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Is Bilateral IMA Use in CABG the Gold Standard?

Thursday, April 14, 2016

Joseph Sabik of the Cleveland Clinic, Cleveland, Ohio, considers the importance of internal mammary artery (IMA) grafts in long-term CABG outcomes. Drawing upon information in the Cleveland Clinic’s 50,000 CABG patient database, Dr. Sabik argues that IMA grafts are the gold standard for all patient populations, including those comprised of diabetics.

This presentation was originally given during the SCTS Ionescu University program at the 2015 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs. 


Dr Sabik Congratulate you on an informative presentation. However, would like to clarify few points 1. Wouldn't it be better if rima is deployed always on the left coronary system where it gives better results and reserve either radial or svg use on the right system based on stenosis?? 2. If you have only moderate stenosis on the lcx and its branches would you still consider bima considering the competitive flow and lower patency? Also what would be your graft on the right system with high grade stenosis in such a scenario- radial or rima???
Many thanks for this nice presentation recaling judicious use of in-situe BITA. Despite being an advocate to more arterial grafting, I woukd add some polemic comments. The presented results are from an area that secondary prevention may not be exerted as vigrous as done currently. Competition flow is not just related to the degrees of proximal stenosis, but the results of a myriade of pathophysiological factors. Therefore, the best decision-making to revascularize or not a branch should be based on preoperative FFR study by the time of angiography. Strategically, SVG does not be as bad as pointed out, but rather implemented badly. Sharing hemodynamic and pharmacological benefits of ITA to SVG and avoiding mechanical injuries driven by cardiac output stroke force by performing composite ITA - SVG grafting may increase overall succes rates. Strategy as how best revasculsrize RCA depends on the role assigned to RCA. A balanced or dominant RCA, or RCA offering considerable collaterals to the left-sided coronary system does even value more than left sided branches. In the case of less than 80% stenosis we do consider the possibility of coronaro-coronary bypassing. Technically, our current anastomosing method may not be optimal to SVG requierments, and there is room to enhance our technical performance. We have chance to work with a pressurized system that keep functionally opened our coronary micro-anastomoses and working with the blood that coagulates to seal our anastomoses. Urologistes do perform better, creating anatomically patent anastomoses as residual pressures causes hydronephrosis and creating anastomoses being per see sealed as urine does not coagulate. Regards
Congratulations for the statistically very much reassuring presentation. If one may take the liberty to come up some notes based on basic research with regard the patency of the IMA grafts. 1. This unique artery produces an exeptionally large amount of endothelium derived NITRIC OXIDE (NO) – Furchgott, Ignarro,Murrad :Nobel prize 1998 . Nitric oxide IS A POTENT VASODILATOR and an inhibitor of platelet aggregation and adhesion. This effect certainly has its effect on the recipient coronary artery by slowing down atherosclerotic process – as its degradant, nitrate easily can be measured in the venous side of the recipient coronary artey (Annals of Thoracic Surg, 2001,Tarr) 2. As mentioned above lesion percentage is to be determined preop. by FFR measurement, which is a basic data for indication of bypass surgery. 3. In coronary stenosis higher than 80 % competitive flow simply does not exist in case of in situ IMA grafting – as CALAFIORE demonstrated, that flow of the IMA grafts happens during DIASTOLE. Sincerely, F.I. TARR
Congratulations Joseph is a very good information but I think if it is posible to consider not put in any risk the left internal mammary to the Lad with any connection one option is to use the rigth mammary as inflow with a vein non touch and the rest of the rigth mammary to créate the others by passes
I congratulate Dr Sabik for providing us the data for the use of bilateral internal mammary artery grafting for coronary revascularization. But I, to some extent, disagree to the use bilateral IMA’s in all patient population. Insulin dependent diabetes is not a contraindication to use bilateral IMA’s. I use skeletonized technique in harvesting the conduits to minimize the chest wall injuries . Although I was trained in the ‘West’ for considerable amount of time before returning to Calcutta, India, where I currently practice cardiac surgery, we see here not only very diffuse coronary artery disease but also the coronaries are smaller than Western population and as a result of this, the target vessels are of poor quality. To my view, total arterial revascularization or the use of bilateral IMA’s in all patient populations may not improve the long term outcome. However, if the target vessels are of good quality and the proximal stenosis are greater than 70% in all target arteries, I use bilateral pedicle IMA’s to left coronary system and for a third conduit I use Radial artery or a vein graft depending on the percentage of stenosis- if greater than 80 % radial may be an ideal conduit. In some suitable younger populations with good LV function and smaller LV dimension, I use LIMA-RIMA [Y]. In situations where I decide to use pedicled IMA’s, I use LIMA to LAD and RIMA to RCA or proximal part of PDA [skeletonizing RIMA or LIMA adds to length], or RIMA to LAD and LIMA-to marginal branches of CX, and for the third conduit, I use radial artery or vein.
A terrific analysis and summary by Dr. Sabik of the wealth of data at the clinic to guide our decision making for the benefit of our patients.

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