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Background:  Composite T-grafts between left internal mammary artery (LIMA) and radial artery (RA) are a common concept in complete arterial myocardial revascularization. The aim of the present study was to investigate whether the use of the great saphenous vein (SV) instead of RA leads to comparably good results in terms of outcome in this context., Methods:  Patients who underwent myocardial revascularization with a T-graft using RA or a segment of SV to the right coronary artery or circumflex artery between the beginning of 2014 and the end of 2019 at the Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel were included. To minimize surgical variation, only patients were observed by a single senior surgeon in the department. Exclusion criteria were previous cardiac surgery, preoperative extracorporeal circulatory support, off-pump surgery, additional aortocoronary bypasses, and cardiac combination procedures., Results:  A total of 115 patients were studied. In 55 patients, the T-graft was placed between the LIMA and SV, and in 60 patients, the T-graft was placed between the LIMA and RA. Patients in the SV group were older (70.6 ± 7.8 vs. 58.5 ± 10.0 years; p  < 0.001), suffered more frequently from non-ST elevation myocardial infarction (12.7 vs. 1.7%; p  = 0.027), arterial hypertension (83.6 vs. 61.7%; p  = 0.009), and atrial fibrillation (18.2 vs. 1.7%; p  = 0.003). They were less likely to be active smokers (16.4 vs. 38.3%; p  = 0.009) and less likely to have a history of variceal surgery (0 vs. 15.0%; p  = 0.003). Calcification of the ascending aorta was also found more frequently in the saphenous group (18.2 vs. 3.3%, p  = 0.009). Operative times and number of distal anastomoses did not differ significantly between the two groups. Postoperative deliriums (16.7 vs. 5.0%; p  = 0.043) were observed more frequently in venous patients. Wound healing disorders of the leg (11.1 vs. 0%; p  = 0.011) did only occur in SV group and wound infections of the arm only in the RA group. Complete follow-up was achieved in 74.8% of cases. Median follow-up was 60.3 (39.6; 73.2) months. Serious adverse cardiac-cerebral events (19.0 vs. 22.7%; p  = 0.675) and mortality (14.5 vs. 6.7%; p  = 0.167) did not differ significantly between the groups at follow-up. Myocardial infarction (0 vs. 2.5%; p  = 1.000) and stroke (0 vs. 7.5%; p  = 0.245) were observed exclusively in RA group. Percutaneous coronary intervention was required in single patients of RA group (0 vs. 15.0%; p  = 0.028). No patient from either group underwent repeat coronary artery bypass grafting (CABG). The patients of SV group had angiographically competent grafts and open anastomoses. Graft failure was noted in a single patient in RA group, in which case both grafts and native coronary vessels were stented. Kaplan-Meier analysis revealed no significant survival disadvantage for SV group compared with RA group., Conclusion:  CABG with a composite T-graft between LIMA and a segment of SV may be comparable to bypass surgery with a composite T-graft between LIMA and RA. This might be true in terms of morbidity and mortality over an intermediate-term observation period. The results of our studies give rise to the hypothesis that the decision not to perform aortic bypass anastomosis may be more important than the choice of graft material., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  A significant impact of surgeons' experience on outcomes of off-pump coronary artery bypass (OPCAB) has been recognized through previous large-scale studies. However, a safe, effective, and concrete OPCAB training was yet to be identified. We evaluate a safety of our OPCAB training model with single left internal mammary artery (LIMA)-left anterior descending artery (LAD) as a reasonable first step., Methods:  Between January 2010 and June 2019, 180 patients with an isolated single coronary bypass of the LAD using LIMA as an in situ graft via median sternotomy fulfilled the inclusion criteria. Coronary arterial bypass under cardiopulmonary bypass (CPB), utilizing other graft material, minimal invasive direct coronary arterial bypass through left-sided thoracotomy, and multiple diseased coronary artery disease were excluded. The primary outcome is an early postoperative outcome (major adverse cardiac and cerebrovascular events [MACCEs]: myocardial infarction, coronary re-revascularization, stroke, acute renal failure, and all causes of death) between residents in training under supervision (group 1: n  = 63) and experienced surgeons (group 2: n  = 117). Trainees were already experienced in on-pump coronary artery bypass grafting., Results:  Preoperative variables were comparable. There was no significant difference in the rate of MACCEs between the two groups including hospital mortality ( p  = 1.000), perioperative myocardial infarction ( p  = 0.246), stroke ( p  = 0.655), and acute renal failure ( p  = 0.175)., Conclusion:  The early postoperative outcome of off-pump LIMA to the LAD performed by trainees was comparable to those by experienced surgeons. Single LIMA-LAD was safely performed by trainees under supervision without CPB. In order to master OPCAB technique, single LAD bypass might be a reasonable first step to get into touch with the technical characteristics of this special procedure., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft., Methods: Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated., Results: Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes., Conclusions: When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

Background: The use of the bilateral internal mammary artery (BIMA) in coronary artery bypass grafting remains controversial. The objective of this study was to investigate the long-term outcomes using the BIMA vs the single internal mammary artery (SIMA) in the United States., Methods: Medicare beneficiaries who underwent primary isolated coronary artery bypass surgery using the SIMA or BIMA from 1999 to 2010 were included in this retrospective study, with follow-up through 2014. Greedy matching algorithms were used for 1:4 matching on propensity score based on age, gender, year of surgery, and comorbidities. Kaplan-Meier survival analyses were performed. The primary outcome was death from any cause., Results: A total of 1,156,339 and 25,005 patients who were 72 ± 7.6 years of age and 70.3 ± 7.9 years of age underwent primary isolated coronary artery bypass surgery using SIMA and BIMA, respectively. Matching created comparable groups with 95,780 SIMA and 24,160 BIMA patients. Matched median survival using SIMA vs BIMA was 11.8 vs 12.4 years (P < .001) and 9.6 vs 10 years in diabetic patients (P = .006), respectively. At 10 years of follow-up, the respective survival rates of using SIMA vs BIMA were 58.3% vs 61.1%, respectively. The stratified matched median survival using SIMA vs BIMA with 1, 2, 3, and 4 or more aortocoronary bypasses were 11.8 vs 12.3 years (P = .005), 11.7 vs 12.5 years (P < .001), 11.9 vs 12.3 years (P = .01), and 11.4 vs 12 years (P = .02), respectively., Conclusions: Primary isolated coronary artery bypass surgery using the BIMA rather than the SIMA was associated with improved long-term survival. This survival advantage was independent of aortocoronary bypass grafts or patient diabetes status., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery bypass grafting is the first-line therapy for severe multivessel coronary artery disease. We aimed to investigate the clinical outcome in patients undergoing isolated off-pump surgery with the single or bilateral internal mammary artery (SIMA or BIMA) approach., Methods: We performed a propensity score-matched analysis in 1,852 consecutive patients, aged 50 to 70 years, who underwent myocardial revascularization at our institution between July 2009 and August 2016. Primary end point was the probability of survival., Results: Mean follow-up was 36.3 (range: 0.1-89.6) months. The probability of survival in the SIMA and BIMA groups was 98.6 and 99.0% at year 1, 92.0 and 92.5% at year 5, and 85.6 and 81.6% at year 7, respectively, with a hazard ratio (HR) of mortality for the BIMA group versus the SIMA group of 0.98 (95% confidence interval[CI]: 0.64-1.52; p  = 0.94). There was evidence for interaction between diabetes and study group on mortality risk (HR = 2.59, 95% CI: 1.07-6.23; p  = 0.034). Freedom from mediastinitis/wound infection was higher in the SIMA group than in the BIMA group (99.5 and 96.9%, respectively; HR of an event = 6.39, 95% CI: 2.88-14.18; p  < 0.001). The corresponding values in the subgroups of diabetic patients were 98.6 and 90.9%, respectively (HR = 6.45, 95% CI: 2.24-18.58; p  = 0.001). Mediastinitis/wound infection was associated with increased mortality risk (HR = 2.96, 95% CI: 1.29-6.78; p  = 0.010)., Conclusion: