Developments in Total Arterial Myocardial Revascularisation

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Citation
Asia Pacific Cardiology - Volume 1 Issue 1;2007:1(1):62-64

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Since the first coronary artery bypass was performed on a human in New York in 1961,1 conduits for coronary artery bypass grafting (CABG) remain in a state of evolution. During the early years of CABG development, saphenous venous grafts (SVGs) were standard conduits for CABG. However, it soon became apparent that vein grafts in the majority of patients have limited longevity.2,3 The internal mammary artery (IMA) soon became the ‘gold standard’ with which all conduits are still compared. The left IMA (LIMA) has been definitively established as the conduit of choice in CABG because of superior survival and event-free survival.4 Better clinical outcomes and superior long-term patency with multiple arterial grafts have led to growing interest in the use of total arterial revascularisation in CABG.3–11 This article details the current status of the conduits used to achieve total arterial myocardial revascularisation.

Internal Mammary Artery

Routine use of the IMA has risen from 3% in the early 1970s to above 99%. IMA is very resistant to atherosclerosis, making it superior to any other conduit for CABG. Multiple reasons have been put forward for the low incidence of atherosclerosis in IMA. These include the developed internal elastic lamina, blood supply from the vasa vasorum, the small amount of smooth muscles in the media and its perivascular lymphatic drainage. IMA is currently used in patients of all ages requiring myocardial revascularisation and patients with unstable angina.12 Spasm of distal IMA, usage in non-critical coronary artery stenosis, low flow in IMA and use in hypertrophied left ventricle still remain controversial. Should IMA be used for myocardial revascularisation in these situations? Harvesting of the IMA without any damage or dissection remains very important and utmost care should be taken. If damage to the IMA occurs in the superior or inferior portion and sufficient length is still available for grafting, it can still be used as a free graft. However, the long-term patency of free IMA is not as good as that of the pedicled IMA. The excellent clinical outcomes, long-term patency and fewer repeat procedures of this graft provides a standard with which all other grafts can be compared, and it should be the mainstay of any cardiac surgeon’s coronary artery bypass operation.4,5,13,14

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References
  1. Goetz RH, Rohman M, Haller JD, et al., J Thorac Cardiovasc Surg, 1961;41:378–86.
  2. Bryan AJ, Angelini GD, Curr Opion Cardiol, 1994;9(6):641–9.
  3. Grooters RK, Nishida H, 1994.
  4. Loop FD, Lytle BW, Cosgrove DM, et al., N Engl J Med, 1986;314:1–6.
  5. Lytle BW, Blackstone EH, Loop Fd, et al., J Thorac Cardiovasc Surg, 1999;117:855–72.
  6. Buxton BF, Komeda M, Fuller JA, Gordan I, Circulation, 1998;98(Suppl. 2):1–6.
  7. Endo M, Nishida H, Tomizawa Y, Kasanuki H, Circulation, 2001;104:2164–70.
  8. Taggart DP, D’Amico R, Alcam DG, Lancet, 2001;358:870–75.
  9. Tautolis J, Buxton BF, Fuller JA, Ann Thorac Surg, 2004;77:93–101.
  10. Pevni D, Mohr R, Lev-Ran O, et al., Chest, 2003;123:1348–54.
  11. Bergsma TM, Grandjean JG, Voors AA, et al., Low recurrence of angina pectoris after coronary artery bypass graft surgery with bilateral internal thoracic and right gastroepiploic arteries, Circulation, 1998;97:2402–5.
  12. Nisanoglu V, Battaloglu B, Erdil N, et al., Thorac Cardiovasc Surg, 2007;55(1):7–12.
  13. Cameron A, Davis KB, Green GE, N Eng J Med, 1996;334:216–19.
  14. Okies JE, Page US, Bigelow JC, et al., Circulation, 1984:70:1213–21.
  15. Parish MA, Asai T, Grossi EA, et al., J Thorac Cardiovasc Surg, 1992;104(5):1303–7.
  16. Matsumoto M, Konshi Y, Miwa S, Minakata K, Ann Thorac Surg, 1997;63:653–5.
  17. Mills NL, Advances in cardiac surgery, Vol 9, 1997;195–216.
  18. Carpentier A, Guermonprez Jl, Deloche, et al., Ann Thorac Surg, 1973;16:111–21.
  19. Carpentier A, Discussion Geha AS, Krone RJ, et al., J Thorac Cardiovasc Surg, 1975;10:414–31.
  20. Curtis JJ, Stoney WS, Alford WC Jr, et al., Ann Thorac Surg, 1975;20:628–35.
  21. Acar C, Iebara VA, Portoghese M, et al., Ann Thorac Surg, 1992;54:652–60.
  22. Brodman RF, Frame R, Camacho M, et al., J Am Coll Cardiol, 1996;28:959–63.
  23. Calafiore AM, DiGimmarco G, Theodori G, Ann Thorac Surg, 1995; 60:517–24.
  24. Acar C, Jebara VA, Portoghese M, et al., Surg Radiol Anat, 1991;13:283–8.
  25. Acar C, Ramshey A, Pagny JT, et al., J Thorac Cardiovasc Surg, 1998;116:981–9.
  26. Pym J, Brown PM, Charette EJ, et al., J Thorac Cardiovasc Surg, 1987:94(2):256–9.
  27. Puig LB, Ciongolli W, Cividames GVD, et al., J Thorac Cardiovasc Surg, 1990;99:251–5.
  28. Catarino PA, Black E, Taggart DP, Heart, 2002;77:794–9.
  29. Lytle BW, Sabik JF, Curr Opion Cardiol, 2002;17:594–7.
  30. Legare JF, Belth KJ, Sullivan JA, Hirsch GM, J Thorac Cardiovasc Surg, 2004;127:160–66.
  31. Royse AG, Royse CF, Tatoulis J, et al., Eur J Cardiothorac Surg, 2000;17:294–304.
  32. Maniar HS, Sundt TM, Barner HB, et al., J Thorac Cardiovasc Surg, 2002;123:45–52.
  33. Rankin JS, Tuttle RH, Wechsler AS, et al., Ann Thorac Surg, 2007;83:1008–15.