Configurations of Arterial Grafts:

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Presentation transcript:

Configurations of Arterial Grafts: Advanced Techniques for State of the Art CABG Session AATS 2015 Configurations of Arterial Grafts: In situ vs. composite arterial conduits David P Taggart MD PhD FRCS FESC Professor of Cardiovascular Surgery, University of Oxford Conflicts of Interest:None 1

In Situ or Composite (‘Y’): BIMA Advantages Technically easy More Distal Anastomoses No Midline Cross Do not need Distal RIMA Disadvantages Cross Midline 20% too short Uses distal RIMA (spasm) and devascularizes xiphisternum Technically more complex ‘All eggs in one basket’ 4 Questions re In Situ or Composite Patency ? Adequate flow to supply whole heart ? Functionality of free IMA (denervation) ? Clinical Outcomes ?

[CIRC 2008] 304 patients Anastomoses In situ (2.4) vs Composite (3.2): p<0.001 6 month patency 97% of 295 In situ 97% of 464 composite

[JTCVS 2010] 17 composite Y grafts studied at 6 months (RITA 10; SVG 7)

[EJCTS 2011] 11 patients 3 years after CABG CONCLUSION: RIMA used as free graft does not affect basal vasomotor tone, endothelial function or vasomotor reserve

[JTCVS 2014]

BIMA CONFIGURATIONS RIMA Intd LIMA LlIMA RIMA OM LAD OM LlIMA Intd OM Diag RIMA OM LAD

In situ vs. composite arterial conduits No difference in patency, endothelial function or vasomotor reserve when BIMA used In situ or as Composite Grafts Composite grafts allow more distal anastomoses, avoid the need to use distal RIMA and avoid crossing midline

43 patients (mortality 5%) 6 BIMA (mortality 0%) Graft Flow Measurements (45ml/min (range 30-60ml/min) Repeat Angiography at 2-3 weeks 97% patency

BIMA SKELETONIZATION Preparation: Harvest, divide distally and clip Wrap in papaverine swab + increase BP to 150 for 5 mins No need to heparinize !!!! No need to inject ARTERY Longer Wider See Full Length Easier composites Easier sequentials CHEST WALL Not denuded Less Bleeding Better Healing

[JTCVS 2014] 224 patients 1 year angio patency 98% SVG and 97% RITA