““Multiple Multiple Arterial Graft Arterial Graft

CABG”CABG”Where do we Where do we

stand?stand?

Mohammad ShihataMohammad Shihata

CABGCABG

• The most performed operation in the developed world.

• Enjoying a re-established role as a gold standard for severe CAD.

• The best treatment for LM and 3 vessel CAD.

Changing DemographicsChanging Demographics

• Aging population: > 20% over the age of 70 by 2030.

• CAD combined with other cardiac pathology (e.g. / Aortic stenosis ) will be more frequent.

• Treatment standards for the elderly need to be defined better.

LIMA to LAD + RSVGs is a very LIMA to LAD + RSVGs is a very good operationgood operation

but ....

can we make it better ?can we make it better ?

Why MAG?Why MAG?

Literature Literature ReviewReview

Probability of saphenous vein graft patency

Age GroupAge Group 5y5y 10y10y

50 - 5950 - 59 93%93% 78%78%

60 – 6960 – 69 92%92% 80%80%

70 – 7970 – 79 94%94% 76%76%

>80>80 80%80% 58%58%

University of Melbourne Database 1986 – 2007;University of Melbourne Database 1986 – 2007;18,588 CABG patients18,588 CABG patients

Buxton B, et al . 23rd EACTS , 2009

3000 patients. At 18 months the portion of occluded or severely diseased SVG was 47% and 38% for endoscopic and open harvesting respectively.

Over 3000 reports 1978 – 1999; 10 analyzed.Over 3000 reports 1978 – 1999; 10 analyzed.

Adjusted 12 y survivalAdjusted 12 y survival

1984 - 1987 ; 1087 patients

Composite Outcome:Composite Outcome:All cause death, non – fatal MI,All cause death, non – fatal MI, PCI, Redo CABGPCI, Redo CABG

Limitations to MAGLimitations to MAG

Patient Factors:• Obese Diabetics (BIMA)• Severe COPD (BIMA)• Immunosuppressants

Technical Factors:• Inadequate IMA or Radial (uncommon)• Large target with moderate stenosis

MAG still stubbornly low!!!MAG still stubbornly low!!!

In North America & UK

• 95% receive a single IMA• < 20% receive 2 arterial grafts (more radial

than BIMA)• STS Database < 5% receive BIMA• < 3% receive 3 arterial grafts.

142 consultant adult cardiac surgeons; 90 replies. 142 consultant adult cardiac surgeons; 90 replies.