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David P Taggart - One of the best experts on this subject based on the ideXlab platform.
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disagreement between randomized and observational evidence on the use of bilateral internal Thoracic Artery grafting a meta analytic approach
Journal of the American Heart Association, 2019Co-Authors: Mario Gaudino, Marcus Flather, David P Taggart, Mohamed Rahouma, Irbaz Hameed, Faiza M Khan, Giuseppe Biondizoccai, Stephen E FremesAbstract:Background The ART (Arterial Revascularization Trial) showed no difference in survival at 10 years between patients assigned to the single versus bilateral internal Thoracic Artery grafting strateg...
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incidence and clinical implications of intraoperative bilateral internal Thoracic Artery graft conversion insights from the arterial revascularization trial
The Journal of Thoracic and Cardiovascular Surgery, 2018Co-Authors: Umberto Benedetto, D G Altman, B Lees, Stephen Gerry, Marcus Flather, Alastair Gray, David P TaggartAbstract:Abstract Background The Arterial Revascularization Trial has been designed to answer the question whether the use of bilateral internal Thoracic arteries can improve 10-year outcomes when compared with single internal Thoracic arteries. In the Arterial Revascularization Trial, a significant proportion of patients initially allocated to bilateral internal Thoracic arteries received other conduit strategies. We sought to investigate the incidence and clinical implication of bilateral internal Thoracic Artery graft conversion in the Arterial Revascularization Trial. Methods Among patients enrolled in the Arterial Revascularization Trial (n = 3102), we excluded those allocated to single internal Thoracic arteries (n = 1554), those who did not undergo surgery (n = 16), and those who underwent operation but withdrew after randomization (n = 7). Propensity score matching was used to compare converted versus nonconverted bilateral internal Thoracic Artery groups. Results A total of 1525 patients were operated with the intention to receive bilateral internal Thoracic Artery grafting. Of those, 233 (15.3%) were converted to other conduit selection strategies. Incidence of conversion largely varied across 131 participating surgeons (from 0% to 100%). The most common reason for bilateral internal Thoracic Artery graft conversion was the evidence of at least 1 internal Thoracic Artery that was not suitable, which was reported in 77 cases. Patients with intraoperative bilateral internal Thoracic Artery graft conversion received a lower number of grafts (2.95 ± 0.84 vs 3.21 ± 0.74; P P = .1), as well as the incidence of major complications. At 5 years, we found a nonsignificant excess of deaths (11.9% vs 8.4%; P = .1) and major adverse events (17.1% 13.2%; P = .1) mainly driven by an excess of revascularization in patients requiring conversion. Conclusions The incidence of intraoperative bilateral internal Thoracic Artery graft conversion is not infrequent. Bilateral internal Thoracic Artery graft conversion is not associated with increased operative morbidity, but its effect on late outcomes remains uncertain.
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unmeasured confounders in observational studies comparing bilateral versus single internal Thoracic Artery for coronary Artery bypass grafting a meta analysis
Journal of the American Heart Association, 2018Co-Authors: Mario Gaudino, Antonino Di Franco, Mohamed Rahouma, Derrick Y Tam, Mario Iannaccone, Saswata Deb, Fabrizio Dascenzo, Ahmed Abouarab, Leonard N Girardi, David P TaggartAbstract:Background Observational studies suggest a survival advantage with bilateral single internal Thoracic Artery (BITA) versus single internal Thoracic Artery grafting for coronary surgery, whereas this conclusion is not supported by randomized trials. We hypothesized that this inconsistency is attributed to unmeasured confounders intrinsic to observational studies. To test our hypothesis, we performed a meta‐analysis of the observational literature comparing BITA and single internal Thoracic Artery, deriving incident rate ratio for mortality at end of follow‐up and at 1 year. We postulated that BITA would not affect 1‐year survival based on the natural history of coronary Artery bypass occlusion, so that a difference between groups at 1 year could not be attributed to the intervention. Methods and Results We searched MEDLINE and Pubmed to identify all observational studies comparing the outcome of BITA versus single internal Thoracic Artery. One‐year and long‐term mortality for BITA and single internal Thoracic Artery were compared in the propensity‐score–matched (PSM) series, that is, the form of observational evidence less prone to confounders. Thirty‐eight observational studies (174 205 total patients) were selected for final comparison. In the 12 propensity‐score–matched series (34 019 patients), the mortality reduction for BITA was similar at 1 year and at the end of follow‐up (incident rate ratio, 0.70; 95% confidence interval, 0.60–0.82 versus 0.77; 95% confidence interval, 0.70–0.85; P for subgroup difference=0.43). Conclusions Unmeasured confounders, rather than biological superiority, may explain the survival advantage of BITA in observational series.
