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DOI: 10.1055/s-0032-1332565
T-grafting of skeletonized free RIMA into patent LIMA-bypass in redo-operations for complete arterial revascularization: 8-year experience and mid-term follow-up
Objectives: The benefits of arterial grafts, especially the bilateral use of skeletonized internal mammary arteries as T-graft (BIMA-TG) in coronary artery bypass grafting (CABG) are well described. However in redo-CABG, no literature is found reporting the consequent use of subsequent T-grafting of free RIMA (s-RIMA-TG) into the patent LIMA-bypass achieving BIMA-TG and complete arterial revascularization. Concerns may rise because of possible injury to the patent LIMA-bypass and prolonged duration of operation (t-OP), cardiopulmonary bypass (t-ECC), or aortic cross clamping (t-AoX).
Methods: We retrospectively reviewed a single surgeon's consecutive series (from 01/2004 to 08/2012) of redo-CABG (n = 100) using s-RIMA-TG (n = 25) with respect to injury of patent LIMA-bypass, number of distal anastomosis, t-OP, t-ECC, t-AoX, and in-hospital mortality. Follow-up data on mid-term survival and freedom from re-intervention were collected.
Results: A total of 25 consecutive patients were analyzed: 17 patients (68%) underwent isolated Re-CABG, 8 patients (32%) had additional valve surgery. Mean age was 68.3 ± 7.0 and 70.5 ± 7.7 years, mean number of peripheral anastomoses performed was 2.1 and 1.6 (both range 1 – 3), mean t-OP was 288 ± 43 min and 381 ± 77 min, mean t-ECC was 82 ± 43 min and 183 ± 85 min, and mean t-AoX was 55 ± 35 min and 137 ± 61 min, respectively. No patent LIMA-bypass was injured. No in-hospital mortality occurred. At a mean follow-up of 4.0 ± 2.2 years (range 19 days – 8.2 years) 19 patients (76%) were alive. One patient of the isolated redo-CABG group suffered of cerebrovascular bleeding after accident and died 6.4 years after re-operation. Five patients of the combined redo-procedure group died due to non-bypass related factors 3.2 ± 2.3 (range 1.1 – 6.1) years after re-operation. Freedom from bypass re-intervention was 100% overall. So far, two patients had coronary re-angiography revealing patent bypass grafts.
Conclusions: The s-RIMA-TG concept is challenging but safe. No LIMA-bypass was injured. T-OP, t-ECC, or t-AoX was acceptable. Regarding the advantages of BIMA-TG, such as excellent patency rates and no need of aortic anastomosis or additional bypass grafts, we believe that s-RIMA-TG is likely the best and the most 'minimal invasive' strategy in redo-CABGs with patent LIMA-bypasses.