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Skeletonized left internal thoracic artery is associated with lower rates of mediastinitis in diabetic patients
, Michel Pompeu Barros de Oliveira;Soares, Evelyn Figueira;Santos, Cecília Andrade;Figueiredo, Omar Jacobina;Lima, Renato Oliveira Albuquerque;Escobar, Rodrigo Renda;Rueda, Fábio Gon?alves de;Ferraz, Paulo Ernando;Lima, Ricardo Carvalho;
Revista Brasileira de Cirurgia Cardiovascular , 2011, DOI: 10.1590/S0102-76382011000200007
Abstract: background: mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. diabetes is a feared risk factor for mediastinitis and viewed with caution by cardiovascular surgeons. objective: to identify risk factors for mediastinitis in diabetics undergoing cabg surgery with use of unilateral ita in the division of cardiovascular surgery of pronto socorro cardiológico de pernambuco - procape. methods: retrospective study of 157 diabetics operated between may 2007 and april 2010. nine preoperative variables, five intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. univariate and multivariate logistic regression analyses were applied. results: the incidence of mediastinitis was 7% (n=11), with a lethality rate of 36.1% (n=4). variables associated with increased risk of mediastinitis were: use of pedicled ita (or 8.25, 95% ci 2.03 to 66.10, p=0.016), postoperative renal complications (or 5.10, 95% ci 1.03 to 25.62, p=0.049) and re-operation (or 7.45, 95% ci 1.24 to 42.17, p=0.023). in multivariate analysis using backward logistic regression, only one variable remained as independent risk factor: use of pedicled ita (or 7.64, 95% ci 1.95 to 61.6, p=0.048), in comparison to skeletonized ita. conclusions: we suggest that diabetics should be considered for strategies to minimize risk of infection. in diabetics that undergo unilateral ita, the problem seems to be related to how ita is harvested. diabetics should always be considered for use of skeletonized ita.
Risk factors for mediastinitis after coronary artery bypass grafting surgery
, Michel Pompeu Barros de Oliveira;Soares, Evelyn Figueira;Santos, Cecília Andrade;Figueiredo, Omar Jacobina;Lima, Renato Oliveira Albuquerque;Escobar, Rodrigo Renda;Rueda, Fábio Gon?alves de;Lima, Ricardo de Carvalho;
Revista Brasileira de Cirurgia Cardiovascular , 2011, DOI: 10.1590/S0102-76382011000100008
Abstract: objective: mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. the aim of this study is to identify risk factors for mediastinitis in patients undergoing coronary artery bypass grafting (cabg), without the use of bilateral internal thoracic artery (ita), at the division of cardiovascular surgery of pronto socorro cardiológico de pernambuco - procape. methods: a retrospective study of 500 consecutive patients operated on between may 2007 and april 2010. ten preoperative variables, seven intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. univariate and multivariate logistic regression analyses were performed. results: the incidence of mediastinitis was 5.6% (n=28), with a lethality rate of 32.1% (n=9). in multivariate analysis using logistic regression, five variables remained as independent risk factors: obesity (or 2.60, 95% ci 1.11 to 6.68), diabetes (or 2.71, 95% ci 1.18 to 6.65), smoking (or 2.10, 95% ci 1.12 to 4.67), use of pedicled internal thoracic artery (or 5.17, 95% ci 1.45 to 18.42) and on-pump cabg (or 2.26, 95% ci 1.14 to 5.85). conclusion: this study identified the following independent risk factors for mediastinitis after cabg: obesity, diabetes, smoking, use of pedicled ita and on-pump cabg.
