Is a patent internal thoracic artery-to-left anterior descending artery still a risk factor in patients undergoing
Rami Alaraj1, Mahmoud Alshneikat1, Ahmed K Awad1
1Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Redo-coronary artery bypass grafting (CABG) with a patent internal thoracic artery (ITA) to left anterior descending artery (LAD) graft is technically challenging. Careful planning and operative strategies are crucial for safe reoperation in select patients.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery
Background:
- Redo-coronary artery bypass grafting (CABG) is performed in patients with prior bypass surgery.
- The internal thoracic artery (ITA) to left anterior descending artery (LAD) graft is crucial for long-term outcomes.
- Revisiting a patent ITA-LAD graft during redo-CABG presents unique challenges.
Purpose of the Study:
- To compare outcomes of redo-coronary artery bypass grafting (CABG) in patients with a patent internal thoracic artery (ITA) to left anterior descending artery (LAD) graft versus those with a stenotic ITA-LAD or no ITA-LAD.
- To assess the incidence of ITA injury during redo-CABG.
- To evaluate major postoperative morbidities and operative mortality in both groups.
Main Methods:
- A retrospective analysis of 5616 patients undergoing isolated redo-CABG from 1990 to 2023.
- Patients were divided into two groups: Group 1 (patent ITA-LAD) and Group 2 (stenotic or absent ITA-LAD).
- Propensity-score matching was used to create 1762 matched pairs for comparison of outcomes, including ITA injury, morbidities, and mortality.
Main Results:
- Internal thoracic artery (ITA) injury occurred in 1.8% of patients with a patent ITA-LAD, primarily affecting the left ITA (LITA) and often related to adherence to the sternum or chest wall.
- Major postoperative complications and the need for postoperative assist devices were similar between the two groups.
- Operative mortality was comparable between Group 1 (3.4%) and Group 2 (3.2%), with no significant difference in mortality among patients with an injured patent ITA-LAD.
Conclusions:
- Redo-coronary artery bypass grafting (CABG) involving a patent internal thoracic artery (ITA) to left anterior descending artery (LAD) graft is technically demanding and carries a risk of ITA injury.
- Graft adherence to the sternum or chest wall is a significant risk factor, often stemming from the initial surgery.
- With meticulous planning and appropriate surgical techniques, redo-CABG can be performed safely in carefully selected patients.
Objective:
To compare outcomes of redo coronary artery bypass grafting (CABG) in the setting of a patent internal thoracic artery (ITA) to left anterior descending artery (LAD) (group 1) versus those with a stenotic ITA-LAD or without ITA-LAD (group 2).
Methods:
From January 1990 to January 2023, 5616 patients underwent isolated redo CABG at the Cleveland Clinic-1792 in group 1 and 3824 in group 2-following institutional reoperative protocols. End points included ITA injury, major postoperative morbidities, and operative mortality. Mean age was 64 ± 9.0 years for group 1 and 66 ± 8.7 for group 2. Propensity-score matching yielded 1762 matched patient pairs.
Results:
Patent ITAs were injured in 1.8% (33/1792), with 32 of 33 (97%) LITAs. Eight (25%) adhered to the sternum, 6 (19%) adhered to the chest wall, and 1 (3%) crossed the midline. A single right ITA injury (3%) was adherent to the sternum. Twelve (36%) were managed by primary suturing and the remaining with complex reconstructions. Occurrence of major complications was similar between groups 1 and 2. Postoperative assist devices, including intra-aortic balloon pumps (7/1762 [0.40%] vs 6/1762 [0.34%], P = .78), were used infrequently. Operative mortality was 3.4% (57/1666) in group 1 and 3.2% (52/1626) in group 2 (P = .72) - 3.1% (1/32) among those with an injured patent ITA-LAD versus 3.4%(56/1634) without injury (P > .99).
Conclusions:
Redo CABG with a patent ITA-LAD is technically demanding and carries risk of ITA injury. Graft adherence to the sternum or chest wall is a particular risk, often related to conduct of the primary operation. With careful planning, reoperation can be performed safely in select patients with effective operative strategies and techniques.
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