Overall, our data indicate similar probability of survival up to a maximum follow-up of 7 years by off-pump surgery with the SIMA or BIMA approach. However, in diabetic patients, the clinical outcome indicates caution regarding the use of the BIMA approach., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Despite the improved survival in patients with multi-vessel coronary disease compared to conventional myocardial revascularization associated with the use of multiple arterial grafting for myocardial revascularization, it has been adopted in the minority of centers. We sought to evaluate the long-term outcome of patients with and without diabetes undergoing total arterial versus conventional myocardial revascularization., Methods: Among 1000 consecutive patients undergoing CABG, we performed a propensity-match analysis to compare patients with multi-vessel disease receiving total arterial (G1 = 618 pts) versus conventional myocardial revascularization (LIMA-LAD plus vein grafts, G2 = 382 pts). The primary end-point was survival free from all-cause and cardiac-related mortality, while the secondary end-point was the occurrence of major cardiac and cerebrovascular accidents., Results: Hospital mortality was similar (G1: 0 pts. vs G2: 1 pts., 0.3%, p = .91). At a median follow-up of 101 months (range 11-185 months), total arterial grafting was associated with significantly improved survival free from overall (G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%; p < .001) and cardiac mortality (general population: G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%, p = .043; diabetics:G1 = 84.7 ± 2.1 vs G2: 79.3 ± 3.4; p = .035) as well as occurrence of MACCEs (general population:G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%; p > .001; diabetics:G1 = 77 ± 6 vs G2 = 53 ± 5.8; p < .001). Cox regression analysis identified diabetes (HR = 1.94, CI 95% = 1.12-2.93; p < .001) and the use of veins (HR = 1.81, CI 95% = 1.32-2.65; p < .001) as independent predictors for all-cause mortality; among diabetics, vein grafts was the strongest predictor of MACCEs (HR = 2.41, CI 95% = 1.27-4.59; p = .007) and cardiac mortality (HR = 3.24, CI 95% = 1.69-6.23; p < .001)., Conclusions: Long-term survival following total arterial CABG is remarkably improved compared to conventional grafting with vein grafts especially in diabetic patients., Competing Interests: Declaration of competing interest None of the authors have conflict of interest to declare., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting., Methods and results: Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001)., Conclusions: Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Background: The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain unproven., Methods and results: Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III-IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively., Conclusions: BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.

Objectives: Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease., Methods: Patients in our institution who underwent BITA grafting during 1996-2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan-Meier analysis was performed, both for the entire cohort and for the matched cohort., Results: SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan-Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001)., Conclusions: Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aims of this study were to evaluate the in-hospital and mid-term outcomes of the off-pump onlay-patch grafting procedure using the left internal mammary artery (LIMA) for a diffusely diseased left anterior descending artery (LAD) and to identify the risk factors for postoperative LIMA graft failure in a single-center retrospective study., Patients and Methods: A total of 63 patients (52 males, 65.7±9.0 years) undergoing LAD arteriotomy with or without concomitant endarterectomy, followed by reconstruction using LIMA onlay-patch at the time of off-pump coronary artery bypass grafting at our institute from January 2014 to December 2016 were reviewed. The operative mortality, major postoperative morbidity, follow-up all-cause mortality, major adverse cardiac events at follow-up, and postoperative LIMA graft patency were analyzed. The risk factors for postoperative LIMA graft failure on the basis of baseline and surgical characteristics were identified by multivariable logistic regression analysis., Results: Eighteen (28.6%) patients underwent concomitant open LAD endarterectomy. The operative mortality rate was 1.6%. Major postoperative morbidity included perioperative myocardial infarction (3.2%), low cardiac output (1.6%), and reoperation for bleeding (1.6%). During the follow-up period of 24.2±9.5 months, all-cause mortality was 1.7% and the incidence of major adverse cardiac events was 6.8%. No repeat revascularization was recorded. In total, 88.1% of LIMA grafts showed FitzGibbon grade A patency determined by noninvasive coronary computed tomography angiography during follow-up. In addition, concomitant LAD endarterectomy and intraoperative LIMA graft flow were found to be independent risk factors for mid-term LIMA graft failure by multivariable logistic regression analysis (odds ratio=2.681, 95% confidence interval: 1.314-9.856, P=0.007 and odds ratio=0.932, 95% confidence interval: 0.791-0.976, P=0.021, respectively)., Conclusion: Revascularization of a diffusely diseased LAD using the off-pump LIMA onlay-patch technique results in encouraging clinical outcomes with favorable angiographic results. Concomitant LAD endarterectomy and intraoperative LIMA graft flow are associated with the risk of postoperative LIMA graft failure.

Background: Exclusive coronary revascularization with both mammary arteries could result in lower rates of adverse events in the long term., Aim: To describe the five-year evolution of a cohort of patients operated on with this technique., Material and Methods: Follow up analyzing survival of 73 patients aged 59 ± 9 years (82% men) who underwent exclusive coronary surgery with two mammary arteries between December 1,2010 and April 12,2017. We studied their clinical characteristics, surgical results, operative morbidity and mortality and adverse events up to June 30, 2018., Results: Six patients had two-vessel lesions and 67 three-vessel lesions. The operative risk calculated by additive and logistic EuroSCORE was 2.5 and 2.3%, respectively. A mean of 3.75 anastomoses /patient were performed, 116 with left mammary artery (73 to the anterior descending artery, 38 to a diagonal artery and 5 for other objectives) and 158 with right mammary artery (69 to a first marginal artery, 23 to a second marginal artery and 64 to posterior descending artery). There was one case of mediastinitis and one (1.5%) patient died. The mean follow-up was 64.6 ± 23.7 months. The 5-year survival was 90.4%., Conclusions: Coronary revascularization with two exclusive mammary arteries allowed a complete revascularization of the heart with a low rate of complications and adverse effects at five years.

Objective: The rate of patients with diffuse left anterior descending artery (LAD) disease being referred for surgery has increased as a result of advances in endovascular techniques. In surgery of diffuse or multisegment LAD disease, surgical procedures with or without endarterectomy can be performed. In this article, we report our results of longsegment onlay patchplasty of the LAD with a left internal thoracic artery (LITA) graft without endarterectomy, on the beating heart, in patients with multisegment LAD disease., Methods: We retrospectively analysed patients who underwent coronary artery bypass grafting surgery in our hospital between 1 January 2015 and 31 July 2017. We included LITA onlay patchplasty patients with multisegment LAD disease who had been operated on the beating heart. We excluded patients who underwent coronary endarterectomy and were operated on under cardiopulmonary bypass., Results: In this period, 54 patients with multisegment LAD disease were treated with LITA patchplasty on the beating heart. The mean length of the arteriotomy was 42.8 ± 13.3 mm (25-75 mm). There were two postoperative myocardial infarctions (3.7%) and three deaths (5.5%). In the remaining patients, there was no haemodynamic instability that needed long-term (> 24 hour) inotropic support. Patients were discharged from hospital on postoperative 9.3 ± 7.1 days with dual antiplatalet therapy., Conclusions: Bypass grafting of the LAD with long-segment LITA onlay patchplasty can safely be performed in patients with multisegment LAD disease, with acceptable early-term results. In this procedure, proximal and distal segments of the diseased LAD are revascularised with LITA grafts, which may improve long-term survival and quality of life.

