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Bilateral internal thoracic artery grafting: time to reconsider our strategy?

Bilateral internal thoracic artery grafting: time to reconsider our strategy? Downloaded from https://academic.oup.com/ejcts/advance-article/doi/10.1093/ejcts/ezaa338/5927567 by DeepDyve user on 18 March 2021 European Journal of Cardio-Thoracic Surgery 00 (2020) 1–1 LETTER TO THE EDITOR up may influence the evaluation of mid-term graft patency, on the one hand, Bilateral internal thoracic artery grafting: and on the other hand, the implementation of two different angiography techniques with varying sensitivities and specificities may bias the results as time to reconsider our strategy? well. According to our experience in performing BITA grafting, preferring pre- a, b c Kyriakos Spiliopoulos *, Dimitrios Magouliotis ,Ilias Angelis and dominant the same, as by the authors proposed, cross arrangement of in situ Brigitte Gansera RITA to LAD and in situ LITA to left lateral wall, with favourable long-term results and acceptable complication rates, we overcame or minimized the risk Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, of RITA damage during resternotomy by covering the vessel graft with a PTFE School of Health Sciences, University of Thessaly, Larissa, Greece sleeve [4, 5]. Others propose securing the graft under the pericardial fat and Department of Surgery, Faculty of Medicine, School of Health Sciences, thymic remnants before chest closure [6]. University of Thessaly, Larissa, Greece Although in situ RITA to LAD grafting in the setting of BITA configuration Department of Cardiac Surgery, European Interbalkan Medical Center, seems reasonable with excellent mid- and long-term outcomes, results from Thessaloniki, Greece prospective randomized trials are still awaited to prove the superiority of the Department of Cardiac Surgery, Chirurgisches Klinikum Mu ¨ nchen Su ¨d, graft over its left counterpart, which may justify a reconsideration of the cur- Munich, Germany rently widely adopted surgical strategy. Received 3 July 2020; accepted 13 August 2020 Keywords: Bilateral internal thoracic artery � Coronary artery bypass grafting REFERENCES [1] Ogawa S, Tsunekawa T, Hosoba S, Goto Y, Kato T, Kitamura H et al. Bilateral internal thoracic artery grafting: propensity analysis of the left We read with great interest the article by Ogawa et al. [1] dealing with the internal thoracic artery versus the right internal thoracic artery as a issue of bilateral internal thoracic artery (BITA) grafting and the results of a bypass graft to the left anterior descending artery. Eur J Cardiothorac propensity analysis indicating the superiority of the right internal thoracic ar- Surg 2020;57:701–8. tery (RITA) over its left counterpart as a bypass graft to the left anterior [2] Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams descending (LAD) artery. GW, Golding LA et al. Influence of the internal-mammary-artery graft on Despite the proven positive effect on the survival of internal thoracic artery 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6. (ITA) grafting in coronary artery bypass grafting surgery through the gold [3] Bakaeen FG, Ravichandren K, Blackstone EH, Houghtaling PL, Soltesz EG, standard approach of in situ left ITA (LITA) to LAD grafting [2], the benefits of Johnston DR et al. Coronary artery target selection and survival after bi- BITA grafting over single ITA (SITA) grafting have been widely reported as well lateral internal thoracic artery grafting. J Am Coll Cardiol 2020;75: [3, 4]. The series by Ogawa and co-authors with its key findings and especially 258–68. the take-home message may ‘rock the boat’. We would like to take the chance [4] Gansera B, Schmidtler F, Gillrath G, Angelis I, Wenke K, Weingartner J to add some comments on the topic. et al. Does bilateral ITA grafting increase perioperative complications? From the technical point of view, the authors advocate for a certain length Outcome of 4462 patients with bilateral versus 4204 patients with single of the in situ RITA graft to enable more distal anastomoses on the LAD. This is ITA bypass. Eur J Cardiothorac Surg 2006;30:318–23. in our eyes not entirely reproducible. An appropriate length of the in situ RITA [5] Gansera B, Schmidtler F, Spiliopoulos K, Angelis I, Neumaier-Prauser P, graft targeting the peripheral LAD has been among cardiac surgeons one of Kemkes BM. Urgent or emergent coronary revascularization using the major concerns throughout the years. Could the authors illustrate more bilateral internal thoracic artery after previous clopidogrel antiplatelet precise insights and pitfalls regarding either harvesting or guidance techniques therapy. Thorac Cardiovasc Surg 2003;51:185–9. to the target vessel (including the positioning in relation to the lung, the way [6] Gurevitch J, Kramer A, Locker C, Shapira I, Paz Y, Matsa M et al. of penetration into the pericardial cavity, etc.)? Technical aspects of double-skeletonized internal mammary artery graft- Furthermore, looking at the baseline characteristics, the unmatched ing. Ann Thorac Surg 2000;69:841–6. and matched cases presented a significantly higher frequency with 12.5% of ‘sequential anastomosis of the LAD graft in the LITA to LAD group’. As sequen- tial anastomoses carry a potential risk of steal syndrome, it appears reasonable * Corresponding author. Department of Thoracic and Cardiovascular Surgery, to analyse a possible correlation between this factor and graft patency. Faculty of Medicine, University of Thessaly, Panepistimiou 3 (Viopolis), Post Notably, 82.7% out of the 877 cases included in the analysis underwent at Box 1400, Larissa 41500, Greece. Tel.: +30-2413502974; fax: +30-2410255488; least one angiography at a mean duration of 2.2 years after surgery. Especially e-mail: spiliopoulos@med.uth.gr (K. Spiliopoulos). in the matched population, the rate increased by up to 89%, 50% of which were within the first postoperative year. Nevertheless, a loss of 11% to follow- doi:10.1093/ejcts/ezaa338 The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. LETTER TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Bilateral internal thoracic artery grafting: time to reconsider our strategy?

