Cabg with lima rima

CABG with LIMA RIMA

CABG• Performed for patients with coronary artery disease (CAD) to improve

quality of life and reduce cardiac-related mortality.

IndicationsClass I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows[1, 2] : • Left main coronary artery stenosis >50%• Stenosis of proximal LAD and proximal circumflex >70%• 3-vessel disease in asymptomatic patients or those with mild or stable

angina• 3-vessel disease with proximal LAD stenosis in patients with poor left

ventricular (LV) function• 1- or 2-vessel disease and a large area of viable myocardium in high-risk

area in patients with stable angina• >70% proximal LAD stenosis with either ejection fraction < 50% or

demonstrable ischemia on noninvasive testing

Sites of conduit harvesting

• Saphenous vein• Radial artery• Left internal thoracic (mammary) artery (LITA)• Right internal thoracic (mammary) artery

(RITA)• Right gastroepiploic artery• Inferior epigastric artery• Splenic artery

Ref: http://emedicine.medscape.com/article/1893992-overview

Consequence of conduitSaphenous vein grafts• Declining patency with time• At 10 years after surgery, only 50-60% of saphenous vein

grafts are patent, and only half of these are free of angiographic atherosclerosis

Internal Thoracic Artery grafts• Exhibit stable patency over time• At 10 years, more than 90% of internal thoracic artery grafts

are patent

For single coronary artery block• LIMA(left internal mammary artery): gold-standard

in conventional CABG

For multi-vessel disease• Either LIMA with saphenous vein grafts(SVG)• Or LIMA with additional arterial conduits:

• RIMA• Radial artery• Right gastro-epiploic artery

Total Arterial Grafting(TAG)

Definition• TAG was defined as the use of any arterial

conduit (LIMA, RIMA, RA or GEPA), either alone or in combination, without concomitant use of SVG

Légaré JF1, Hassan A, Buth KJ, Sullivan JA. The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting. J Cardiothorac Surg. 2007 Oct 23;2:44.

LIMA Pedicled + RIMA skeletonized in situ

LIMA + RIMA skeletonized in situ

LIMA in situ + RIMA (Y grafted)

Types of TAG

Why is TAG not popular?

• Perceived ‘lack of evidence’ in their favour• Increased sternal morbidity• Increased operative time• Reluctance to perform it in elderly as they

would not be conferred the survival benefits as in younger patients

Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

The burning question:Is it really better than conventional CABG?

The Evidence

Studies comparing BIMA with SIMA

More evidence…

Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

Sternal wound infection

Increase in Sternal wound dehiscence in BIMA group but mortality unchanged at 1 yr as compared to SIMA

Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

Conclusions

• Using TAG & BIMA is time consuming & technically difficult

• But it is justified by the Increased long term survival ratesLess incidence of MACCEOverall improved patient outcomes

Thank You