Rad The Evidence For Conduit Choice Joseph Zacharias

Rad The Evidence For Conduit Choice Joseph Zacharias Lancashire Cardiac Centre Blackpool Victoria Hospital

My Practice • Total Cases 2004 -2009: 459 • Elective/ Urgent/ Emergency: 82. 8%/15. 3%/1. 9% • Reoperation: Bleeding : 5%, Rewiring: 0. 4% • Alive: Died in Hospital; 99. 1%: 0. 9% • Average Additive Euro. SCORE: 3. 43

My Practice • LIMA usage: 445 cases (96. 6%) • BIMA usage: 91 cases (19. 82%) • RA usage: 19 cases (4. 5%) • SVG usage: 420 cases (91. 5%) • Cephalic Vein usage !!! : 2 cases (0. 1%)

UK BIMA usage

LIMA vs SVG to LAD

IMA vs SVG to other targets

IMA vs SVG to other targets

Mammary artery Patency

Saphenous Vein graft Patency

Saphenous Vein graft Patency

Circulation. 2008 Sep 30; 118(14 Suppl): S 216 -21. Comparison of bilateral internal thoracic artery revascularization using in situ or Y graft configurations: a prospective randomized clinical, functional, and angiographic midterm evaluation. Glineur D, Hanet C, Poncelet A, D'hoore W, Funken JC, Rubay J, Kefer J, Astarci P, Lacroix V, Verhelst R, Etienne PY, Noirhomme P, El Khoury G.

Circulation. 1994 Nov; 90(5 Pt 2): II 129 -32. Patency of internal thoracic artery grafts: comparison of right versus left and importance of vessel grafted. Chow MS, Sim E, Orszulak TA, Schaff HV. Section of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905. RITA patency was 74% (26/35)

Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1 -year results of the Arterial Revascularisation Trial (ART). Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, Campbell H, Flather M; on behalf of the ART Investigators. Eur Heart J. 2010 Aug 30. • Coronary artery bypass graft patients were enrolled in 28 hospitals in seven countries. • Three thousand one hundred and two patients were randomly assigned to SIMA (n = 1554) or BIMA (n = 1548). The mean number of grafts was 3 for both groups. • Forty per cent of the SIMA procedures and 42% of the BIMA were performed off-pump. • Mortality at 30 days was 18 of 1548 (1. 2%) for SIMA and 19 of 1537 (1. 2%) for BIMA, and at 1 year was 36 of 1540 (2. 3%) and 38 of 1529 (2. 5%), respectively. • The rates of stroke, myocardial infarction, and repeat revascularization were all </=2% at 1 year and similar between the two groups. • Sternal wound reconstruction was required in 0. 6 and 1. 9% of the SIMA and BIMA groups, respectively.

Radial artery • 300 case series • 2 randomised trials – RAPS trial (NEJM 2004) – RAPCO trial (JTCVS 2003)

Radial artery patency

Radial Vs SVG (Target stenosis)

Radial Vs SVG (target size)

Radial vs SVG

Effect of Peripheral Vascular disease

Gastroepiploic Artery

Gastroepiploic Artery

Effect of Conduit on re-intervention

Patients with Normal LV

Patients with Impaired LV

Effect of patient factors on reintervention

Effect of patient factors on reintervention

The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting Jean-Francois Légaré , Ansar Hassan , Karen J Buth and John A Sullivan Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada Journal of Cardiothoracic Surgery 2007, 2: 44 doi: 10. 1186/1749 -8090

Conclusion • • LIMA = RIMA to LAD (. 5 years)* LIMA > SVG (10 - 15 years) RA > SVG (8 years)* RA = FRIMA (<70) = SVG (>70) (6 years)* RA > SVG in small vessels and probably females* SVG > RA in target vessel stenosis < 80% & PVD* SVG > GEA to RCA (except in vessels < 1 mm)* Patient factors have a big role to play.