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Publisher
Oxford University Press
Copyright
Copyright © 2021 European Association for Cardio-Thoracic Surgery
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1093/ejcts/ezaa338
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Abstract

Downloaded from https://academic.oup.com/ejcts/advance-article/doi/10.1093/ejcts/ezaa338/5927567 by DeepDyve user on 18 March 2021 European Journal of Cardio-Thoracic Surgery 00 (2020) 1–1 LETTER TO THE EDITOR up may influence the evaluation of mid-term graft patency, on the one hand, Bilateral internal thoracic artery grafting: and on the other hand, the implementation of two different angiography techniques with varying sensitivities and specificities may bias the results as time to reconsider our strategy? well. According to our experience in performing BITA grafting, preferring pre- a, b c Kyriakos Spiliopoulos *, Dimitrios Magouliotis ,Ilias Angelis and dominant the same, as by the authors proposed, cross arrangement of in situ Brigitte Gansera RITA to LAD and in situ LITA to left lateral wall, with favourable long-term results and acceptable complication rates, we overcame or minimized the risk Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, of RITA damage during resternotomy by covering the vessel graft with a PTFE School of Health Sciences, University of Thessaly, Larissa, Greece sleeve [4, 5]. Others propose securing the graft under the pericardial fat and Department of Surgery, Faculty of Medicine, School of Health Sciences, thymic remnants before chest closure [6]. University of Thessaly, Larissa, Greece Although in situ RITA to LAD grafting in the setting of BITA configuration Department of Cardiac Surgery, European Interbalkan Medical Center, seems reasonable with excellent mid- and long-term outcomes, results from Thessaloniki, Greece prospective randomized trials are still awaited to prove the superiority of the Department of Cardiac Surgery, Chirurgisches Klinikum Mu ¨ nchen Su ¨d, graft over its left counterpart, which may justify a reconsideration of the cur- Munich, Germany rently widely adopted surgical strategy. Received 3 July 2020; accepted 13 August 2020 Keywords: Bilateral internal thoracic artery � Coronary artery bypass grafting REFERENCES [1] Ogawa S, Tsunekawa T, Hosoba S, Goto Y, Kato T, Kitamura H et al. Bilateral internal thoracic artery grafting: propensity analysis of the left We read with great interest the article by Ogawa et al. [1] dealing with the internal thoracic artery versus the right internal thoracic artery as a issue of bilateral internal thoracic artery (BITA) grafting and the results of a bypass graft to the left anterior descending artery. Eur J Cardiothorac propensity analysis indicating the superiority of the right internal thoracic ar- Surg 2020;57:701–8. tery (RITA) over its left counterpart as a bypass graft to the left anterior [2] Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams descending (LAD) artery. GW, Golding LA et al. Influence of the internal-mammary-artery graft on Despite the proven positive effect on the survival of internal thoracic artery 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6. (ITA) grafting