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randomized trial of bilateral versus single internal Thoracic Artery grafts
The New England Journal of Medicine, 2016Co-Authors: David P Taggart, D G Altman, B Lees, Stephen Gerry, Umberto Benedetto, Alastair Gray, Marcus FlatherAbstract:BackgroundThe use of bilateral internal Thoracic (mammary) arteries for coronary-Artery bypass grafting (CABG) may improve long-term outcomes as compared with the use of a single internal-Thoracic-Artery plus vein grafts. MethodsWe randomly assigned patients scheduled for CABG to undergo single or bilateral internal-Thoracic-Artery grafting in 28 cardiac surgical centers in seven countries. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. Interim analyses were prespecified at 5 years of follow-up. ResultsA total of 3102 patients were enrolled; 1554 were randomly assigned to undergo single internal-Thoracic-Artery grafting (the single-graft group) and 1548 to undergo bilateral internal-Thoracic-Artery grafting (the bilateral-graft group). At 5 years of follow-up, the rate of death was 8.7% in the bilateral-graft group and 8.4% in the single-graft group (hazard ratio, 1.04; 95% confidence interval [CI],...
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pedicled and skeletonized single and bilateral internal Thoracic Artery grafts and the incidence of sternal wound complications insights from the arterial revascularization trial
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, D G Altman, B Lees, Stephen Gerry, Marcus Flather, Rafal Pawlaczyk, Alastair Gray, David P TaggartAbstract:Abstract Objectives The question of whether skeletonized internal Thoracic Artery harvesting reduces the incidence of sternal wound complications in comparison with the pedicled technique, in the context of single or bilateral internal Thoracic arteries, remains controversial. We studied the impact of the internal Thoracic Artery harvesting strategy on sternal wound complication in the Arterial Revascularization Trial. Methods Patients enrolled in the Arterial Revascularization Trial (n = 3102) were randomized to coronary Artery bypass grafting with single or bilateral internal Thoracic arteries. Sternal wound complication rates were examined according to the harvesting technique that was documented in 2056 patients. The internal Thoracic Artery harvesting technique, based on the surgeon's preference, resulted in 4 groups: pedicled single internal Thoracic Artery (n = 607), pedicled bilateral internal Thoracic Artery (n = 459), skeletonized single internal Thoracic Artery (n = 512), and skeletonized bilateral internal Thoracic Artery (n = 478). Propensity scores weighting was used to estimate the impact of the harvesting technique on sternal wound complications. Results A total of 219 of 2056 patients (10.6%) experienced a sternal wound complication within 1 year from the index operation. Of those, only 25 patients (1.2%) required sternal wound reconstruction. Pedicled bilateral internal Thoracic Artery (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.23-2.63) but not skeletonized bilateral internal Thoracic Artery (OR, 1.00; 95% CI, 0.65-1.53) or skeletonized single internal Thoracic Artery (OR, 0.89; 95% CI, 0.57-1.38) was associated with a significantly increased risk of any sternal wound complications compared with pedicled single internal Thoracic Artery. Conclusions The present Arterial Revascularization Trial substudy suggests that, with a skeletonization technique, the risk of sternal wound complication with bilateral internal Thoracic Artery grafting is similar to that after standard pedicled single internal Thoracic Artery harvesting, whereas skeletonized single internal Thoracic Artery harvesting did not add any further benefit when compared with pedicled single internal Thoracic Artery harvesting.
Marcus Flather - One of the best experts on this subject based on the ideXlab platform.
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disagreement between randomized and observational evidence on the use of bilateral internal Thoracic Artery grafting a meta analytic approach
Journal of the American Heart Association, 2019Co-Authors: Mario Gaudino, Marcus Flather, David P Taggart, Mohamed Rahouma, Irbaz Hameed, Faiza M Khan, Giuseppe Biondizoccai, Stephen E FremesAbstract:Background The ART (Arterial Revascularization Trial) showed no difference in survival at 10 years between patients assigned to the single versus bilateral internal Thoracic Artery grafting strateg...
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incidence and clinical implications of intraoperative bilateral internal Thoracic Artery graft conversion insights from the arterial revascularization trial
The Journal of Thoracic and Cardiovascular Surgery, 2018Co-Authors: Umberto Benedetto, D G Altman, B Lees, Stephen Gerry, Marcus Flather, Alastair Gray, David P TaggartAbstract:Abstract Background The Arterial Revascularization Trial has been designed to answer the question whether the use of bilateral internal Thoracic arteries can improve 10-year outcomes when compared with single internal Thoracic arteries. In the Arterial Revascularization Trial, a significant proportion of patients initially allocated to bilateral internal Thoracic arteries received other conduit strategies. We sought to investigate the incidence and clinical implication of bilateral internal Thoracic Artery graft conversion in the Arterial Revascularization Trial. Methods Among patients enrolled in the Arterial Revascularization Trial (n = 3102), we excluded those allocated to single internal Thoracic arteries (n = 1554), those who did not undergo surgery (n = 16), and those who underwent operation but withdrew after randomization (n = 7). Propensity score matching was used to compare converted versus nonconverted bilateral internal Thoracic Artery groups. Results A total of 1525 patients were operated with the intention to receive bilateral internal Thoracic Artery grafting. Of those, 233 (15.3%) were converted to other conduit selection strategies. Incidence of conversion largely varied across 131 participating surgeons (from 0% to 100%). The most common reason for bilateral internal Thoracic Artery graft conversion was the evidence of at least 1 internal Thoracic Artery that was not suitable, which was reported in 77 cases. Patients with intraoperative bilateral internal Thoracic Artery graft conversion received a lower number of grafts (2.95 ± 0.84 vs 3.21 ± 0.74; P P = .1), as well as the incidence of major complications. At 5 years, we found a nonsignificant excess of deaths (11.9% vs 8.4%; P = .1) and major adverse events (17.1% 13.2%; P = .1) mainly driven by an excess of revascularization in patients requiring conversion. Conclusions The incidence of intraoperative bilateral internal Thoracic Artery graft conversion is not infrequent. Bilateral internal Thoracic Artery graft conversion is not associated with increased operative morbidity, but its effect on late outcomes remains uncertain.