Background: Arterial conduits are preferred to venous conduits for coronary artery bypass grafting because of longer patency. A single internal mammary artery (SIMA) is used routinely. Bilateral internal mammary arteries (BIMA) are used less frequently. We sought to determine whether BIMA were superior to SIMA., Methods: From our regional registry of consecutive open heart operations, we identified 47,984 patients who underwent isolated coronary artery bypass grafting from 1992 to 2014. Of the 1,482 BIMA patients, 1,297 were propensity matched to a cohort of SIMA patients. Short-term outcomes were compared using standard statistical techniques. Long-term survival was compared using Kaplan-Meier estimators and compared using a log-rank test., Results: BIMA patients were younger and had fewer comorbid conditions than SIMA patients. After propensity weighting, BIMA and SIMA patients were well matched. There was no difference in in-hospital outcomes for BIMA versus SIMA patients for mortality (1.2% [n = 15] vs 0.8% [n = 10], p = 0.315), stroke (0.7% [n = 9] vs 0.7% [n = 9), p = 1.000), bleeding (2.2% [n = 28] vs 2.8% [n = 36], p = 0.311), or mediastinitis (0.8% [n = 10] vs 0.9% [n = 12], p = 0.667). The median follow-up was 12 years. Survival was better for BIMA than SIMA (adjusted hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.91; p < 0.001). Survival curves began to separate after 5 years. At 15 years, the absolute difference in survival was 8.4%., Conclusions: In a large regional experience, BIMA is associated with no upfront risk of adverse events and improved long-term survival compared with SIMA. Our results indicate that BIMA conduits should be considered more frequently during coronary artery bypass grafting due to their demonstrated survival advantage., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Saphenous vein grafts (SVGs) most often used in coronary artery bypass grafting (CABG) are subject to graft disease and have poor long-term patency, however the clinical implication of this is not completely known. We aim to assess the influence of graft failure on the postoperative recurrence of coronary artery disease (CAD) symptoms in relation to the contribution from progression of atherosclerosis in the native coronary vessels., Design: Within the SWEDEHEART registry we identified 46,663 CABG cases between 2001 and 2015 with patient age 40-80 years where single internal mammary artery (IMA) anastomosis (IMA), single IMA with one (1SVG) or multiple SVG anastomoses (2+ SVG) had been performed. Clinical characteristics as well as mortality and postoperative incidence of coronary angiography were recorded and multivariable adjusted hazard ratios were calculated. Indications for the angiographies and occurrence of graft failure were also registered., Results: The adjusted hazard ratio for death was similar for the three groups. The adjusted hazard ratio for being submitted to angiography as compared to 2+ SVG was (95% CI) 1.24 (1.06-1.46) for IMA and 1.21 (1.15-1.28) for 1SVG. Failed grafts were found at the first postoperative angiography with preceding CAD symptoms in 21.4% of patients in the IMA group, 41.6% in the 1SVG group and 61.1% in the 2+ SVG group., Conclusions: A substantial amount of angiographies occur in patients without any graft failure and a large part of postoperative recurrence of CAD symptoms and are likely attributed to IMA failure or progression of atherosclerosis in the native coronary arteries.

Background: The Arterial Revascularization Trial has been designed to answer the question whether the use of bilateral internal thoracic arteries can improve 10-year outcomes when compared with single internal thoracic arteries. In the Arterial Revascularization Trial, a significant proportion of patients initially allocated to bilateral internal thoracic arteries received other conduit strategies. We sought to investigate the incidence and clinical implication of bilateral internal thoracic artery graft conversion in the Arterial Revascularization Trial., Methods: Among patients enrolled in the Arterial Revascularization Trial (n = 3102), we excluded those allocated to single internal thoracic arteries (n = 1554), those who did not undergo surgery (n = 16), and those who underwent operation but withdrew after randomization (n = 7). Propensity score matching was used to compare converted versus nonconverted bilateral internal thoracic artery groups., Results: A total of 1525 patients were operated with the intention to receive bilateral internal thoracic artery grafting. Of those, 233 (15.3%) were converted to other conduit selection strategies. Incidence of conversion largely varied across 131 participating surgeons (from 0% to 100%). The most common reason for bilateral internal thoracic artery graft conversion was the evidence of at least 1 internal thoracic artery that was not suitable, which was reported in 77 cases. Patients with intraoperative bilateral internal thoracic artery graft conversion received a lower number of grafts (2.95 ± 0.84 vs 3.21 ± 0.74; P < .001). However, the hospital mortality rate was comparable to that of those who did not require bilateral internal thoracic artery graft conversion (0% vs 1.6%; P = .1), as well as the incidence of major complications. At 5 years, we found a nonsignificant excess of deaths (11.9% vs 8.4%; P = .1) and major adverse events (17.1% 13.2%; P = .1) mainly driven by an excess of revascularization in patients requiring conversion., Conclusions: The incidence of intraoperative bilateral internal thoracic artery graft conversion is not infrequent. Bilateral internal thoracic artery graft conversion is not associated with increased operative morbidity, but its effect on late outcomes remains uncertain., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

There is strong retrospective data demonstrating that bilateral internal mammary artery (BIMA) grafting leads to better long-term survival as compared to left internal mammary artery grafting. However, this survival advantage was not corroborated by the interim results of the Arterial Revascularization Trial. Today, there are barriers to widespread adoption of BIMA grafting. One of the main disadvantages of the use of BIMA grafts is the higher risk of deep sternal wound infection. Deep sternal wound infections can be minimized by skeletonized harvesting of the internal mammary artery grafts, which preserve blood flow to the sternum. Also, utilizing the BIMA graft as a "Y" graft may lead to more complete revascularization compared to its in situ use. BIMA grafting on average takes 25 minutes longer operating time with a higher in-hospital costs. We eagerly await the 10-year results of the Arterial Revascularization Trial to determine the truly unbiased randomized long-term effectiveness of BIMA grafting., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The use of bilateral internal thoracic artery (BITA) grafting has been proposed for dialysis patients with multivessel coronary artery disease, primarily because of hypothetical long-term survival benefits., Aims: To investigate the outcome of BITA grafting in dialysis patients., Methods: This was a retrospective analysis of the use of BITA grafting in 105 consecutive patients with end-stage renal failure on chronic dialysis in three European centres with extensive experience in BITA. Baseline patient characteristics, operative data, early postoperative complications and late survival were reviewed. Outcomes of patients from one of the three centres who underwent either BITA (n=40) or single internal thoracic artery (SITA) grafting (n=19) were also analysed; a one-to-one propensity score (PS)-matched analysis was performed., Results: There were 19 (18.1%) hospital deaths. Despite differences in preoperative patient characteristics and surgical features, in each centre, hospital mortality was greater than the 75th percentile of expected operative risk (EuroSCORE II). Diseased ascending aorta and extracardiac arteriopathy were found to be predictors of hospital death (odds ratio 9.7; P=0.006) and complicated hospital course (odds ratio 2.54; P=0.035), respectively. The 7-year non-parametric estimates of freedom from all-cause death and cardiac or cerebrovascular death were 59% (95% confidence interval: 52.3-65.7%) and 75.6% (95% confidence interval: 71.2-80%), respectively. There were no significant differences in early and late outcomes between BITA and SITA PS-matched groups., Conclusions: BITA grafting remains a risky operation for chronic dialysis patients, even when performed routinely. No long-term survival benefits for the use of BITA versus SITA were proven., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objectives: In a nationwide cohort, we analyzed long-term outcome following coronary artery bypass grafting, using the combined strategy of left internal mammary artery to the left anterior descending artery and saphenous vein as secondary graft to other coronary targets., Methods: 1,507 consecutive patients that underwent myocardial revascularization during 2001-2012 in Iceland. Mean follow-up was 6.8 years. Major adverse cardiac and cerebrovascular events were depicted using the Kaplan-Meier method. Cox-regression was used to define risk factors. Relative survival was estimated by comparing overall survival to the survival of Icelanders of the same age and gender., Results: Mean age was 66 years, 83% were males, mean EuroSCOREst was 4.5, and 23% of the procedures were performed off-pump. At 5 years, 19.7% had suffered a major adverse cardiac or cerebrovascular event, 4.5% a stroke, 2.2% myocardial infarction, and 6.2% needed repeat revascularization. Overall 5-year survival was 89.9%, with a relative survival of 0.990. Independent predictors of major adverse cardiac and cerebrovascular events were left ventricular ejection fraction ≤30%, a previous history of percutaneous coronary intervention, chronic obstructive lung disease, chronic kidney disease, diabetes, and old age. The same variables and an earlier year of operation were predictors of long-term mortality., Conclusions: The long-term outcome following myocardial revascularization, using the left internal mammary artery and the great saphenous vein as conduits, is favourable and improving. This is reflected by the 5-year survival of 89.9%, deviating minimally from the survival rate of the general Icelandic population, together with a freedom from major adverse cardiac and cerebrovascular events of 80.3%.