in coronary artery bypass grafting surgery through the gold [3] Bakaeen FG, Ravichandren K, Blackstone EH, Houghtaling PL, Soltesz EG, standard approach of in situ left ITA (LITA) to LAD grafting [2], the benefits of Johnston DR et al. Coronary artery target selection and survival after bi- BITA grafting over single ITA (SITA) grafting have been widely reported as well lateral internal thoracic artery grafting. J Am Coll Cardiol 2020;75: [3, 4]. The series by Ogawa and co-authors with its key findings and especially 258–68. the take-home message may ‘rock the boat’. We would like to take the chance [4] Gansera B, Schmidtler F, Gillrath G, Angelis I, Wenke K, Weingartner J to add some comments on the topic. et al. Does bilateral ITA grafting increase perioperative complications? From the technical point of view, the authors advocate for a certain length Outcome of 4462 patients with bilateral versus 4204 patients with single of the in situ RITA graft to enable more distal anastomoses on the LAD. This is ITA bypass. Eur J Cardiothorac Surg 2006;30:318–23. in our eyes not entirely reproducible. An appropriate length of the in situ RITA [5] Gansera B, Schmidtler F, Spiliopoulos K, Angelis I, Neumaier-Prauser P, graft targeting the peripheral LAD has been among cardiac surgeons one of Kemkes BM. Urgent or emergent coronary revascularization using the major concerns throughout the years. Could the authors illustrate more bilateral internal thoracic artery after previous clopidogrel antiplatelet precise insights and pitfalls regarding either harvesting or guidance techniques therapy. Thorac Cardiovasc Surg 2003;51:185–9. to the target vessel (including the positioning in relation to the lung, the way [6] Gurevitch J, Kramer A, Locker C, Shapira I, Paz Y, Matsa M et al. of penetration into the pericardial cavity, etc.)? Technical aspects of double-skeletonized internal mammary artery graft- Furthermore, looking at the baseline characteristics, the unmatched ing. Ann Thorac Surg 2000;69:841–6. and matched cases presented a significantly higher frequency with 12.5% of ‘sequential anastomosis of the LAD graft in the LITA to LAD group’. As sequen- tial anastomoses carry a potential risk of steal syndrome, it appears reasonable * Corresponding author. Department of Thoracic and Cardiovascular Surgery, to analyse a possible correlation between this factor and graft patency. Faculty of Medicine, University of Thessaly, Panepistimiou 3 (Viopolis), Post Notably, 82.7% out of the 877 cases included in the analysis underwent at Box 1400, Larissa 41500, Greece. Tel.: +30-2413502974; fax: +30-2410255488; least one angiography at a mean duration of 2.2 years after surgery. Especially e-mail: spiliopoulos@med.uth.gr (K. Spiliopoulos). in the matched population, the rate increased by up to 89%, 50% of which were within the first postoperative year. Nevertheless, a loss of 11% to follow- doi:10.1093/ejcts/ezaa338 The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. LETTER TO THE EDITOR

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European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Oct 17, 2020

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