Coronary Artery Revascularization Using Both ITAs as Free Conduits in Patients with Three-Vessel Disease - The Lambda Graft

Abstract

Background: There is little information on using internal thoracic arteries (ITA) as free conduits in coronary artery bypass grafting. This study examines the results using both ITAs as free grafts in a λ configuration implanting the common trunk into the ascending aorta. Methods: Over a 6-year period, 317 patients underwent coronary artery revascularization with both ITAs as free grafts in a λ configuration. Results: An average of 4.9 distal anastomoses per patient was performed. There were 4 deaths (three early and one late). The mean NYHA class improved from preoperatively 2.8 to 1.1 at the last check. All 16 patients with suspected recurrent angina or a pathologic exercise test were restudied by angiography. Segmental graft stenosis or occlusion was found in 13 (in only one at aortic anastomosis). Five patients underwent late PTCA, and two underwent coronary reoperation. The six-year actuarial survival was 98% (90 % CL ± 2 %), intervention-free survival 96 % (90 % CL ± 2 %). Conclusion: Revascularization using both ITAs as free grafts in a λ configuration gives good early and mid-term results for up to 6 years. The aortic ITA anastomosis can be considered safe.

Coronary artery revascularization - Internal thoracic artery - Free graft

References

• 1 Cameron A, Davis K B, Green G, Schaff H V. Coronary bypass surgery with internal-thoracic-artery grafts - effects on survival over a 15-years period.  N Engl J Med. 1996;  334 216-219
• 2 Pick A W, Orszulak T A, Anderson B J, Schaff H V. Single versus bilateral internal mammary artery grafts: 10-year outcome analysis.  Ann Thorac Surg. 1997;  64 599-605
• 3 Lytle B W, Blackstone E H, Loop F D, Houghtaling P L, Arnold J H, Akhrass R, McCarthy P M, Cosgrove D M. Two internal thoracic artery grafts are better than one.  J Thorac Cardiovasc Surg. 1999;  117 855-872
• 4 Earner H B. The continuing evolution of arterial conduits.  Ann Thorac Surg. 1999;  68 S 1-8
• 5 Tector A J, Amundsen S, Schmal T M, Kress D C, Peter M. Total arterial revascularization with T-Grafts.  Ann Thorac Surg. 1994;  57 33-39
• 6 Wendler O, Hennen B, Markwirth T, Konig J, Tscholl D, Huang Q, Shahangi E, Schäfers H J. Grafts with the right internal thoracic artery to left internal thoracic artery versus the left internal thoracic artery and radial artery flow dynamics in the internal thoracic artery main stem.  J Thorac Cardiovasc Surg. 1999;  118 841-848
• 7 Nakadi B E, Choghan C, Jons M. Complete myocardial revascularization with bilateral internal thoracic artery T Graft.  Ann Thorac Surg. 2000;  69 498-500
• 8 Kramer A, Mastasa M, Paz Y, Locker C, Pevni D, Gurevitch J, Shapira I, Lev-Ran O, Mohr R. Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older.  J Thorac Cardiovasc Surg. 2000;  120 290-297
• 9 Loop F D, Lytle B W, Cosgrove D M, Goldmg L AR, Taylor P C, Stewart R W. Free (arota-coronary) internal mammary artery graft.  J Thorac Cardiovasc Surg. 1986;  92 827-831
• 10 Tatoulis J, Buxton B F, Fuller J A. Results of 1,454 free right internal thoracic artery-to-coronary artery grafts.  Ann Thorac Surg. 1997;  64 1263-1269
• 11 Tashiro T, Nakamura K, Sukehiro S, Nakamura M, Shibano R, Motomura T, Kimura M. Midterm results of free internal thoracic artery grafting for myocardial revascularization.  Ann Thorac Surg. 1998;  65 951-954
• 12 Buxton B F, Ruengsakulrach P, Fuller J, Rosalion A, Reid C M, Tatoulis J. The right internal thoracic artery graft-benefits of grafting the left coronary system and native vessels with a high grade stenosis.  Eur J Cardio-Thorac Surg. 2000;  18 255-261
• 13 Tedonya T, Kawasuji M, Ueyama K, Sakakibara N, Takemura H, Wanatabe Y. Physiologic characteristics of coronary artery bypass grafts.  Ann Thorac Surg. 1993;  56 951-956
• 14 Kawasuji M, Tedonya T, Takemura H, Sakakibara N, Taki J, Wanatabe Y. Flow capacities of arterial grafts for coronary artery bypass grafting.  Ann Thorac Surg. 1993;  56 957-962
• 15 Pagni S, Storey J, Ballen J, Montgomery W, Chiang B Y, Etoch S, Spence P A. ITA versus SVG a comparison of instantaneous presure and flow dynamics during competitive flow.  Eur J Cardio-Thorac Surg. 1997;  11 1086-1092
• 16 Dion R. Complete arterial revascularization with the internal thoracic arteries: Operative techniques.  Card Thorac Surg. 1996;  1 84-107
• 17 Uva M S, Braunberger E, Fisher M, Frames Y, Deleuze P H, Celestin J A, Bical O M. Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients?.  Ann Thorac Surg. 1998;  65 2051-2055
• 18 Siebenmann R, Egloff L, Hierzel H, Rothlin M, Studer M, Tartini R. The internal mammary artery “string phenomenon”: Analysis of 10 years.  Eur J Cardio-Thorac Surg. 1993;  7 235-238