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randomized trial of bilateral versus single internal Thoracic Artery grafts
The New England Journal of Medicine, 2016Co-Authors: David P Taggart, D G Altman, B Lees, Stephen Gerry, Umberto Benedetto, Alastair Gray, Marcus FlatherAbstract:BackgroundThe use of bilateral internal Thoracic (mammary) arteries for coronary-Artery bypass grafting (CABG) may improve long-term outcomes as compared with the use of a single internal-Thoracic-Artery plus vein grafts. MethodsWe randomly assigned patients scheduled for CABG to undergo single or bilateral internal-Thoracic-Artery grafting in 28 cardiac surgical centers in seven countries. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. Interim analyses were prespecified at 5 years of follow-up. ResultsA total of 3102 patients were enrolled; 1554 were randomly assigned to undergo single internal-Thoracic-Artery grafting (the single-graft group) and 1548 to undergo bilateral internal-Thoracic-Artery grafting (the bilateral-graft group). At 5 years of follow-up, the rate of death was 8.7% in the bilateral-graft group and 8.4% in the single-graft group (hazard ratio, 1.04; 95% confidence interval [CI],...
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pedicled and skeletonized single and bilateral internal Thoracic Artery grafts and the incidence of sternal wound complications insights from the arterial revascularization trial
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, D G Altman, B Lees, Stephen Gerry, Marcus Flather, Rafal Pawlaczyk, Alastair Gray, David P TaggartAbstract:Abstract Objectives The question of whether skeletonized internal Thoracic Artery harvesting reduces the incidence of sternal wound complications in comparison with the pedicled technique, in the context of single or bilateral internal Thoracic arteries, remains controversial. We studied the impact of the internal Thoracic Artery harvesting strategy on sternal wound complication in the Arterial Revascularization Trial. Methods Patients enrolled in the Arterial Revascularization Trial (n = 3102) were randomized to coronary Artery bypass grafting with single or bilateral internal Thoracic arteries. Sternal wound complication rates were examined according to the harvesting technique that was documented in 2056 patients. The internal Thoracic Artery harvesting technique, based on the surgeon's preference, resulted in 4 groups: pedicled single internal Thoracic Artery (n = 607), pedicled bilateral internal Thoracic Artery (n = 459), skeletonized single internal Thoracic Artery (n = 512), and skeletonized bilateral internal Thoracic Artery (n = 478). Propensity scores weighting was used to estimate the impact of the harvesting technique on sternal wound complications. Results A total of 219 of 2056 patients (10.6%) experienced a sternal wound complication within 1 year from the index operation. Of those, only 25 patients (1.2%) required sternal wound reconstruction. Pedicled bilateral internal Thoracic Artery (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.23-2.63) but not skeletonized bilateral internal Thoracic Artery (OR, 1.00; 95% CI, 0.65-1.53) or skeletonized single internal Thoracic Artery (OR, 0.89; 95% CI, 0.57-1.38) was associated with a significantly increased risk of any sternal wound complications compared with pedicled single internal Thoracic Artery. Conclusions The present Arterial Revascularization Trial substudy suggests that, with a skeletonization technique, the risk of sternal wound complication with bilateral internal Thoracic Artery grafting is similar to that after standard pedicled single internal Thoracic Artery harvesting, whereas skeletonized single internal Thoracic Artery harvesting did not add any further benefit when compared with pedicled single internal Thoracic Artery harvesting.
