NGHIÊN CỨU CHỈ ĐỊNH PHẪU THUẬT BẮC CẦU MẠCH VÀNH

NGUYỄN HOÀNG ĐỊNH, MD. PhD.
LÊ MINH KHÔI, MD, PhD.
University of Medicine and Pharmacy of HCM City
University Medical Center
SYNTAX
• RCT study included 1800 pts: CABG vs. PCI
• MACCE at 12 months
From: CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting
J Am Coll Cardiol. 2015;66(13):1417-1427. doi:10.1016/j.jacc.2015.07.060
Figure Legend:
Survival After Percutaneous and Surgical CAD Treatment Modalities
Comparisons of unadjusted 9-year all-cause mortality (A) and unplanned reintervention-free (B) survival shown for all 4 coronary
revascularization groups: 2,207 bare-metal stent (BMS) percutaneous coronary intervention (PCI) (age 66.6 ± 11.9 years); 2,381
drug-eluting stent (DES)-PCI (age 65.9 ± 11.7 years); 2,289 single-arterial (SA) coronary artery bypass graft (CABG) (age 69.3 ± 9.0
years); and 1,525 multiarterial (MA)-CABG (age 58.3 ± 8.7 years). The p values were derived by log-rank test. CAD = coronary artery
disease.
Date of download: 10/4/2015
Copyright © The American College of Cardiology. All rights reserved.
From: CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting
Optimal Revascularization of
Multivessel CAD: Comparison of 9Year Propensity Matched All-Cause
Mortality Survival Data for Both PCI
Treatment Cohorts
Each cohort is separately compared to
single-arterial (SA) and multiarterial
(MA) coronary artery bypass graft
(CABG) surgery: (A) bare-metal stent
(BMS) percutaneous coronary
intervention (PCI) versus SA-CABG;
(B) BMS-PCI versus MA-CABG; (C)
drug-eluting stent (DES)-PCI versus
SA-CABG; and (D) DES-PCI versus
MA-CABG. The p values were derived
by log-rank test. CAD = coronary
artery disease.
J Am Coll Cardiol. 2015;66(13):1417-1427. doi:10.1016/j.jacc.2015.07.060
Date of download: 10/4/2015
Copyright © The American College of Cardiology. All rights reserved.
IMA vs SVG vs RA
• Morphology: IMA has thin smooth muscle media + tight
internal elastic lamina
• Physiology: IMA produces more NO than RA and SVG
• Increased EDRFs produced by IMAs results in superior
graft patency and additional protects native coronary
artery circulation.
Thomas F. Luscher, New Eng J Med 1998, Circ 2007
ber
mortality
of
Dùng
Không
ĐMNT
dùng
Risk
trái
ĐMNT
ratio
2
4
2,25
2
3,2
6,5
2.03
8797
1,6
3,7
2,31
432
3,2
10,5
3,26
Yea patie
(STS)
Grover
(VACS)
Dabal
(COAP)
Nguyen H
Dinh
nts
199 38.57
4
8
199 14.17
4
0.25
Edwards
r
TMH
200
3
201
0
0.00
Authors
DMNTT
0.75
Inhospital
0.50
Num
1.00
LIMA to LAD
0
20
40
60
ONE MAMMARY ARTERY IS GOOD,
IS TWO BETTER?
• Lytle 2004: survival rate of
BITA group is higher than
LITA group after 7 – 20
years of follow-up.
Lytle, B. W., Blackstone, E. H., Sabik, J. F., Houghtaling, P., Loop, F. D., Cosgrove, D. M. (2004). Ann
Thorac Surg, 78(6), 2005-2012; discussion 2012-2004.
ONE MAMMARY ARTERY IS GOOD,
IS TWO BETTER? META ANALYSIS
• Taggart 2001: BITA
significantly improved
survival rate HR=0,81
•
Taggart, D. P., D'Amico, R., Altman, D. G. (2001). Lancet, 358(9285), 870-875.
Effects of bilateral internal mammary artery grafting on long-term survival.
Gijong Yi et al. Circulation. 2014;130:539-545
Copyright © American Heart Association, Inc. All rights reserved.
Randomized Trial to Compare Bilateral Versus Single Internal
Mammary Coronary Artery Bypass Grafting (CABG):
One Year Results of the Arterial Revascularisation Trial (ART)
DP Taggart, DG Altman, AM Gray, B Lees, F Nugara, LM Yu, H Campbell, M Flather, on
behalf of the ART Investigators
John Radcliffe Hospital Oxford, University of Oxford, Royal Brompton & Harefield NHS Foundation Trust London
and Imperial College London
ESC Hot Line 2010, Stockholm
On Line publication in EHJ
LONG-TERM SURVIVAL BENEFIT
ART (ARTERIAL REVASCULARISATION TRIAL)
• The only RCT study available involved 28 centers in 7
•
•
•
•
countries
3102 patients, LITA vs BITA groups
Ten-year results expected
2010: Results at one year: BITA does not increase
inhospital morbidity and mortality.