Histologic examination of the clipped internal thoracic artery by transmission electron microscope in patients undergoing coronary artery bypass grafting  [PDF]
Cenap Ozkara
World Journal of Cardiovascular Diseases (WJCD) , 2012, DOI: 10.4236/wjcd.2012.23035
Abstract: Object?ves: As we known that the internal thoracic artery (ITA) has an excellent patency rate in coronary artery bypass grafting (CABG). However, early graft failure due to occlusion and spasm is still the major problem after coronary artery bypass surgery. We examined histopathologic findings of the clipped internal thoracic artery (ITA) in patients undergoing CABG using transmission electron microscope (TEM). Methods: To investigate the histopathololojic ITA examination, 60 patients were randomly selected. The ITA was harvested in a standart fashion with the use of low voltage electrocotery and its distal end was cut prior to bifurcation and clipped. Just before the ITA anastomosis 1 mm lenght of ITA ring was cut and saved in 2.5% Glutaraldehide solution for fixation and examination of transmission electron microscope (TEM). One blinded anatomopatholog examined all specimens and described the endothelial integrity according to the score system proposed by Fischlein et al. Results: In ten cases (17.5%) different degree of histopathologic findings (endothelial cells, intercellular and intracellular organels and adventitia) were recorded The most important histopatholojic findings of ITA were as follows: endothelial vacuolisation, intimal thickening and/or intimal seperation, suben-dothelial edema, swallowing of cytoplasma and mito-condria. Conclusion: Our results showed that the endothelial pathology is high when the ITA clipped. Unfortunataly, because our study did not include the non-clipped ITA we have not concluded the comparison or statistical results. In our opinion, for absolute definition of the effects of the clipping the ITA it should be planned the comparative results between the clipped and non-clipped ITA histologic examinations.
In situ pedicle graft and coronary-coronary bypass grafting using internal thoracic artery in management of multiple lesions of the left anterior descending coronary artery
Ne?i? Du?ko G.,Kne?evi? Aleksandar M.,?irkovi? Milan V.,Jovi? Miomir ?.
Medicinski Pregled , 2004, DOI: 10.2298/mpns0412601n
Abstract: Introduction Nowadays, coronary-coronary bypass grafting (CCBG) has been applied in patients with heavily calcified ascending aorta or due to lack of graft material. Case report We describe a case in which the patient's large left anterior descending (LAD) coronary artery, running well over the cardiac apex, presented with proximal and distal stenosis. Although the pedicled left internal thoracic artery (ITA) graft is sometimes too short for sequential bypass in cases of distal stenosis of the LAD coronary artery, we used a free, short segment of the pedicled left ITA for coronary-coronary bypass grafting. The in situ remnant of the left pedicled ITA was used to bypass the proximal LAD stenosis. The patient's postoperative course was uneventful. Predischarge angiogram (on the 9th postoperative day) showed an in situ left ITA graft as well as a free coronary-coronary ITA graft. The patient had a regular follow-up after 3 months, and was classified as New York Heart Association (NYHA) class I. Discussion Primarily used in aorto-coronary bypass surgery (termino-terminal interposition of the saphenous vein between two parts of a resected coronary artery), CCBG was revised latter on, and from hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed. CCBG might be an attractive approach for bypassing distal lesions of large coronary arteries (combined with arterial or venous grafting of targeted arteries, if proximal stenoses are also present). The proximal remnant of ITA can be used as an in situ or free graft.