Objectives: The aim of the study was to determine if there is a long-term outcomes disadvantage associated with using the internal mammary artery (IMA) as a free graft to the left anterior descending artery (LAD) during coronary artery bypass graft surgery., Methods: Between 1991 and 2014, 21 876 consecutive patients underwent isolated primary coronary artery bypass graft surgery at our institution. Among these, 238 underwent a free IMA (f-IMA) graft to bypass the LAD. Propensity score matching with bootstrap analysis was performed to produce a cohort of 222 f-IMA patients matched to 222 patients with in situ IMA grafting to the LAD. Early and long-term outcomes including survival, readmission for cardiovascular causes and repeat revascularization up to a maximum of 23 years post-coronary artery bypass graft surgery were compared. Provincial vital statistics and administrative hospital readmission data were used to analyse long-term outcomes., Results: Operative mortality [3.2% f-IMA vs 1.9% in situ IMA; odds ratio = 1.79, 95% confidence interval (CI) = 0.91-3.52] and the majority of postoperative adverse events were not significantly different among matched patients. The risk of late death was not significantly different between the 2 matched groups (hazard ratio = 1.14, 95% CI = 0.92-1.41, P = 0.15). The risk of hospital readmission for cardiovascular reasons was significantly higher in the f-IMA group (54.5% vs 47.3%, odds ratio = 1.4; 95% CI = 1.10-1.72), although repeat revascularization (18.4% vs 13.5%; odds ratio = 1.53, 95% CI = 0.96-2.44) was not significantly different between the matched groups., Conclusions: Late survival and the need for repeat coronary revascularization were not influenced by using the IMA as a free graft to the LAD. However, there is a small but significant increase in the risk of hospital readmission for cardiac reasons., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Coronary artery disease represents a major health problem worldwide for which coronary artery bypass surgery remains a standard of care. Among the several grafts that are available, the internal thoracic artery (ITA) has long been considered the best as several advantages have been described compared with other vessels (e.g. saphenous vein or radial artery), namely, an absent to minor atherosclerotic development. In fact, several studies showed the presence of preatherosclerotic lesions, such as intimal and/or medial thickening, medial fibrosis, among others, in the presence of certain cardiovascular risk factors as well as established atherosclerotic lesions (i.e. type II or more lesions). This paper primarily aimed at reviewing the current knowledge on the histomorphological characteristics of ITA as well as the comparative histomorphology of ITA with other vessel grafts currently in use in coronary surgery. As some of the evidence is not clear or consensual, this paper also aimed at reviewing the main histopathological, histomorphometrical, and ultrastructural findings in ITAs from patients with known cardiovascular risk factors (e.g. aging, obesity, hypertension, diabetes, smoking, and others). As the presence of preatherosclerotic and/or atherosclerotic lesions may compromise the success of the myocardial revascularization and lead to graft failure, contributing toward the associated morbidity and/or mortality, it is essential to improve the scientific knowledge on the structural characterization of ITAs and its correlation with the cardiovascular risk profile.

Background: Whether the use of the radial artery (RA) can improve clinical outcomes in coronary artery bypass graft surgery remains unclear. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral internal thoracic artery (BITA) over single left internal thoracic artery (SITA). In the ART, a large proportion of patients (≈20%) also received an RA graft instead of a saphenous vein graft (SVG). We aimed to investigate the associations between using the RA instead of an SVG to supplement SITA or BITA grafts and outcomes by performing a post hoc analysis of the ART., Methods: Patients enrolled in the ART (n=3102) were classified on the basis of conduits actually received (as treated). The analysis included 2737 patients who received an RA graft (RA group; n=632) or SVG only (SVG group; n=2105) in addition to SITA or BITA grafts. The primary end point was the composite of myocardial infarction, cardiovascular death, and repeat revascularization at 5 years. Propensity score matching and stratified Cox regression were used to compare the 2 strategies., Results: Myocardial infarction, cardiovascular death, and repeat revascularization cumulative incidence was 2.3% (95% confidence interval [CI], 1.1-3.4), 3.5% (95% CI, 2.1-5.0), and 4.4% (95% CI, 2.8-6.0) in the RA group and 3.4% (95% CI, 2.0-4.8), 4.0% (95% CI, 2.5-5.6), and 7.6% (95% CI, 5.5-9.7) in the SVG group, respectively. The composite end point was significantly lower in the RA group (8.8%; 95% CI, 6.5-11.0) compared with the SVG group (13.6%; 95% CI, 10.8-16.3; P =0.005). This association was present when an RA graft was used to supplement both SITA and BITA grafts (interaction P =0.62)., Conclusions: This post hoc ART analysis showed that an additional RA was associated with lower risk for midterm major adverse cardiac events when used to supplement SITA or BITA grafts., Clinical Trial Registration: URL: https://www.situ.ox.ac.uk/surgical-trials/art. Unique identifier: ISRCTN46552265., (© 2017 American Heart Association, Inc.)

