1. Total coronary revascularization with the internal thoracic arteries T graft B. El Nakadi, Y. De Bruyne, M. Joris C.H.U. de Charleroi, Belgium

2. Total coronary revascularization with the internal thoracic arteries T graft 1960 : RITA RCA 1965 : LITA LAD 1973 : RITA + LITA in situ 80’s : LITA on LAD improves long-term survival

3. Total coronary revascularization with the internal thoracic arteries T graft sITA > < bITA grafting

4. Total coronary revascularization with the internal thoracic arteries T graft Complications of bITA grafting

5. Total coronary revascularization with the internal thoracic arteries T graft Sternal infection risk factors –Univariate analysis : bITA grafting Obesity Diabetes Prolonged mechanical ventilation –Multivariate regressive analysis : bITA grafting p=0.0001 Obesity p=0.0014 Prolonged ventilation p=0.0018 Kouchoukos. Ann. Thorac. surg. 1990

6. Total coronary revascularization with the internal thoracic arteries T graft ITAs have proved to be the best bypass graft but have an inadequate length to bypass Cx pl and RC arteries to achieve a complete revascularization.

7. Total coronary revascularization with the internal thoracic arteries T graft

9. Material:( jan. 94 sept.97 ) –106 patients, 1 E /10 G –Age: 51 ys (35-69) –Redo: 8 % –Diabetes: 21% –Obesity: 38 %

10. Total coronary revascularization with the internal thoracic arteries T graft Material: –NYHA: II: 49 % III: 13 % IV: 22 % –Stress test: 58 patients. 90 % –EF: 0.60 (0.22-0.85) +

11. Total coronary revascularization with the internal thoracic arteries T graft

12. Operative data: –Anastomoses: 4.25 (3-6) 3 (2-4) redo patients. –Aortic cross clamping: 94 ñ 18 min. –IABP: 1 (EF:0.25) –Exploration for bleeding: 0

13. Total coronary revascularization with the internal thoracic arteries T graft Morbidity: –Transient s-t elevation: 12 (11 %) –Q wave infarction: 3 (3 %) –Sternal infection: 1 (1%) Mortality: 0

14. Total coronary revascularization with the internal thoracic arteries T graft Follow-up(105 patients) –26 ñ 13 months –Survival: 99 % –Stress test: 90 % –Recurrent angina: 7 NYHA II (7 %) –infarct: 0 –Sternal instability: 2 % rewiring -

15. Total coronary revascularization with the internal thoracic arteries T graft Is the blood supply sufficient? –clinical results. –Experimental studies. What about subclavian artery atherosclerosis? –before surgery free LITA + in situ RITA. –after surgery - Extraanatomic bypass. -Angioplasty.

16. Total coronary revascularization with the internal thoracic arteries T graft Follow-up: –Symptoms, stress test, thallium test. –Graft evaluation: Duplex(supraclavicular fossa) :qualitative flow information in 95 % of cases. Spiral CT scan : graft patency sensitivity 85 %& specificity 100% Angiography.

17. Total coronary revascularization with the internal thoracic arteries T graft Has the potential to increase event-free survival and reduce the need for reoperation in patients with three-vessel disease. Can be performed with a low mortality and morbidity in a selected population, even in patients requiring reoperation.