Intrathoracic fire during preparation of the left internal thoracic artery for coronary artery bypass grafting
Martin Friedrich, Theodor Tirilomis, Jan D Schmitto, Aron F Popov, Suyog A Mokashi, Marc Hinterthaner, Gunnar G Hanekop, Paul Zwaka, Friedrich A Schoendube
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-10
Abstract: While surgical fires are rare, they can potentially result in significant morbidity and mortality [1-3]. A comprehensive literature search revealed only a limited number of intraoperative fires. The vast majority of cases involved endotracheal ventilation and the use of electrocautery or laser. Surgical fires are created with an igniting source (an oxidizer and fuel). Igniting agents include electrocautery or laser, which combine with either oxygen or nitrous oxide as the oxidizer. The fuel for the fire may be the surgical drapes, prepping agents, or even human tissue itself [2,4,5]. We present an interesting case of an intrathoracic fire in a patient undergoing LIMA harvesting during CABG surgery.A 57-year-old male was presented to our institution with angina pectoris. The patient was significant for chronic obstructive pulmonary disease (COPD), for which he was receiving maximal medical therapy - beclometasone, formoterole, and salbutamole. Results of the incentive spirometry summarized in Table 1. Cardiac catheterization established the presence of severely calcified coronary disease with multiple high grade stenoses of the left anterior descending and circumflex artery, along with middle grade stenoses of the right coronary artery. The patient was taken to the operating room for CABG surgery.After the patient was successfully intubated, general anesthesia was maintained with sufentanil, propofol, and sevoflurane. After median sternotomy, the oxygen saturation dropped to 82%. At this point, a pneumothorax was noted, both pleura were immediately opened and the FiO2 was increased from 0.7 to 1.0 (high pressure ventilation). On examination, the lungs contained several small blebs with a large, intact bulla in the basal segments of the left lower lobe. We were not able to detect a laceration on the lungs, however, the respirator (closed system; Zeus Aryl-0021, Dr?ger, Luebeck, Germany) signaled an air leakage of 1.2 L/min. The ventilator was modified to decrease the
Meta-analysis of randomized controlled trials on the efficacy of thoracic epidural anesthesia in preventing atrial fibrillation after coronary artery bypass grafting  [cached]
Gu Wan-Jie,Wei Chun-Yin,Huang De-Qing,Yin Rui-Xing
BMC Cardiovascular Disorders , 2012, DOI: 10.1186/1471-2261-12-67
Abstract: Background Postoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG. Methods MEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Results Five studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I2 = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results. Conclusions The limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.
The radial artery for coronary artery bypass grafting  [PDF]
Ne?i? D.,Milojevi? P.,?irkovi? M.,Kne?evi? A.
Acta Chirurgica Iugoslavica , 2005, DOI: 10.2298/aci0503011n
Abstract: Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularisation, compared with internal mammary artery grafts. Recently, the use of radial artery for CABG has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent reports of encouraging mid-term and long-term patency rates of the radial artery, supports its continued use as a bypass conduit. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.
冠脉旁路移植术中两种乳内动脉游离方法的临床效果对比
Two internal mammary artery free method by coronary artery bypass grafting in clinical research
 [PDF]

李晓峰,张伟华,,鸿,,,臧素华,李豪威,,
- , 2017, DOI: 10.13705/j.issn.1671-6825.2017.03.026
Abstract: 目的:对比分析冠状动脉旁路移植术(CABG)中带蒂法和骨骼化法游离乳内动脉对术后近期结果的影响。方法:选取单纯行CABG的冠心病患者526例为研究对象,分为带蒂法游离乳内动脉组(262例)和骨骼化法游离乳内动脉组(264例),分析两组围术期相关指标、主要术后并发症及随访术后桥血管通畅率等。结果:526例患者全部顺利完成手术。带蒂法游离乳内动脉组动脉桥血流量为(22.8±7.8)mL/min,游离时间为(18.1±5.5)min,获得乳内动脉长度(13.5±0.8)cm; 骨骼化法游离乳内动脉组分别为(41.6±8.3)mL/min、(32.5±6.8)min和(15.8±0.9)cm,差异均有统计学意义(P<0.05)。带蒂法游离乳内动脉组手术总时间(245±21)min,围术期死亡4例,围手术期心梗12例; 骨骼化法游离乳内动脉组分别为(252±18)min、5例和10例,两组各有1例胸骨不愈合,差异均无统计学意义(P>0.05)。术后随访3~12个月,两组1 a内动脉桥通畅率均为99.6%。结论:冠脉旁路移植术中,采取骨骼化与带蒂法游离乳内动脉对术后近期效果无明显差异。