Background: Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI., Methods and Results: In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3-vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, P =0.01), and sternal infections and strokes were similar. Median follow-up was 15.21 years (range: 0-21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, P <0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; P =0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; P =0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; P =0.009; Cox model)., Conclusions: This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow., Methods: A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause., Results: The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months.Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group., Conclusions: In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Objectives  Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal wound complications. In the present study, early- and long-term outcomes of the use of left-sided BITA versus single internal thoracic artery (SITA) grafting in young (< 65 years of age) diabetic patients were reviewed retrospectively. Methods  A total of 250 propensity score pair-matched diabetic patients, operated on between February 2000 and December 2011, receiving either BITA ( n  = 125) or SITA ( n  = 125) grafting were analyzed retrospectively. In each group, 104 patients were males, and mean age was 60.1 ± 5.3 years. Follow-up was 2.1 to 14.8 years (mean, 9.3 ± 3.5 years) and complete for 100%. Results  Incidence of deep sternal wound infection was 2.4 versus 3.2% ( p  = 0.722). Rethoracotomy due to bleeding occurred in 4.8 versus 3.2% ( p  = 0.608). The 5-, 10-, and 14-year estimates of survival were 93.4, 76.6, and 67.5% (BITA) versus 89.5, 81.5, and 32.8% (SITA); p  = 0.288. Freedom from reangiography/intervention (60.5 vs. 63.9%) during follow-up was comparable ( p  = 0.507) as well as infarction rate (93.8 vs. 95.1%, p  = 0.833) and redoes ( p  = 0.672, exclusively valve surgery) were comparable. Freedom from thromboembolic or cerebrovascular events did not show any significant differences (94.0 vs. 94.0%, p  = 0.78). Multivariate analysis identified poor ejection fraction as predictor for decreased long-term survival. Neither age nor gender or urgency had an influence on long-term mortality. Conclusion  Left-sided BITA grafting may be performed routinely even in diabetic patients without increased incidence of postoperative wound-healing complications. Survival rates after 5, 10, and 14 years were comparable for BITA and SITA grafting., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods  Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999-September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed. Results  Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p  = 0.66) and the PS-matched series (0 vs. 4.3%; p  = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall ( p  = 0.037) and the PS-matched series of BITA patients ( p  = 0.092); duration of surgery was increased but not quite significantly ( p  = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly ( p  = 0.11 for both). Conclusion  BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better., Competing Interests: Conflicts of Interest: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction  Multivessel coronary artery bypass graft (CABG) with bilateral internal thoracic arteries (BITA) has only been uncommon and technically demanding. We describe our experience with BITA only CABGs requiring ≥ 4 anastomoses. Material and Methods  The department's database was queried for patients undergoing isolated CABG with ≥ 4 anastomoses. The surgical technique included systematically a right internal thoracic artery (ITA) of left ITA Y graft. The multivariate model included variables with a p  < 0.3 at univariate analysis. Results  Between January 2006 and December 2009, 251 consecutive patients (71 ± 10 years) (on-pump: 130, off-pump: 121) had CABG with ≥ 4 anastomoses, representing 21% of total isolated CABGs for the same period; all patients received a totally arterial BITA only revascularization. Follow-up was 4.9 ± 1.6 years. Overall and cardiac cumulative survivals were 78 and 92%, respectively, at 5 years. The occurrence of any major postoperative complication was associated with overall and cardiac mortality (odds ratio [OR]: 3.6, 95% confidence interval [CI]: 1.3-9.9 and OR: 5.4, 95% CI: 1.3-21.9, respectively). Major sternal wound complication requiring surgical revision was not associated with impaired glucose control ( n  = 9; diabetics: 6/82, 7.3%; nondiabetics: 3/169, 1.8%, p  = 0.06). Preoperative kidney failure was associated with incomplete revascularization (OR: 6.2; 95% CI: 1.2-33.5), that was unfailingly due to ungraftable right coronary artery targets. Discussion  BITA only revascularization was a valuable and safe procedure, with favorable results in terms of morbidity and mortality at a 5 years' follow-up., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Utilization of bilateral internal mammary arteries (BIMAs) has been shown to improve long-term outcomes in patients undergoing coronary artery bypass grafting. To achieve complete revascularization, BIMAs may be used as either sole conduits for revascularization through a Y-graft configuration (BIMA-Y) or deployed with additional grafts used in conjunction with BIMAs. The purpose of this study was to compare the long-term outcomes of two institutions that predominantly used either the BIMA-Y configuration or BIMA plus additional grafts to achieve optimal revascularization., Methods: From 1 January 2000 to 31 December 2010, 436 patients were revascularized using a non-sequential BIMA grafting at one institution (Group A), with veins being used for additional targets. At the second institution (Group B), 771 patients were revascularized using a BIMA-Y graft for all distal targets. Kaplan–Meier analysis was used to compare unadjusted survival between the groups. Cox proportional hazards regression modelling was used to provide an adjusted comparison of survival between the groups., Results: There was no statistically significant difference between the average number of anastomotic sites used in Group A and Group B (A = 4.0 ± 0.7 vs B = 4.0 ± 0.7; P = 0.24). Group A did not have a significantly greater in-hospital mortality (0.7% vs 1.0% P = 0.39), stroke (0.5% vs 0.8% P = 0.40), deep sternal wound infection (0.0% vs 0.6% P = 0.11) or reoperation for bleeding (1.6% vs 0.6% P = 0.10) than Group B. Cox proportional hazards analyses demonstrated that at 14 years, Group B had a significantly improved survival compared to Group A (Group B = 88% vs Group A = 81%) with an overall reduction in mortality (adjusted hazard ratio 0.780, 95% confidence interval 0.448–0.849; P = 0.043)., Conclusion: Utilization of the BIMA-Y configuration was associated with improved survival when compared to BIMA grafting with additional vein grafts. Further studies are necessary to evaluate the efficacy of BIMA-Y grafting against other means of providing complete arterial revascularization., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender., Methods: Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70±7.7years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models., Results: There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2±6.1%); glomerular filtration rate<50ml/min was an independent risk factor (p=0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35kg/m 2 (p=0.0094), diabetes (p=0.005), non-elective surgical priority (p=0.0087) and multiple blood transfusions (p=0.016). The mean follow-up was 6.8±4.5years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p=0.04) and left main coronary artery disease (p=0.0095) were predictors of major adverse cardiac and cerebrovascular events., Conclusions: BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area., Methods: The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score., Results: In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p = 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p = 0.645) and 80.7% and 77.4% (p = 0.300), respectively., Conclusions: In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The use of bilateral internal thoracic arteries (BITAs) is associated with improved long-term survival after coronary artery bypass grafting (CABG). However, it is unclear whether the addition of a radial artery (RA) in patients already receiving BITA confers any additional survival benefit over that of a saphenous vein (SV). As such, we reviewed our multicentre experience and compared both strategies., Methods: From 1995 to 2010, 1497 patients underwent primary isolated CABG for three-vessel coronary disease using BITAs. An SV was used as a third conduit in 460 (31%) patients and an RA in 1037 (69%). A total of 1258 distal anastomoses were performed using RAs and these were to the diagonal territory in 169, the circumflex in 454 and the right coronary in 635. Survival data were obtained using the National Death Index and propensity-score matching was used for risk-adjustment., Results: The overall cohort was young (mean age 61 ± 9 years). Patients receiving RAs were more likely to be younger, and were less likely to have experienced a prior myocardial infarction. At 30 days, mortality was similar (BITA + SV: 5, 1.1% vs BITA + RA: 9, 0.9%, P = 0.77). At 15 years, BITA + RA patients experienced improved unadjusted survival (BITA + SV: 67 ± 4.6% vs BITA + RA: 82 ± 3.2%, P < 0.0001). Multivariable Cox regression in the entire cohort also showed the BITA + RA group to be associated with better survival (HR 0.58, 95% CI 0.44-0.75, P < 0.001). After propensity-score matching of 262 patient-pairs, BITA + RA experienced similar 30-day mortality (BITA + SV: 3, 1.1% vs BITA + RA: 3, 1.1%, P > 0.99). However, at 15 years, BITA + RA patients experienced improved risk-adjusted survival (BITA + SV: 72 ± 6.0% vs BITA + RA: 82 ± 5.2%, P = 0.021). The RA was associated with better risk-adjusted survival for grafting of the right coronary and its branches (148 matched pairs; SV-RCA: 74 ± 7.8% vs RA-RCA: 86 ± 6.5%, P = 0.0046 at 15 years)., Conclusions: The addition of an RA graft even in patients already receiving BITAs is associated with a survival benefit. In younger patients with a reasonable long-term life expectancy, surgeons should strive to achieve total arterial revascularization with BITAs and radial arteries., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8 ± 7.7 vs. 7.6 ± 6.1 %, p = 0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2 %, p = 0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2 %, p = 0.022). The mean follow-up was 4.7 ± 3.3 years. There were no differences between the two groups in overall survival (p = 0.79), freedom from cardiac and cerebrovascular deaths (p = 0.73), major adverse cardiac and cerebrovascular events (p = 0.63) and heart failure hospital readmission (p = 0.64). Predictors of decreased late survival were diabetes (p = 0.0062) and congestive heart failure (p = 0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.