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the effect of internal Thoracic Artery grafts on long term clinical outcomes after coronary bypass surgery
The Journal of Thoracic and Cardiovascular Surgery, 2011Co-Authors: Mark A Hlatky, Marcus Flather, David Shilane, Derek B Boothroyd, Eric Boersma, Maria M Brooks, Didier Carrie, Tim Clayton, N Danchin, Christian W HammAbstract:Objectives We sought to compare long-term outcomes after coronary bypass surgery with and without an internal Thoracic Artery graft. Methods We analyzed clinical outcomes over a median follow-up of 6.7 years among 3,087 patients who received coronary bypass surgery as participants in one of 8 clinical trials comparing surgical intervention with angioplasty. We used 2 statistical methods (covariate adjustment and propensity score matching) to adjust for the nonrandomized selection of internal Thoracic Artery grafts. Results Internal Thoracic Artery grafting was associated with lower mortality, with hazard ratios of 0.77 (confidence interval, 0.62–0.97; P = .02) for covariate adjustment and 0.77 (confidence interval, 0.57–1.05; P = .10) for propensity score matching. The composite end point of death or myocardial infarction was reduced to a similar extent, with hazard ratios of 0.83 (confidence interval, 0.69–1.00; P = .05) for covariate adjustment to 0.78 (confidence interval, 0.61–1.00; P = .05) for propensity score matching. There was a trend toward less angina at 1 year, with odds ratios of 0.81 (confidence interval, 0.61–1.09; P = .16) in the covariate-adjusted model and 0.81 (confidence interval, 0.55–1.19; P = .28) in the propensity score–adjusted model. Conclusions Use of an internal Thoracic Artery graft during coronary bypass surgery seems to improve long-term clinical outcomes.
Eugene H. Blackstone - One of the best experts on this subject based on the ideXlab platform.
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similar outcomes in diabetes patients after coronary Artery bypass grafting with single internal Thoracic Artery plus radial Artery grafting and bilateral internal Thoracic Artery grafting
The Annals of Thoracic Surgery, 2017Co-Authors: Sajjad Raza, Penny L Houghtaling, Eugene H. Blackstone, Marijan Koprivanac, Kirthi Ravichandren, Hoda Javadikasgari, Faisal G Bakaeen, Lars G Svensson, Joseph F. SabikAbstract:Background The purpose of this study was to determine in patients with diabetes mellitus whether single internal Thoracic Artery (SITA) plus radial Artery (RA) grafting yields outcomes similar to those of bilateral internal Thoracic Artery (BITA) grafting. Methods From January 1994 to January 2011, 1,325 diabetic patients underwent primary isolated coronary Artery bypass graft surgery with either (1) SITA plus RA with or without saphenous vein (SV) grafts (n = 965) or (2) BITA with or without SV grafts (n = 360); an internal Thoracic Artery was used in all patients to graft the left anterior descending coronary Artery. Endpoints were in-hospital outcomes and time-related mortality. Median follow-up was 7.4 years, with a total follow-up of 9,162 patient-years. Propensity score matching was performed to identify 282 well-matched pairs for adjusted comparisons. Results Unadjusted in-hospital mortality was 0.52% for SITA plus RA with or without SV grafts and 0.28% for BITA with or without SV grafts, and prevalence of deep sternal wound infection was 3.2% and 1.7%, respectively. Unadjusted survival at 1, 5, 10, and 14 years was 97%, 88%, 68%, and 51% for SITA plus RA with or without SV grafts, and 97%, 95%, 80%, and 66% for BITA with or without SV grafts, respectively. Among propensity-matched patients, in-hospital mortality (0.35% versus 0.35%) and prevalence of deep sternal wound infection (1.4% versus 1.4%) were similar ( p > 0 . 9) in the two groups, as was 1-, 5-, 10-, and 14-year survival: 97%, 90%, 70%, and 58% for SITA plus RA with or without SV grafting versus 97%, 93%, 79%, and 64% for BITA with or without SV grafting, respectively (early p = 0.8, late p = 0.2). Conclusions For diabetic patients, SITA plus RA with or without SV grafting and BITA with or without SV grafting yield similar in-hospital outcomes and long-term survival after coronary Artery bypass graft surgery. Therefore, both SITA plus RA and BITA plus SV grafting should be considered for these patients.
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decision making for patients with patent left internal Thoracic Artery grafts to left anterior descending
The Annals of Thoracic Surgery, 2009Co-Authors: Sreekumar Subramanian, Joseph F. Sabik, Penny L Houghtaling, Edward R Nowicki, Eugene H. BlackstoneAbstract:Background It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal Thoracic Artery graft to the left anterior descending coronary Artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary Artery bypass grafting in such patients who developed non-LAD territory jeopardy. Methods From 1971 to 2000, 4,640 patients with prior coronary Artery bypass grafting that included left internal Thoracic Artery to LAD grafting were found on angiography during active follow-up to have a patent left internal Thoracic Artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary Artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary Artery bypass grafting or percutaneous intervention. Results In the intent-to-treat analysis, propensity-adjusted early ( p ≤ 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups. Conclusions Patients with patent left internal Thoracic Artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal Thoracic Artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.
