Comparison of the right internal thoracic artery and radial artery as a second arterial conduit in ‘Y’ composite fashion in patients undergoing coronary artery bypass grafting using total arterial revascularization

Document Type: Original Article

Authors

Thoracic Surgeon, Department of Cardiovascular and Thoracic Surgery, LTM General Hospital, Sion, Mumbai, India

Abstract

Introduction: The use of two arterial conduits for CABG is rapidly increasing. The second arterial conduit to LITA is usually RITA or radial artery. We sought to compare outcomes when either RITA or radial artery is exclusively used as a Y composite graft to LITA for total arterial revascularization.
Material and methods:  We retrospectively analyzed 231 patients who underwent CABG in the period from 2010 to 2014. RITA was used in 178 patients (RITA group) and radial artery was used in 53 patients (radial group).
Results: Radial was used more frequently in female patients and in diabetic patients. Radial group had comparable number of distal anastomoses and lesser operative time to RTIA group. Early postoperative outcomes (low cardiac output syndrome, post-operative myocardial infarction, use of intra-aortic balloon pump, post-operative stroke, re-explorations, incidence of deep sternal wound infection and death) were all comparable in both the groups. Late deaths and need for repeat revascularization were also similar in both the groups for up to 4 years after surgery. Only the incidence of major acute cardiac and cerebrovascular events (MACCE) was more in the radial group.
Conclusion: Radial artery has comparable short- and mid-term outcomes to RITA when used as a second arterial conduit in CABG. Its use should be especially considered in diabetic patients when DSWI is a concern.