Background: We studied long-term survival using bilateral internal thoracic artery (BITA) grafting in a T-configuration exclusively versus using single internal thoracic artery (SITA) grafting in patients with multivessel disease., Methods: Consecutive coronary operations performed at a single center between 1996 and 2014 were reviewed. Long-term survival among patients receiving coronary revascularization exclusively with BITA grafting in a T-configuration (n = 2,098) versus SITA grafts plus other types of conduits (saphenous vein graft [SVG] and radial artery [RA]) grafts (n = 1,659). In patients who underwent BITA grafting, the left internal thoracic artery (LITA) was grafted mainly to the left anterior descending artery, whereas the right internal thoracic artery (RITA) was used more commonly to graft the circumflex (Cx) artery and the right coronary system as T-grafts. A total of 485 pairs of patients were matched using propensity scores. Cox proportional hazard models were generated to examine the association of arterial BITA grafting with mortality., Results: Patients in the BITA group were more likely to be younger (BITA, 63.7 ± 9.1 versus SITA, 65.0 ± 9.9; p < 0.0001). At 30 days, patients who underwent BITA grafting experienced reduced unadjusted mortality (BITA, 1.2% versus SITA, 4.4%; p < 0.0001). At 10 years, patients who underwent BITA grafting experienced superior unadjusted survival (BITA, 82.6% ± 1.8% versus SITA, 76.1% ± 1.3%; p = 0.001). Cox regression analysis in the entire study cohort showed that BITA grafting was associated with improved survival (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.58-0.87; p < 0.001). In the propensity-score-adjusted analysis, patients who underwent BITA grafting had similar in-hospital mortality (BITA, 1.6% versus SITA, 2.9%; p = 0.196). Patients who underwent BITA grafting still showed improved survival at 10 years (BITA, 81.0% ± 4.1% versus SITA, 71.8% ± 2.5%; p = 0.039)., Conclusions: This study suggests that coronary artery operations exclusively with BITA grafting in a T-configuration may be associated with better long-term survival than grafting with SITA plus other types of conduits., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery (LIMA)-left anterior descending artery (LAD) bypass with percutaneous intervention of non-LAD vessels. The purpose of this study was to compare outcomes of HCR to conventional coronary artery bypass graft (CABG) surgery with single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting., Methods: Between October 2003 and September 2013, 306 consecutive patients who underwent HCR were compared with 8254 patients who underwent CABG with SIMA (7381; 89.4%) or BIMA (873; 10.6%) at a US academic center. The primary outcome was a composite of 30-day death, myocardial infarction, and stroke (major cerebrovascular and cardiac event [MACCE]). In addition to multiple logistic and linear regression analysis, a propensity score-matched analysis was used to compare HCR with SIMA and with BIMA., Results: The Society of Thoracic Surgeons-predicted risk of mortality was 1.6% for HCR, 2.1% for SIMA, and 1.1% for BIMA (P < .001). Factors associated with HCR use were older age, lower body mass index, history of percutaneous coronary intervention, and 2-vessel disease. In propensity-matched groups, 30-day MACCE rates were comparable (3.3% for HCR vs 1.3% for BIMA [odds ratio (OR), 2.50; P = .12] and vs 3.6% for SIMA [OR, 1.00; P = 1.00]). In-hospital complications were lower after HCR versus SIMA or BIMA (OR, 0.59; P = .033 and OR, 0.55; P = .015, respectively), as was the need for blood transfusion (OR, 0.44; P < .001 and OR, 0.57; P < .001). HCR was associated with shorter hospital stay compared with SIMA (OR, 1.28; P = .038) or BIMA (OR, 1.40; P = .006). No survival difference between matched groups was found at midterm follow-up (HCR vs SIMA: hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.32-1.38; P = .66; HCR vs BIMA: HR, 1.05; 95% CI, 0.48-2.29; P = .91)., Conclusions: HCR may represent a safe, less invasive alternative to conventional CABG in carefully selected patients, with similar short-term and midterm outcomes as CABG performed with either SIMA or BIMA grafting., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The use of bilateral internal thoracic arteries (BITA) in coronary artery bypass graft surgery improves patient survival. The optimum BITA graft configuration is unknown. This study evaluates outcomes after the use of bilateral internal mammary Y grafting as the primary grafting strategy., Methods: Patients who underwent BITA composite Y grafting (n = 1,011) between October 1994 and March 2009 were identified from a cardiac surgical database. Follow-up (mean 12 years) was obtained by cross-reference with the state death registry and local cardiology databases., Results: Perioperative mortality was 1.6%. Kaplan-Meier 10-year survival was 87.2%. There were 464 episodes of postdischarge angiography in 296 patients, at an average of 5.5 years to first angiography. Graft failure occurred in 151 patients, predominately affecting the right ITA limb (n = 139). Degree of native vessel stenosis (odds ratio [OR] 0.66 per 10% increase), anatomic territory grafted (circumflex OR 2.64, right coronary OR 6.73 versus anterior), and end-to-side free wall anastomoses (OR 1.98) predicted anastomotic occlusion. The left anterior descending artery graft patency was unaffected by sequential grafting. Progression to graft failure after the first angiogram was rarely seen in the 111 patients who had serial angiography., Conclusions: Outcomes of BITA Y grafting are similar to those for other BITA configurations. The rate of presentation with arterial graft dysfunction decreases over time. Although competitive flow affects anastomotic patency, there is no threshold at which risk of occlusion substantially increases., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To evaluate the early and long-term outcomes of stent placement for left subclavian artery stenosis (LSAS) in patients scheduled for left internal mammary artery-coronary artery bypass grafting (LIMA-CABG)., Background: Few studies have demonstrated the safety and effectiveness of endovascular therapy for the treatment of LSAS before LIMA-CABG; therefore, use of this therapy requires further exploration and evaluation., Methods: Between February 2000 and April 2014, the clinical data of 167 consecutive patients (mean age 64  ± 9 years, 141 males) scheduled for LIMA-CABG with LSAS who were treated by stenting at the Fuwai Hospital were collected and analyzed retrospectively., Results: The technical success rate of the procedure was 97.6% (163/167). The mean stenosis of target lesions decreased from 86.5 ± 9.9% to 7.6 ± 4.6% (P < 0.001). The incidences of death, stroke, and myocardial infarction, as well as the combined incidence of death, stroke, and myocardial infarction from the time of stenting to 30 days after the stenting procedure were 0.6% (n = 1), 1.8% (n = 3), 0% (n = 0), and 1.8% (n = 3), respectively. The 10-year rate of follow-up was 94.6%. The overall survival rate was 98.8% at 1 year, 97.5% at 2 years, 93.9% at 5 years, and 86.2% at 10 years. A total of 14.1% (23/163) of patients developed in-stent restenosis. Stent restenosis-related angina and myocardial infarction were observed in 13 and 3 patients, respectively. The patency rates of the left subclavian artery were 95.7, 93.8, 86.5, and 75.2% at 1, 2, 5, and 10 years, respectively. The target vessel reconstruction rate was 8.0% (13/163)., Conclusions: Stenting of LSAS at experienced medical centers for patients scheduled for LIMA-CABG was safe and effective with a low incidence of complication and in-stent restenosis., (© 2016 Wiley Periodicals, Inc.)

