Arterial conduits in emergency coronary artery surgery
A Zapolanski1, M B Pliam, M H Bronstein
1Department of Cardiovascular Surgery, San Francisco Heart Institute, Seton Medical Center, Daly City, California, USA.
Insights
The internal thoracic artery (ITA) is a preferred choice for coronary artery bypass grafting (CABG). This study found ITA grafts safe and effective for emergency CABG, showing better outcomes than saphenous vein grafts (SVGs).
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- The internal thoracic artery (ITA) is the preferred graft for coronary artery bypass grafting (CABG).
- Hesitancy exists in using ITA for emergency CABG procedures.
- Saphenous vein grafts (SVGs) are commonly used alternatives.
Purpose of the Study:
- To evaluate the safety and efficacy of ITA grafts in emergency CABG.
- To compare outcomes between ITA and SVG use in emergency CABG.
- To assess the impact of prior percutaneous transluminal coronary angioplasty (PTCA) on ITA graft utilization and outcomes.
Main Methods:
- Retrospective analysis of 484 patients undergoing emergency CABG between 1986 and 1993.
- Patients were categorized into noninstrumented (no failed PTCA) and instrumented (within 24 hours of failed PTCA) groups.
- Graft types (ITA vs. SVG) and postoperative outcomes were compared between groups.
Main Results:
- ITA grafts were used in 62% of noninstrumented and 49.3% of instrumented patients.
- ITA recipients had similar postoperative complication rates (new Q waves, reexploration, infection, stroke) compared to SVG recipients.
- Patients receiving ITA grafts experienced fewer cardiac deaths (2.7% vs. 9.4%) and an event-free postoperative course.
- No significant differences in outcomes were observed between instrumented and noninstrumented patients.
Conclusions:
- The internal thoracic artery (ITA) is a viable and safe option for emergency coronary artery bypass grafting (CABG) in selected patients.
- Emergency CABG using ITA grafts is associated with reduced cardiac mortality and improved postoperative outcomes compared to SVG grafts.
- Prior percutaneous transluminal coronary angioplasty (PTCA) did not negatively impact the use or outcomes of ITA grafts in emergency CABG.
Abstract:
The internal thoracic artery (ITA) is considered to be the conduit of choice for coronary bypass (CABG), but there has been some reluctance to utilize the ITA for revascularization in emergency situations. In a 9-year retrospective analysis from 1986 through 1993, 484 patients had emergency CABG, 237 were not associated with failed PTCA (noninstrumented) and 247 were within 24 hours of PTCA (instrumented). About 62% of noninstrumented and 49.3% of instrumented patients received one or more ITA grafts, the others receiving only saphenous vein grafts (SVGs). Those who received an ITA graft tended toward male sex, better ejection fraction, and a generally lower clinical risk score. Instrumented patients tended toward a lower incidence of diabetes and left main coronary disease, higher ejection fraction, and lower clinical risk score than noninstrumented patients. The postoperative results were not significantly different between ITA and SVG groups with respect to new Q waves, need for reexploration, sternal wound infection, respiratory complications, or stroke. However, ITA patients more often had an event-free postoperative course, received fewer blood transfusions, and experienced fewer cardiac deaths (2.7% vs 9.4%, p < 0.01). There were few obvious differences in postoperative results between instrumented and noninstrumented patients. These results indicate that the ITA can be used for emergency CABG in selected patients with good results.
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