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comparison of saphenous vein and internal Thoracic Artery graft patency by coronary system
The Annals of Thoracic Surgery, 2005Co-Authors: Joseph F. Sabik, Eugene H. Blackstone, Penny L HoughtalingAbstract:Background We sought to compare saphenous vein and internal Thoracic Artery graft patency by coronary system. Methods From 1972 to 1999, 50,278 patients underwent primary coronary surgery; subsequently, 4,333 had angiography of 2,121 internal Thoracic Artery and 8,733 saphenous vein grafts. Longitudinal analysis was used to model graft occlusion and identify risk factors. Using the model, patency was calculated twice for each graft and compared first as if an internal Thoracic Artery, and second as if a saphenous vein, were used. Results Unadjusted 1-, 5-, and 10-year patency was 93%, 88%, and 90% for internal Thoracic arteries and 78%, 65%, and 57% for saphenous veins. At 10 years, internal Thoracic arteries were more likely than saphenous veins to be patent to left anterior descending in 99.1% of cases, to diagonals in 98.3%, to circumflex in 98.3%, to posterior descending Artery in 98.5%, and to right coronary arteries in 82.5%. For right coronary arteries, saphenous vein patency was equivalent to or better than internal Thoracic Artery patency early after surgery. However, by 10 years, internal Thoracic Artery patency was better in right coronary arteries with 70% stenosis or greater. At all times after surgery and all levels of clinically important coronary stenosis, internal Thoracic Artery patency surpassed saphenous vein patency in grafts to the left anterior descending, diagonal, circumflex, and posterior descending arteries. Conclusions Internal Thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed right coronary arteries. When bypassing right coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.
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the effect of bilateral internal Thoracic Artery grafting on survival during 20 postoperative years
The Annals of Thoracic Surgery, 2004Co-Authors: Eugene H. Blackstone, Joseph F. Sabik, Penny L Houghtaling, Floyd D. LoopAbstract:Background To compare survival of patients receiving bilateral internal Thoracic Artery grafts and single internal Thoracic Artery grafts more than 20 postoperative years, assess magnitude of benefit, and identify predictors of benefit. Methods From cohorts of 8123 patients receiving single internal Thoracic Artery grafts and 2001 receiving bilateral internal Thoracic Artery grafts during primary isolated bypass operations for multivessel coronary disease between 1971 and 1989, we identified 1152 propensity-matched pairs. Mean follow-up of survivors was 16.5 years, with 51 patients followed for 20 years or more. Hazard function methodology was used to identify risk factors for mortality, compare survival, and assess magnitude of benefit. Results Comparison of the matched pairs showed survival of the bilateral internal Thoracic Artery and single internal Thoracic Artery groups at 7, 10, 15, and 20 years was 89% versus 87%, 81% versus 78%, 67% versus 58%, and 50% versus 37%, respectively ( p Conclusions Bilateral internal Thoracic Artery grafting produces improved survival compared with single internal Thoracic Artery grafting during the second postoperative decade, and the magnitude of that benefit increases through 20 postoperative years.
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does competitive flow reduce internal Thoracic Artery graft patency
The Annals of Thoracic Surgery, 2003Co-Authors: Joseph F. Sabik, Penny L Houghtaling, Eugene H. Blackstone, Bruce W Lytle, Mohammad K Khan, Delos M CosgroveAbstract:Abstract Background In coronary arteries with moderate stenosis, competitive flow may lead to internal Thoracic Artery (ITA) graft occlusion. The goals of this study were to determine if competitive flow reduces ITA patency, and if there is a degree of coronary stenosis below which ITAs should not be used. Methods From 1972 to 1999, 50,278 patients underwent primary coronary Artery bypass grafting (CABG). Of these, 2,002 had at least one ITA graft and postoperative angiography before coronary reintervention; 2,999 angiograms of 2,121 ITAs were made. Time-related ITA occlusion was modeled using longitudinal analysis to identify its risk factors while accounting for lack of independence introduced by repeated angiography and multiple ITA anastomoses per patient. Proximal coronary stenosis (maximum preoperative stenosis between ITA anastomosis and aorta) was the surrogate for competitive flow. Results Unadjusted ITA patency was 93%, 89%, 90%, and 92% at 1, 5, 10, and 15 years after CABG. Risk factors associated with ITA occlusion were lesser degree of proximal coronary stenosis ( p p p = 0.0003); later date of CABG ( p = 0.01); right ITA ( p p Conclusions Internal Thoracic Artery patency decreases as coronary competitive flow increases. However, the nature of this relationship indicates ITAs should not be abandoned at moderate grades of stenosis.
Joseph F. Sabik - One of the best experts on this subject based on the ideXlab platform.
