Bilateral IMA Grafting CONTRA

Transcription

1 Bilateral IMA Grafting CONTRA A. Moritz (nothing to declare) Klinik für Thorax- Herz und thorakale Gefäßchirurgie Klinikum der Johann Wolfgang Goethe Universität

2 Aortocoronary Bypass Palliative procedure Best configuration unclear

3 Syntax Studie Noninferiority despite limited use of multiple arterial grafts

4 Stent vs CABG Randomized Studies Will conversion to a 2VD normalize survival? Is then complete revascularization and graft durability still an issue?

5 Survival after CACG w/o IMA CCF NEJM Class I Evidence Level B

6 Comparison single vs bilateral IMA B. Lytle et al., J Thorac Cardiovasc Surg 1999 Inhomogeneous populations

7 Effect of Second Arterial Graft Taggart D Lancet 2001 Mohammadi Eur J CTSurg 2008 Age cut off für BIMA Schwann 2008 RA in diabetics

8 The massive impact of increased use of arterial grafting on reintervention Why ist there no gaph for the third arterial graft? P. Sergeant Leuven

9 Patient specific prediction of the independent influence of renal function on risk and outcome after CABG for a median patient CCF P. Sergeant Leuven

10 Vein Degeneration 90% 94,5% 5 a Patency Vein 8 yrs postop Dialysis Hayward/Buxton rand studies (RIMA vsrad/rad vs Vene) Vein 9 yrs Vein 8yrs vasculitis

11 Vein Grafts Randomized Hayward, Buxton BF AnnThS 2011 Tatoulis J, Buxton BF JThCVS 2011

12 Total arterial Revascularisation T Grafts LAD CX

13 T Graft Arterial Revascularisation Legare JCTSurg 2007 prospektive 1019 TAG vs 3677 IMA+Vein

14 T Graft Flow Limitation Hydrodynamics static flow Afflek

15 Coronary Physiology Uneven coronary resistance and flow pattern

16 T-Grafts GlineurCirc 2005 Y Graft.. Even distribution of perfusion pressure

17 T-Grafts Coronary flow Reserve and Survival (Britten) Sakaguchi AnnTh Surg2002 MRT Flow reserve Y vs individual Grafts CFR 1,4 at stress

18 Two years after surgery: Injection to the left system demonstrating residual patent segment of Right Internal Thoracic Artery (RITA) graft between Circumflex artery (Cx) and Posterior Descending Artery (PDA) R. Mohr

19 Six years after surgery: Injection to LITA graft demonstrating patent Right Internal Thoracic Artery (RITA) graft to Circumflex artery (Cx) and to Posterior Descending Artery (PDA). Narrowing of LITA and poor opacification of its anastomotic site to the LAD

20 Table 2: Interaction between patency of RITA and severity of CX stenosis. Kruskal-Wallis test (univariable, p=0.002) Total CX Stenosis (%) n=168 < (n=23) (n=29) (n=116) Patent RITA n= (47.8%) 19 (65.5%) 108(93.1%) Occluded RITA n=30 12 (52.2%) 10 (34.5%) 8 (6.9%) R. Mohr

21 T - Grafts Maniar HS ( Barner, Damiano) Ann Th Surg 2003 RCA T Graft 58% RCA Ao 67% El Kouhry/ Glineur EJCTSurg / 152 elektive Angio BITA T ( Y) Graft 97% patent 75% functional 65% to RCA

22 Is All Relevant Knowledge Published? EACTS Geneva 2007

23 Vein Graft Degeneration Vein harvest with surrounding tissue ( wall nutrition and support) Souza DS JTHCVS 2006 Randomised 76% vs. 90% 8a patency

24 Histology (M. A. Konerding, Anatomy, University Mainz) native Dacron wrap Dept. of Thoracic & Cardiovascular Surgery Johann Wolfgang Goethe - Universität Frankfurt am Main

25 Venous Valves

26 Vein Valves Lajos TZ J Card Surg 2007 Own study: 145 Pat, 45 CT angio after 18 months 97% patency to RCA

27 LIMA Sequential Grafting P. Sergeant Leuwen R Dion EurJCTCVS 2000

28 Sequentielle LIMA: Frankfurt / Vienna 470 Pat Inclusion1987 bis pt/yrs, 9.2 ± 6 DM 31% vs 8% ( MONICA) Hypert 68 vs 50% Vein vs RITA DM 33% 23% Renal 9.6% 1.3% PAVK 7.3% 11.4%

29 Revascularisation with Triple Inflow

30 Summary Long term survival after CABG is multifactorial. There is prooven advantage of a second arterial anastomosis for most patient populations. A second durable graft is advisable. Vein grafts patency appears inferior not at least for usage to less ideal coronary provinces. Vein graft patency can be improved by technical modifications. T graft all arterial may be suboptimal due to inferior functional patency rates to the right system. Secondary prophylaxis is not standardized.

31 Graftprobleme

32 Revaskularisationsstrategien

33 Einfluß der Operationstechnik M.R.Moon 358 Patienten 80 bis 94 Jahre C.Muneretto 200 Patienten > 70 a randomisiert zu LIMA + Venen oder total arteriell mit Y Grafts

34 LIMA Evidenz Eine (Pseudo) randomisierte Studie Hacker Bad Neustadt 1999 (1100 Patienten in jedem Arm geplant 800 IMA + Vene 1400 Vene Angiographie bei Symptomen IMA Patency 86% Venen Patency 76% Geringer Unterschied Vene IMA auf RIVA Nach 8 Jahren Überleben nicht signifikant ( OR 1,2 unter Diabetes und Alter) Ab 8 Jahren geringer Vorteil bei Symptomen für IMA Gruppe Selbst bei einer für erhöhten LIMA Verschlußrate 14% ( dzt 5%) zeigen sich klinische Vorteile für den LIMA RIVA Bypass Chirurgen müssen mit der guten Technik vertraut sein

35 Adjunctive Therapy peri

36 L peri

37 BIMA bei Diabetes und LV Dsfunktion B. Lytle et al., J Thorac Cardiovasc Surg 1999

38 ,5 96,4 CARRACASS 600 pat total L-ITA R-ITA RADIAL VEIN Graft Patency

39 Gaudino M JTHCVS 2004 Radialis L