Keywords


  1. Tatoulis J, Wynne R, Skillington PD, Buxton BF. Total arterial revascularization: a superior strategy for diabetic patients who require coronary surgery. Ann Thorac Surg. 2016;102:1948-55.
  2. Naik MJ, Abu-Omar Y, Alvi A, Wright N, Henderson A, Channon K, et al. Total arterial revascularisation as a primary strategy for coronary artery bypass grafting. Postgrad Med J. 2003;79:43-8.
  3. Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U, et al. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med. 2016;375:2540-9.
  4. Algarni KD, Maganti M, Yau TM. Predictors of low cardiac output syndrome after isolated coronary artery bypass surgery: trends over 20 years. Ann Thorac Surg. 2011;92:1678-84.
  5. Wang TK, Stewart RA, Ramanathan T, Kang N, Gamble G, White HD. Diagnosis of MI after CABG with high-sensitivity troponin T and new ECG or echocardiogram changes: relationship with mortality and validation of the Universal Definition of MI. Eur Heart J Acute Cardiovasc Care. 2013;2:323-33.
  6. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.Am J Infect Control. 1999;27:97-134.
  7. Laukkanen JA, Kunutsor SK, Niemelä M, Kervinen K, Thuesen L, Mäkikallio TH. All-cause mortality and major cardiovascular outcomes comparing percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: a meta-analysis of short-term and long-term randomised trials. Open Heart. 2017;4:e000638.
  8. Goldman S, Sethi GK, Holman W, Thai H, McFalls E, Ward HB, et al. Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial. JAMA. 2011;305:167-74.
  9. Gaudino M, Taggart D, Suma H, Puskas JD, Crea F, Massetti M. The choice of conduits in coronary artery bypass surgery. J Am Coll Cardiol. 2015;66:1729-37.
  10. Melly L, Torregrossa G, Lee T, Jansens JL, Puskas JD. Fifty years of coronary artery bypass grafting. J Thorac Dis. 2018;10:1960-7.
  11. Sauvage LR, Wu HD, Kowalsky TE, Davis CC, Smith JC, Rittenhouse EA, et al. Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries. Ann Thorac Surg. 1986;42:449-65.
  12. Fukui T, Tabata M, Manabe S, Shimokawa T, Morita S, Takanashi S. Angiographic outcomes of right internal thoracic artery grafts in situ or as free grafts in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2010;139:868-73.
  13. Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: the forgotten conduit--5,766 patients and 991 angiograms. Ann Thorac Surg. 2011;92:9-15.
  14. Glineur D, Hanet C, Poncelet A, D'hoore W, Funken JC, Rubay J, et al. Comparison of bilateral internal thoracic artery revascularization using in situ or Y graft configurations: a prospective randomized clinical, functional, and angiographic midterm evaluation. Circulation. 2008;118:S216-21.
  15. Otsuka F, Yahagi K, Sakakura K, Virmani R. Why is the mammary artery so special and what protects it from atherosclerosis? Ann Cardiothorac Surg. 2013;2:519-26.
  16. Manenti A, Roncati L, Caprili L, Fedeli C. Histological characterization of the internal thoracic artery as preferred conduit for coronary bypass. J Mol Histol Med Physiol. 2016;1:1-4.
  17. De Paulis R, de Notaris S, Scaffa R, Nardella S, Zeitani J, Del Giudice C, et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization. J Thorac Cardiovasc Surg. 2005;129:536-43.
  18. Dai C, Lu Z, Zhu H, Xue S, Lian F. Bilateral internal mammary artery grafting and risk of sternal wound infection: evidence from observational studies. Ann Thorac Surg. 2013;95:1938-45.
  19. Deo SV, Shah IK, Dunlay SM, Erwin PJ, Locker C, Altarabsheh SE, et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg. 2013;95:862-9.
  20. He GW, Taggart DP. Spasm in arterial grafts in coronary artery bypass grafting surgery. Ann Thorac Surg. 2016;101:1222-9.
  21. Onorati F, Rubino AS, Cristodoro L, Scalas C, Nucera S, Santini F, et al. In vivo functional flowmetric behavior of the radial artery graft: is the composite Y-graft configuration advantageous over conventional aorta–coronary bypass? J Thorac Cardiovasc Surg. 2010;140:292-7.e2.
  22. Gaudino M, Crea F, Cammertoni F, Mazza A, Toesca A, Massetti M. Technical issues in the use of the radial artery as a coronary artery bypass conduit. Ann Thorac Surg. 2014;98:2247-54.
  23. Watson RA, Hamza M, Tsakok TM, Tsakok MT. Radial artery for coronary artery bypass grafting: does proximal anastomosis to the aorta or left internal mammary artery achieve better patency? Interact Cardiovasc Thorac Surg. 2013;17:1020-4.
  24. Ruttmann E, Fischler N, Sakic A, Chevtchik O, Alber H, Schistek R, et al. Second internal thoracic artery versus radial artery in coronary artery bypass grafting. Circulation. 2011;124:1321-9.
  25. Tranbaugh RF, Dimitrova KR, Lucido DJ, Hoffman DM, Dincheva GR, Geller CM, et al. The second best arterial graft: a propensity analysis of the radial artery versus the free right internal thoracic artery to bypass the circumflex coronary artery. J Thorac Cardiovasc Surg. 2014;147:133-42.
  26. Caputo M, Reeves B, Marchetto G, Mahesh B, Lim K, Angelini GD. Radial versus right internal thoracic artery as a second arterial conduit for coronary surgery: early and midterm outcomes. J Thorac Cardiovasc Surg. 2003;126:39-47.
  27. Gaudino M, Benedetto U, Fremes S, Biondi-Zoccai G, Sedrakyan A, Puskas JD, et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378:2069-77.
  28. Deb S, Cohen EA, Singh SK, Une D, Laupacis A, Fremes SE, et al. Radial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study). J Am Coll Cardiol. 2012;60:28-35.
  29. Navia D, Vrancic M, Piccinini F, Camporrotondo M, Thierer J, Gil C, et al. Is the second internal thoracic artery better than the radial artery in total arterial off-pump coronary artery bypass grafting? A propensity score–matched follow-up study. J Thorac Cardiovasc Surg. 2014;147:632-8.
  30. Hayward PA, Buxton BF. Mid-term results of the radial artery patency and clinical outcomes randomized trial. Ann Cardiothorac Surg. 2013;2:458-66.
  31. Gaudino M, Lorusso R, Rahouma M, Abouarab A, Tam DY, Spadaccio C, et al. Radial artery versus right internal thoracic artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a network meta‐analysis of clinical outcomes. J Am Heart Assoc. 2019;8:e010839.