Objectives: Few studies have reported the free right internal thoracic artery (RITA) being used in an aorto-coronary fashion. This study aimed to evaluate the free RITA with modified proximal anastomosis in an aorto-coronary fashion., Methods: Between January 2000 and December 2012, 282 patients underwent coronary artery bypass grafting with bilateral internal thoracic arteries for complete revascularization of the left coronary system at our institution. The left internal thoracic artery (LITA) was anastomosed to the left anterior descending artery (LAD) and the RITA was anastomosed to the left circumflex branches (LCX). The RITA was used as a free graft in 213 patients (free group) and as an in situ graft in 69 patients (in situ group). Proximal anastomosis of the free RITA onto the ascending aorta was performed in two different ways. We compared early and late results and graft patency of the free RITA with those of the in situ RITA retrospectively., Results: The numbers of anastomoses per patient and anastomoses of the RITA were larger in the free group than in the in situ group (P < 0.01). There was no significant difference in postoperative survival between the groups (free group: 93.3% vs in situ group: 90.0%, P = 0.82). The 5-year patency of the free RITA was higher than that of the in situ RITA (97.0 vs 80.3%, P = 0.01). The 5-year patency of the free RITA was comparable with that of the in situ LITA anastomosed to the LAD (97.0 vs 92.9%, P = 0.28)., Conclusions: The free RITA anastomosed to the LCX might have better late patency than the in situ RITA. The free RITA with modified proximal anastomosis in an aorto-coronary fashion enables complete revascularization of the left coronary system with the in situ LITA to the LAD., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We sought to estimate the reduction in deaths and the number of additional person-years of life that could potentially be gained by nationwide adoption of routine multiple arterial bypass grafting (MABG)., Methods: Propensity matching on 4883 patients undergoing primary, isolated coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) from January 1995 to June 2011, resulted in 1023 matched pairs of LITA-radial artery and LITA-saphenous vein patients. Kaplan-Meier estimated survivals were used to calculate the potential number of lives that could be saved based on a 20% and an 80% rate of MABG, compared with the national 10% rate, when applied to a hypothetical national sample of 200,000 similar patients., Results: Our overall MABG rate was 40% with >80% rate for the past 3 years. Kaplan-Meier estimated 10-year survival was better for LITA-radial artery patients (83.1%) compared with LITA-saphenous vein patients (75.7%) (log rank test, P < .001). When compared with the current national 10% MABG rate, a 20% and an 80% MABG rate could potentially result in 1400 and 10,000 fewer annual deaths, respectively, among a hypothetical national cohort, yielding >9000 and >64,000 person-years of life over a 10-year period., Conclusions: An 80% rate of MABG has the potential to prevent more than 10,000 deaths annually and add >64,000 person-years of life over the course of 10 years. The use of a second arterial graft during CABG should be routine in the majority of patients undergoing CABG., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate 1-year clinical and angiographic results after hybrid coronary revascularization (HCR) combining off-pump left internal mammary artery (LIMA) grafting through an inferior J-hemisternotomy with percutaneous coronary intervention (PCI)., Methods: Prospective, single-arm clinical feasibility study including 100 consecutive patients with multivessel disease undergoing staged HCR. The primary endpoint was the major adverse cardiac and cerebrovascular event rate at 1 year. Secondary endpoints included 1-year all-cause death, stroke, myocardial infarction, repeat revascularization, and angiographic graft and stent patency., Results: One-year clinical follow-up data were available in all patients. The primary endpoint was met by 20 patients (20%). Individual endpoints were as follows: 1 death due to heart failure; 1 stroke, 2 procedure-related myocardial infarctions; and 1 spontaneous myocardial infarction during follow-up. A total of 16 patients underwent repeat revascularization: 5 surgical reinterventions during the index hospitalization for angiographically suspected internal mammary artery graft dysfunction, and 3 repeat PCIs. Only 1 patient had evidence of ischemia. After discharge, PCI was performed in 6 patients who had recurrent angina, and in 2 asymptomatic patients who had angiographic restenosis. At the 1-year angiographic follow-up, 87 of 89 (98%) patients had patent internal mammary artery grafts. Angiographic restenosis was present in 10 of 100 lesions treated by PCI., Conclusions: Angiographically controlled HCR was associated with a high repeat revascularization rate. The 1-year 98% LIMA-graft patency rate, and low risk of death and stroke, seem promising for the long-term outcome. Non-left anterior descending coronary artery lesion revascularization remains a challenge., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Composite grafting using the right internal thoracic artery (RITA) is occasionally performed when the in situ RITA does not have sufficient length to reach the target vessel. In this study, we assessed the clinical and angiographic outcomes of coronary artery bypass grafting (CABG) with V-composite grafting (defined as a distance between the proximal anastomosis of the RITA and the ascending aorta of ≤1 cm) using the RITA anastomosed to aortocoronary (A-C) bypass grafts., Methods: Between September 2004 and December 2012, 177 patients underwent CABG with V-composite grafting using the RITA and the A-C bypass graft [radial artery (RA) or saphenous vein graft (SVG)] at our institution. The mean age was 69.2 ± 8.5 years and 149 (84.2%) were men. The clinical outcomes and patency rates of distal anastomoses of the composite RITA were retrospectively evaluated., Results: Mean distal anastomoses per patient were 4.6 ± 1.0, and mean distal anastomoses of the RITA per patient were 1.3 ± 0.5. Inflow conduit of the RITA was the RA in 16 (9.0%) patients and an SVG in 161 (91.0%) patients. The 30-day mortality rate was 1.1% (2/177). The overall patency rate of distal anastomoses of the composite RITA on early (before discharge) and follow-up (at 1 year) angiography was 97.6 and 93.6%, respectively. The inflow conduit (RA or SVG), stenosis grade of target vessel and sequential grafting did not affect the patency rate of the composite RITA., Conclusions: V-composite grafting using the RITA and the A-C bypass graft provides excellent clinical outcomes with satisfactory early and 1-year patency rates., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Bilateral internal thoracic artery grafting in elderly patients is controversial. We compared the outcome of bilateral internal thoracic artery grafting with that of single internal thoracic artery and saphenous vein and radial artery conduits in these patients., Methods: Patients aged 70 years or more who underwent bilateral internal thoracic artery grafting between 1996 and 2008 (n = 1045) were compared with patients who underwent coronary artery bypass grafting with a single internal thoracic artery + saphenous vein graft (n = 582) or a single internal thoracic artery + radial artery (n = 249)., Results: Prevalence of female gender, diabetes, emergency operation, and chronic obstructive pulmonary disease was lower in the bilateral internal thoracic artery grafting group compared with the internal thoracic artery + radial artery and internal thoracic artery + saphenous vein graft groups, whereas congestive heart failure and recent myocardial infarction were more prevalent in the bilateral internal thoracic artery grafting group. Operative mortality and sternal wound infections were not significantly different between groups. The mean follow-up was 8.17 ± 4.45 years. Ten-year survival (Kaplan-Meier) in the internal thoracic artery + saphenous vein graft group was significantly lower than in the bilateral internal thoracic artery grafting and internal thoracic artery + radial artery groups (P < .001). Assignment to the saphenous vein graft group was also associated with decreased adjusted survival (P < .001) compared with the bilateral internal thoracic artery and internal thoracic artery + radial artery groups., Conclusions: This study supports the use of arterial grafts in elderly patients undergoing coronary artery bypass grafting., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hybrid coronary revascularization (HCR) and off-pump coronary artery bypass grafting (OPCABG) are both feasible, less invasive techniques for coronary revascularization. Although both techniques utilize the left internal mammary artery to left anterior descending artery graft, HCR uses drug-eluting stents instead of saphenous vein bypass. It remains unclear whether HCR is equal to, better or worse than OPCABG., Methods and Results: A meta-analysis was carried out using a random-effects model. Seven observational studies were included. There was no significant difference either in in-hospital mortality [relative risk (RR) 0.57, 95% confidence interval (CI) 0.13-2.59, P=0.47] or in the MACCE rate (RR 0.63, 95% CI 0.24-1.64, P=0.34) between the HCR group and the OPCABG group. A significant difference was observed between the two groups in the length of hospitalization (RR 0.55, 95% CI 0.13-0.97, P=0.01), length of ICU stay (RR 0.45, 95% CI 0.10-0.80, P<0.05), intubation time (RR 0.48, 95% CI 0.13-0.84, P<0.01), need for red blood transfusion (RR 0.67, 95% CI 0.56-0.82, P<0.001), and total in-hospital costs (RR 0.90, 95% CI 0.39-1.42, P<0.01)., Conclusion: Compared with OPCABG, HCR did not improve early survival but decreased the length of hospitalization, length of ICU stay, intubation time, and need for red blood transfusion, and increased total in-hospitalcosts.