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similar outcomes in diabetes patients after coronary Artery bypass grafting with single internal Thoracic Artery plus radial Artery grafting and bilateral internal Thoracic Artery grafting
The Annals of Thoracic Surgery, 2017Co-Authors: Sajjad Raza, Penny L Houghtaling, Eugene H. Blackstone, Marijan Koprivanac, Kirthi Ravichandren, Hoda Javadikasgari, Faisal G Bakaeen, Lars G Svensson, Joseph F. SabikAbstract:Background The purpose of this study was to determine in patients with diabetes mellitus whether single internal Thoracic Artery (SITA) plus radial Artery (RA) grafting yields outcomes similar to those of bilateral internal Thoracic Artery (BITA) grafting. Methods From January 1994 to January 2011, 1,325 diabetic patients underwent primary isolated coronary Artery bypass graft surgery with either (1) SITA plus RA with or without saphenous vein (SV) grafts (n = 965) or (2) BITA with or without SV grafts (n = 360); an internal Thoracic Artery was used in all patients to graft the left anterior descending coronary Artery. Endpoints were in-hospital outcomes and time-related mortality. Median follow-up was 7.4 years, with a total follow-up of 9,162 patient-years. Propensity score matching was performed to identify 282 well-matched pairs for adjusted comparisons. Results Unadjusted in-hospital mortality was 0.52% for SITA plus RA with or without SV grafts and 0.28% for BITA with or without SV grafts, and prevalence of deep sternal wound infection was 3.2% and 1.7%, respectively. Unadjusted survival at 1, 5, 10, and 14 years was 97%, 88%, 68%, and 51% for SITA plus RA with or without SV grafts, and 97%, 95%, 80%, and 66% for BITA with or without SV grafts, respectively. Among propensity-matched patients, in-hospital mortality (0.35% versus 0.35%) and prevalence of deep sternal wound infection (1.4% versus 1.4%) were similar ( p > 0 . 9) in the two groups, as was 1-, 5-, 10-, and 14-year survival: 97%, 90%, 70%, and 58% for SITA plus RA with or without SV grafting versus 97%, 93%, 79%, and 64% for BITA with or without SV grafting, respectively (early p = 0.8, late p = 0.2). Conclusions For diabetic patients, SITA plus RA with or without SV grafting and BITA with or without SV grafting yield similar in-hospital outcomes and long-term survival after coronary Artery bypass graft surgery. Therefore, both SITA plus RA and BITA plus SV grafting should be considered for these patients.
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decision making for patients with patent left internal Thoracic Artery grafts to left anterior descending
The Annals of Thoracic Surgery, 2009Co-Authors: Sreekumar Subramanian, Joseph F. Sabik, Penny L Houghtaling, Edward R Nowicki, Eugene H. BlackstoneAbstract:Background It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal Thoracic Artery graft to the left anterior descending coronary Artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary Artery bypass grafting in such patients who developed non-LAD territory jeopardy. Methods From 1971 to 2000, 4,640 patients with prior coronary Artery bypass grafting that included left internal Thoracic Artery to LAD grafting were found on angiography during active follow-up to have a patent left internal Thoracic Artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary Artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary Artery bypass grafting or percutaneous intervention. Results In the intent-to-treat analysis, propensity-adjusted early ( p ≤ 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups. Conclusions Patients with patent left internal Thoracic Artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal Thoracic Artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.
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comparison of saphenous vein and internal Thoracic Artery graft patency by coronary system
The Annals of Thoracic Surgery, 2005Co-Authors: Joseph F. Sabik, Eugene H. Blackstone, Penny L HoughtalingAbstract:Background We sought to compare saphenous vein and internal Thoracic Artery graft patency by coronary system. Methods From 1972 to 1999, 50,278 patients underwent primary coronary surgery; subsequently, 4,333 had angiography of 2,121 internal Thoracic Artery and 8,733 saphenous vein grafts. Longitudinal analysis was used to model graft occlusion and identify risk factors. Using the model, patency was calculated twice for each graft and compared first as if an internal Thoracic Artery, and second as if a saphenous vein, were used. Results Unadjusted 1-, 5-, and 10-year patency was 93%, 88%, and 90% for internal Thoracic arteries and 78%, 65%, and 57% for saphenous veins. At 10 years, internal Thoracic arteries were more likely than saphenous veins to be patent to left anterior descending in 99.1% of cases, to diagonals in 98.3%, to circumflex in 98.3%, to posterior descending Artery in 98.5%, and to right coronary arteries in 82.5%. For right coronary arteries, saphenous vein patency was equivalent to or better than internal Thoracic Artery patency early after surgery. However, by 10 years, internal Thoracic Artery patency was better in right coronary arteries with 70% stenosis or greater. At all times after surgery and all levels of clinically important coronary stenosis, internal Thoracic Artery patency surpassed saphenous vein patency in grafts to the left anterior descending, diagonal, circumflex, and posterior descending arteries. Conclusions Internal Thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed right coronary arteries. When bypassing right coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.