Aim: To compare the postoperative effect of pedicled and skeletonized free internal mammary artery after coronary artery bypass grafting(CABG).Methods: A total of 526 patients with coronary heart disease who underwent CABG were selected and randomly allocated into two groups, among them, 262 cases in group P underwent surgery with the use of pedicle internal mammary artery, and 264 cases in group S underwent surgery with the use of skeletonized internal mammary artery. The main complications, perioperative related indicators and postoperative follow-up records of graft patency rate of the 2 groups were compared.Results: The surgery of 526 cases were successfully completed. The artery blood flow during operation in group P was(22.8±7.8)mL/min and that in group S was(41.6±8.3)mL/min; the time for freeing internal mammary artery was(18.1±5.5)min in group P and(32.5±6.8)min in group S; the length of free internal mammary artery was(13.5±0.8)cm in group P and(15.8±0.9)cm in groups; and there were significant differences in the above parameters between the 2 groups(P<0.05). The total time of surgery for group P was(245±21)min and that for group S was(252±18)min; perioperative death in group P and group S was 4 cases and 5 cases; there were 12 cases and 10 cases in group P and group S during perioperative period occured myocardial infarction; there was 1 case in both groups developed sternal nonunion; the difference between the 2 groups had no statistical significance(P>0.05). The patients were followed up for 3 to 12 months, and the patency rate of artery graft for the 2 groups within 1 years was both 99.6%.Conclusion: In CABG, the skeletonized and pedicled method of obtaining free internal mammary artery have no significant effects on recent postoperative results
Aorta-LITA Bypass Grafting with Saphenous Vein in a Patient Undergoing Coronary Artery Surgery with Subclavian Artery Stenosis  [PDF]
G?khan Laf??,Adnan Yal??nkaya,Kumral Ergün ?a?l?,Ersin Kadiro?ullar?
Ko?uyolu Kalp Dergisi , 2011,
Abstract: The internal thoracic artery (ITA) is the primary graft for coronary artery bypass grafting and can not be used if there is subclavian artery stenosis (SAS). Aorto-axillary, carotid-subclavian bypass and also angioplasty with stenting or other interventional treatments are acceptable procedures for SAS treatment. Aorta-ITA bypass with saphenous vein can be alternative and simple technique for SAS to save Winslow pathway for patients with peripheral artery disease.
Perioperative Avulsion of a Left Internal Mammary Artery Graft in a Patient with Syphilis  [PDF]
Vasily I. Kaleda,Sergei A. Belash,Alexei V. Barsuk,Kirill O. Barbuhatti
Surgery Research and Practice , 2014, DOI: 10.1155/2014/574346
Abstract: Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis. 1. Introduction Avulsion of a graft after coronary artery bypass grafting (CABG) surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. It was reported to occur after minimally invasive direct coronary artery bypass (MIDCAB) surgery due to a graft tension and after conventional CABG due to mediastinitis. In this paper we report a very rare case of a left internal mammary artery (LIMA) graft avulsion on the day of CABG surgery in a patient with syphilis. 2. Case Report A 54-year-old male patient presented with 3rd CCS class angina pectoris. Risk factors of coronary artery disease included class I obesity, hypertension, hyperlipidemia, and smoking. Transthoracic echocardiography showed normal size of the ascending aorta with a slight thickening of its wall, normal aortic valve function without regurgitation, and slightly decreasedleft ventricular ejection fraction with local hypokinesia. Pulmonary examination revealed no evidence of chronic obstructive pulmonary disease or marked emphysema. Coronary angiography showed multivessel lesions including proximal left anterior descending artery (LAD) stenosis and occlusion of left circumflex and posterior descending (PDA) arteries. There was no evidence of any arteritis or connective tissue disorder. The patient denied any history of sexually transmitted infection, but preoperative screening for syphilis with rapid plasma reagin (RPR) test was positive (this test is a part of standard examination before surgery in Russia). It was then confirmed with enzyme immunoassay (EIA) test, Treponema pallidum passive particle agglutination assay (TPPA) test, and fluorescent treponemal antibody absorption (FTA-ABS) test. The skin and visible mucous membranes were free from any sign of syphilis. The patient was suspected to have latent syphilis and was offered surgery. CABG was performed by experienced staff surgeon (S.A.B.) using cardiopulmonary bypass (CPB) and cold crystalloid cardioplegia with LIMA to LAD and vein grafts to obtuse marginal artery and PDA. LIMA was dissected from its origin to the bifurcation using pedicled in situ technique, and after cutting off it had a satisfactory blood flow. There was no doubt in the good
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