Background: We compared the outcomes in propensity score-matched patients who had chronic kidney disease (CKD) undergoing off-pump coronary bypass grafting, with either a bilateral or single skeletonized internal thoracic artery (ITA)., Methods: Of 1254 consecutive patients undergoing isolated coronary bypass surgery (1248 by the off-pump technique without emergent conversion to cardiopulmonary bypass), the 1203 who received a skeletonized, single (n = 453) or bilateral (n = 750), ITA graft were enrolled, after excluding the 6 patients who received preoperative percutaneous cardiopulmonary support and the 75 who had only 1 target vessel in the left coronary area. A total of 412 pairs were matched using propensity scores. Kaplan-Meier analyses were used to assess all-cause and cardiac-related mortality, by CKD stage (assessed by glomerular filtration rate [GFR]: <30; 30-60; >60 mL/minute/1.73 m(2)). Multivariate Cox proportional hazard models were used to assess for association of bilateral grafting with mortality. A test for interaction of bilateral ITA grafting and estimated GFR was conducted., Results: No significant difference was found in the incidence of 30-day mortality, stroke, or deep sternal infection between the 2 groups. Although an advanced stage of CKD decreased overall survival, a benefit of bilateral ITA grafting for all-cause and cardiac-related mortality occurred relatively early in the follow-up period and was not influenced by CKD stage. Bilateral ITA grafting was independently associated with a lower risk of both all-cause and cardiac-related mortality in patients with an estimated GFR of <60. No interaction was found between bilateral ITA grafting and estimated GFR in either model., Conclusions: In patients who have CKD, off-pump, skeletonized, left-side bilateral ITA grafting is associated with lower risk of all-cause and cardiac-related mortality, and does not increase operative risk., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Aim: Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high burden of coronary disease. Prior studies in non-dialysis patients show better outcomes in coronary artery bypass surgery using the internal mammary artery (IMA) compared with the saphenous vein graft (SVG), but less is known about outcomes in ESRD. We sought to compare the effectiveness of multivessel bypass grafting using IMA versus SVG in patients on maintenance dialysis in the United States., Methods: Cohort study using data from the United States Renal Data System to examine IMA versus SVG in patients on maintenance dialysis undergoing multivessel coronary revascularization. We used Cox proportional hazards regression with multivariable adjustment in the full cohort and in a propensity-score matched cohort. The primary outcome was death from any cause; the secondary outcome was a composite of non-fatal myocardial infarction or death., Results: Overall survival rates were low in this patient population (5-year survival in the matched cohort 25.3%). Use of the IMA compared to SVG was associated with lower risk of death (adjusted hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.84-0.92) and lower risk of the composite outcome (adjusted HR 0.89; CI 0.85-0.93). Results did not materially change in analyses using the propensity-score matched cohort. We found similar results irrespective of patient sex, age, race, or the presence of diabetes, peripheral vascular disease or heart failure., Conclusion: Although overall survival rates were low, IMA was associated with lower risk of mortality and cardiovascular morbidity compared to SVG in patients on dialysis.

Background: Retroaortic right internal thoracic artery grafting has failed to gain popularity. We aimed to delineate patient correlates of eligibility, distribution of targets, and effects of target remoteness on outcome and risk of retroaortic bleeding., Methods: Data of 861 patients undergoing skeletonized bilateral internal thoracic artery grafting (2007-2012) were analyzed according to retroaortic (n = 300) or T-graft configuration. Retroaortic graft subgroups were categorized according to proximal (first obtuse marginal, ramus) or distal (2nd, 3rd, or sequential 1st-2nd obtuse marginal) circumflex artery targets., Results: LOESS curve analyses revealed that taller patients had a higher likelihood of retroaortic grafting. The distribution of 337 retroaortic graft targets (300 patients) was first obtuse marginal in 74.5%, 2nd marginal in 12.4%, ramus in 11.2%, 3rd marginal in 1.9% and sequential 1st-2nd marginal in 12.3%. The success rate in reaching proximal and distal circumflex artery targets was 97% and 30%, respectively, 5-year survival (92.2%) and freedom from major adverse cardiac and cerebrovascular events (85.8%) were comparable between proximal and distal retroaortic graft subgroups. Distal circumflex artery targets had no effect on the occurrence of major adverse cardiac and cerebrovascular events. The incidence of retroaortic bleeding from skeletonized retroaortic grafts was 0.6%., Conclusions: Taller patients have a greater likelihood of qualifying for retroaortic grafting. This technique is highly reproducible for proximal but not distal circumflex artery targets. Distal circumflex artery targets are not independent correlates of early or late adverse outcomes. The risk of retroaortic bleeding is low despite retroaortic right internal thoracic artery skeletonization., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG., Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes., Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46)., Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Objectives: A limited number of patients undergoing coronary artery bypass grafting (CABG) currently receive bilateral internal thoracic arteries (BITA) as a consequence of lack of evidence on survival benefit and concerns about sternal wound complications. This study was undertaken to determine the impact of BITA grafting on short- and long-term outcomes in obese patients., Methods: Propensity score matching for short- and long-term outcomes was conducted for 1522 obese (body mass index ≥ 30 kg/m(2)) patients undergoing CABG using BITA (n = 229, 15.0%) or a single internal thoracic artery (SITA, n = 1293, 85.0%)., Results: Propensity score matching created 229 matching sets. In the matched sample, operative mortality (within 30 days) occurred in 3 (1.3%) and 4 (1.7%) patients in the BITA and SITA groups, respectively (P = 1). Deep sternal wound infection occurred in 6 (2.6%) and 2 (0.9%) patients (P = .2) in the BITA and SITA group, respectively. After a median follow-up of 4.5 ± 3.3 years, the use of BITA was associated with an improved late survival (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.13-0.97; P = .03) and a reduced need for repeat revascularization (HR, 0.45; 95% CI, 0.23-0.85; P = .01)., Conclusions: BITA grafting can be safely offered to obese patients with significant long-term advantages without substantial additional risk of operative complications including deep sternal wound infection., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In this study, we retrospectively reviewed our experience in a meticulously selected group of patients undergoing redo off-pump coronary artery bypass graft (CABG) surgery from the descending aorta to the circumflex artery (Cx) and its branches., Methods: Between January 2001 and October 2013, 32 patients at our hospital underwent redo off-pump CABG from the descending aorta to the Cx and its branches via a left posterolateral thoracotomy. Of these patients, 27 were male (84.3%) and five were female (15.7%), with a mean age of 61.66 ± 8.63 years. All patients had a patent left internal thoracic artery-to-left anterior descending coronary artery (LITA-LAD) anastomosis. Thoracotomy was performed through the fifth intercostal space. The saphenous vein or radial artery was prepared as a graft at the same time as the left posterolateral thoracotomy from the contralateral extremity, without any positional problem., Results: The main reasons for surgery in this group of patients were new lesion formation in 19, graft occlusion in six, and both in seven patients. The average operating time was 143.90 ± 36.93 minutes, respiratory assist time was 5.08 ± 1.88 hours, intensive care unit (ICU) stay was 21.3 ± 4.41 hours and hospital stay was 5.06 ± 2.74 days. Thirty-eight bypasses were performed. The follow-up period was 56.17 ± 39.2 months. Six patients were lost in the follow-up period and four patients died. Twenty-two were alive and free of cardiac problems., Conclusion: Redo off-pump CABG via a left posterolateral thoracotomy provided a safe and effective surgical approach with lower rates of postoperative morbidity and mortality in patients who required revascularisation of the Cx and its branches.