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the effect of bilateral internal Thoracic Artery grafting on survival during 20 postoperative years
The Annals of Thoracic Surgery, 2004Co-Authors: Eugene H. Blackstone, Joseph F. Sabik, Penny L Houghtaling, Floyd D. LoopAbstract:Background To compare survival of patients receiving bilateral internal Thoracic Artery grafts and single internal Thoracic Artery grafts more than 20 postoperative years, assess magnitude of benefit, and identify predictors of benefit. Methods From cohorts of 8123 patients receiving single internal Thoracic Artery grafts and 2001 receiving bilateral internal Thoracic Artery grafts during primary isolated bypass operations for multivessel coronary disease between 1971 and 1989, we identified 1152 propensity-matched pairs. Mean follow-up of survivors was 16.5 years, with 51 patients followed for 20 years or more. Hazard function methodology was used to identify risk factors for mortality, compare survival, and assess magnitude of benefit. Results Comparison of the matched pairs showed survival of the bilateral internal Thoracic Artery and single internal Thoracic Artery groups at 7, 10, 15, and 20 years was 89% versus 87%, 81% versus 78%, 67% versus 58%, and 50% versus 37%, respectively ( p Conclusions Bilateral internal Thoracic Artery grafting produces improved survival compared with single internal Thoracic Artery grafting during the second postoperative decade, and the magnitude of that benefit increases through 20 postoperative years.
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does competitive flow reduce internal Thoracic Artery graft patency
The Annals of Thoracic Surgery, 2003Co-Authors: Joseph F. Sabik, Penny L Houghtaling, Eugene H. Blackstone, Bruce W Lytle, Mohammad K Khan, Delos M CosgroveAbstract:Abstract Background In coronary arteries with moderate stenosis, competitive flow may lead to internal Thoracic Artery (ITA) graft occlusion. The goals of this study were to determine if competitive flow reduces ITA patency, and if there is a degree of coronary stenosis below which ITAs should not be used. Methods From 1972 to 1999, 50,278 patients underwent primary coronary Artery bypass grafting (CABG). Of these, 2,002 had at least one ITA graft and postoperative angiography before coronary reintervention; 2,999 angiograms of 2,121 ITAs were made. Time-related ITA occlusion was modeled using longitudinal analysis to identify its risk factors while accounting for lack of independence introduced by repeated angiography and multiple ITA anastomoses per patient. Proximal coronary stenosis (maximum preoperative stenosis between ITA anastomosis and aorta) was the surrogate for competitive flow. Results Unadjusted ITA patency was 93%, 89%, 90%, and 92% at 1, 5, 10, and 15 years after CABG. Risk factors associated with ITA occlusion were lesser degree of proximal coronary stenosis ( p p p = 0.0003); later date of CABG ( p = 0.01); right ITA ( p p Conclusions Internal Thoracic Artery patency decreases as coronary competitive flow increases. However, the nature of this relationship indicates ITAs should not be abandoned at moderate grades of stenosis.
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the right internal Thoracic Artery is it underutilized
Current Opinion in Cardiology, 2011Co-Authors: James Tatoulis, Brian F Buxton, John A. FullerAbstract:Purpose of reviewThe left internal Thoracic Artery is acknowledged as the best coronary conduit. The right internal Thoracic Artery (RITA) is identical to the left ITA (LITA), yet, despite excellent published results, the RITA [as part of bilateral ITA (BITA) grafting] is rarely used in coronary art
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which arterial conduit radial Artery versus free right internal Thoracic Artery six year clinical results of a randomized controlled trial
The Annals of Thoracic Surgery, 2007Co-Authors: Philip A R Hayward, David L Hare, Ian Gordon, George Matalanis, Brian F BuxtonAbstract:Background To investigate the optimum revascularization conduit for coronary territories other than that of the left anterior descending Artery, long-term clinical outcomes after use of a radial Artery or right internal Thoracic Artery were evaluated as part of the Radial Artery Patency and Clinical Outcomes (RAPCO) study. Methods As part of a 10-year prospective randomized single-center trial, patients aged less than 70 years undergoing primary coronary surgery were randomly allocated to the use of the radial Artery (n = 198) or free right internal Thoracic Artery (n = 196) for grafting the largest target other than the left anterior descending Artery. Annual follow-up documented death, myocardial infarction, or revascularization as primary endpoints. Analysis was on an intention-to-treat basis. Results There were no significant differences in the preoperative status of the two groups including age, sex, diabetes mellitus, hypertension, and urgency of surgery. One hundred eighty-six of 198 patients in the radial Artery group and 179 of 196 patients in the right internal Thoracic Artery group received the intended conduit. Mean number of grafts was 3.1 ± 0.8 and 3.2 ± 0.9 in the radial Artery and the right internal Thoracic Artery groups, respectively. During surveillance of as long as 10.4 years (mean, 6.0), absolute survival and event-free survival were equivalent between groups, with 13 versus 18 deaths and 24 versus 37 events (death, myocardial infarction, or revascularization) in the radial Artery and the right internal Thoracic Artery groups, respectively (log rank: p = 0.36 for survival, p = 0.08 for event-free survival). Conclusions These two arterial conduits may yield equivalent clinical outcomes at 5 or more years. That finding will be compared with mean 5-year angiographic patency when available. For now, equivalent clinical results offer surgeons flexibility in planning revascularization.
