disease. CABG was performed using either a pedicled skeletonized RITA, LITA or PITA technique. There was no perioperative mortality. Overall median follow-up time was 43 months. One patient presented with recurrent angina secondary to graft failure at 2 years and there were two non-cardiac-related deaths at 4 and 35 months.
Conclusion:
The use of internal thoracic artery grafts can provide a durable treatment option in patients with anomalous coronary arteries. The potential risk of graft failure in patients with no flow-limiting disease should be very carefully considered. However, a proposed benefit of this technique is the use of a pedicle flow to increase the long-term patency. More consistent results are obtained when ischaemia can be demonstrated preoperatively.
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