Page 25 - Read Online
P. 25

Dewantoro et al. Vessel Plus 2018;2:20  I  http://dx.doi.org/10.20517/2574-1209.2018.50                                              Page 5 of 9

               Table 1. 5-year outcome of patients in TACABG and VCABG in patients with left main disease
                                                                   VCABG                      TACABG
                                                                    ART          TAR                TAR
                                                       NOBLE*                             RAPCO**
                                                               Single- graft group  Non-TAR group  TAR group
                Average age (years)                    66.2        63.5         64.7        60.1    64.4
                Number of patients                     592         1554         6232        140     6232
                MACCE                                  80 (18%)    198 (12.7%)*  N/A        N/A     N/A
                All-cause mortality                    32 (9%)     130 (8.4%)   9.9%***     3 (2%)  8.7%***
                Cardiac death                          15 (3%)     N/A          N/A         N/A     N/A
                Vascular death                         1 (< 1%)    N/A          N/A         N/A     N/A
                Non-procedural myocardial infarction   10 (2%)     N/A          N/A         N/A     N/A
                Revascularisation (total)              47 (10%)    103 (6.6%)   N/A         N/A     N/A
                Revascularisation with PCI             45 (10%)    N/A          N/A         3 (2%)  N/A
                Revascularisation with CABG            2 (< 1%)    N/A          N/A         N/A     N/A
                Target lesion revascularisation        36 (8%)     N/A          N/A         N/A     N/A
                Target LMCA revascularisation          33 (9%)     N/A          N/A         N/A     N/A
                De novo lesion revascularisation       11 (3%)     N/A          N/A         N/A     N/A
                (new lesion in non-grafted segment)
                Symptomatic graft occlusion or definite stent thrombosis  15 (4%)  N/A  N/A  N/A    N/A
                Stroke                                 7 (2%)      49 (3.2%)    N/A         N/A     N/A

               *Composite death, myocardial infarction, and stroke; **RAPCO only take RA conduit; ***Derived from Kaplan-Meier survival. CABG:
               coronary artery bypass graft; TACABG: total arterial CABG; VCABG: CABG that involves venous graft; PCI: percutaneous coronary
               intervention; LMCA: left main coronary artery; MACCE: major adverse cardiac and cerebrovascular events; TAR: total-arterial
               revascularization; NOBLE/ART/RAPCO refer to names of clinical trials


               check for saphenous vein collateral circulation. However, it has been shown that checking for saphenous vein
                                                                          [16]
               through the use of Doppler ultrasound improves the prognosis of SVG .

               Secondly, in term of operation time, the total of cross-clamp time and perfusion time is shorter in the TA-
               CABG than in VCABG (as has been discussed above), a retrospective study has shown that the operative
                                                                        [17]
               time taken for total arterial revascularization was 30 minutes longer . This is true especially when bilateral
               ITA or RA was used. The paper further added that the additional time taken was due to the extra conduit
                                                    [17]
               harvest and not to actual grafting procedure .

               Also, BIMA could be performed using two different configurations, in situ versus Y-graft. A recent study
               evaluated whether graft configuration might affect long-term outcomes in 2150 patients using a propensity-
                            [18]
               score approach . Late mortality and incidence of MACCES were similar between groups, and therefore the
               clinical outcome of BIMA grafting is independent of surgical configuration. However, Y-grafting increases
               the flexibility of BIMA grafting and should be taken into account when a surgical strategy for myocardial
                                               [18]
               revascularization needs to be planned .

               Thirdly, it is important to consider the short term post-operative outcome of a surgical procedure. An ex-
               ample of this is the healing of any surgical wounds inflicted during CABG procedure, especially in high risk
                                                      [19]
               patients (such as those with diabetes mellitus) . One of the main topic of interest is the healing outcome of
               the sternum and chest wall after the collections of ITA, especially if bilateral ITAs were harvested. However,
               through careful harvesting of such grafts while preserving pleural cavities’ integrity, it reduces the post-
               operative morbidity as well as lowering hospital cost [19,20] . One of the fear of TACABG is deep sternal wound
               infection (DSWI), especially if bilateral ITA was used. However, reports from various studies have shown
               that there were low rates of DSWI, that is lower than 1%, in TACABG [4,21-24] . The incidence of DSWI may be
               significantly higher after the harvest of both internal thoracic arteries in the elderly, with an odds risk of 1.86
                       [25]
               (P < 0.01) . However, the risk of deep sternal wound infection can be minimized in diabetic patients under-
               going CABG by performing ITA harvested in a skeletonized manner with meticulous attention to preserv-
               ing sternal blood flow. Pedicled harvest is to be discouraged when utilizing both ITA owing to a significant
   20   21   22   23   24   25   26   27   28   29   30