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has the in situ right internal Thoracic Artery been overlooked an angiographic study of the radial Artery internal Thoracic arteries and saphenous vein graft patencies in symptomatic patients
European Journal of Cardio-Thoracic Surgery, 2005Co-Authors: Pallav J Shah, John A. Fuller, David L Hare, Ian Gordon, Shane Blackmore, Siven Seevanayagam, Brian F BuxtonAbstract:Objective: The right internal Thoracic Artery is being used infrequently despite favorable observational angiographic data. Conversely, the radial Artery utilization has increased with only limited data available. The purpose of this paper is to re-evaluate the roles of the right internal Thoracic Artery and the radial Artery grafts. Methods: We reviewed all ischemia-directed coronary angiographic procedures from January 1996 to December 2003. A total of 219 patients had primary coronary Artery bypass grafting with an internal Thoracic Artery and a radial Artery as two of the bypass grafts. Six hundred and seventy-nine (679) graft angiograms (45 saphenous vein, 363 radial Artery, 54 right internal Thoracic Artery and 217 left internal Thoracic Artery) were studied. The mean period from operation to re-angiogram was 1104G761 days. Angiographic outcomes were divided into groups as: (1) patent (!50% stenosis) or (2) failed (R50% stenosis, string sign or occluded). A generalized linear mixed model was used to analyze predictors of graft patency. Turnbull’s estimates of cumulative patency were used to compare graft failure rates over time. Results: A total of 632/679 (93%) grafts were patent and 47/679 (7%) grafts had failed. Empirical saphenous vein graft patency was 40/45 (89%), radial Artery patency 329/363 (91%), right internal Thoracic Artery patency 51/54 (94%) and left internal Thoracic Artery patency 212/217 (98%). Pairwise comparisons of patency from the generalized linear mixed model were: LITAORITA, ORZ1.5 (PZ0.5); LITAO RA, ORZ5.7 (P!0.001); LITAOSV, ORZ6.5 (P!0.001); RITAORA, ORZ3.9 (PZ0.01); RITAOSV, ORZ4.4 (PZ0.01); RAOSV, ORZ1.1 (PZ0.7). Five-year patency estimates from the Turnbull’s model were the left internal Thoracic Artery (95.9%), right internal Thoracic Artery (91.2%), the radial Artery (90.6%) and the saphenous vein (81.8%). Conclusions: Consideration should be given to the routine use of both internal Thoracic arteries for coronary Artery bypass grafting. When additional grafts are required, there is no evidence to suggest that either the radial Artery or saphenous vein is superior. q 2005 Elsevier B.V. All rights reserved.
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results of 1 454 free right internal Thoracic Artery to coronary Artery grafts
The Annals of Thoracic Surgery, 1997Co-Authors: James Tatoulis, Brian F Buxton, John A. FullerAbstract:Background After beginning our use of bilateral internal Thoracic Artery grafts in 1985, we found the pedicled right internal Thoracic Artery grafts limiting, and expanded the application of the right internal Thoracic Artery by elective use as a free graft. We evaluated the results of patients having a free right internal Thoracic Artery (FRITA)-to-coronary Artery graft as part of their coronary revascularization. Methods From 1986 to 1995, 1,454 patients had a FRITA graft. Preoperative characteristics included mean age, 58.8 years (range 29 to 84 years); non–insulin-dependent diabetes, 116 (8%); insulin-dependent diabetes, 7 (0.5%); left ventricular ejection fraction from 0.30 to 0.40, 159 (11%); left ventricular ejection fraction less than 0.30 ± 14 (1%); and unstable angina, 144 (9.9%). In 11 patients the FRITA was the only graft, in 1,443 a left internal Thoracic graft was also used and revascularization completed with additional arterial and vein grafts. There were 3.3±1.1 distal anastomoses per patient, the aortic clamp time was 49±12 minutes, and bypass time was 69±16 minutes. The FRITA was used to reach the circumflex marginal arteries in 718 patients (49.5%), posterior descending Artery in 286 (19.7%), diagonal or intermediate in 172 (11.8%), left anterior descending Artery in 119 (8.1%), right coronary Artery in 115 (7.9%), and left ventricular branch of right coronary Artery in 44 (3%). The proximal anastomosis was directly on the aorta in 1,441, other arterial graft in 8, and vein graft in 5. Results Operative mortality was 13 patients (0.9%); stroke occurred in 14 patients (1%) and myocardial infarction in 19 (1.3%). The peak creatine kinase myocardial isoenzyme serum level was 20.6±13.6 IU/L. Complications included sternal infection in 18 patients (1.2%) and reoperation for hemorrhage in 23 (1.6%). Survival at 5 and 7 years, respectively, was 96% ± 2.1% and 94% ± 2.5%. In 71 patients with a FRITA studied at a mean of 41.5±14 months postoperatively for recurrent symptoms, 67 FRITA grafts were widely patent (94.5%), 3 displayed a string sign, and 1 was totally occluded. Conclusions Use of the right internal Thoracic Artery as a free graft is safe and effective and allows greater flexibility in arterial coronary revascularization.