2018: 10-year survival
Taggart, D. P., Altman, D. G., Gray, A. M., Lees, B., Nugara,
F., Yu, L. M., et al. (2010), "Randomized trial to compare
bilateral vs. single internal mammary coronary artery bypass
grafting: 1-year results of the Arterial Revascularisation Trial
(ART)". Eur Heart J, 31(20), 2470-2481.
ART Summary and Conclusions
o
Shows that routine use of BIMA is feasible in CABG patients
o Testament to safety of contemporary CABG with 1 or 2 IMA
•
o
30 day mortality 1.2%; 1 year mortality 2.5%
Use of BIMA does not increase
30 day or 1 year mortality
duration of post op stay
risk of stroke, MI, revascularization
•
•
•
o Use of BIMA results in a slight increase in the risk of sternal wound
reconstruction by 1.3%
o
ART is funded for 10 years to determine if BIMA reduce mortality
and need for repeat revascularization (expected completion 2018)
• Class IIa: When anatomically and clinically suitable, use
of a second IMA to graft the left circumflex or right
coronary artery (when critically stenosed and perfusing LV
myocardium) is reasonable to improve the likelihood of
survival and to decrease reintervention (LOE: B)
• Class IIa: Bilateral IMA grafting should be considered in
patients < 70 years of age (LOE: B)
• Class IIa: Routine skeletonized IMA dissection should be
considered (LOE: B)
• Class I: Skeletonized IMA dissection is recommended in
patients with diabetes or when bilateral IMAs are
harvested (LOE: B)
WHY LESS SURGEONS PERFORM BIMA GRAFTING?
North America: 4.4% (2011 STS database)
United Kingdom and Australia: <10%
• Lack of RCT?
• Longer operating time. Increased technical demands.
Work load pressure?
• Potential increased risk of wound complications?
• The intense scrutiny of immediate outcomes following
CABG surgery forces surgeons to choose operation less
beneficial in long term but less risky in short term.
Patient characteristics
UMC Heart Center 2008-2014
N=151 pts
Age
54 ± 8.0
History of stroke
9 (6%)
Sex
116 (78%)
PCI
10 (6.6%)
Diabetes
35 (23.2%)
LM disease
53 (35.1%)
Hypertension
102 (76.5%)
N. of disease vessels
2.9
Smoking
91 (60.3%)
EF
64.8 ± 8.6
Lipidemia disorders
90 (59.6)
Hypokenisia
31 (20.5%)
COPD
1 (0.7%)
Clopidogrel
79 (52,3%)
Chronic renal failure
4 (2.6%)
Unstable angina
100 (66.2%)
Ancient MI
28 (18.5%)
EuroSCORE II
2.96 ± 2.38
CCS classification
• N=151
CCS IV,
CCS1%
I, 1%
CCS II, 45%
CCS III, 53%
CCS I
CCS II
CCS III
CCS IV
Operative characteristics
Onpump
(n=59)
OPCAB
(n=92)
Total
(n=151)
Planned
52
87
139
Urgent
1
3
8
Emergent
6
2
4
Preop
5
1
6
CPB weaning
6
0
6
Post-op
1
0
1
Op. time
411 ± 85
356 ± 60
CPB time
115 ± 42
Cross-clamp
74 ± 35
Urgency
IABP
BITA combination strategies
IMA
Conduits
Target vessels
No. of grafts
LAD
121
Diagonal
52
OM
33
Total
216
LAD
35
Ramus
10
Diagonal
9
Cx
1
OM
114
PDA
64
PLA
10
RCA
5
Total
248
Left coronary artery
385
Right coronary artery
79
Total
464
IMA graft per patient
3.07
SHORT-TERM
OUTCOMES
Ramus
10
LIMA
RIMA
Early outcomes
Ventilating time
16 g (13,22)
ICU stay
3 ngày (3,4)
Chest reopen
Bleeding
DSWI
Neurologic complications
Stroke
6 (4%)
5
1
9 (6%)
0
Renal failure
4 (2,6%)
SWI
1 (0.7%)
AMI
5 (3,3%)
Mortality
Sepsis
AMI
MR (adjusted)
3 (2%)
1
2
2%/2,96% = 0,68
Follow-up
• 142 pts (6 lost of follow-up)
• 3 months - 6 years, mean 40 months.
• Mortality: 2 (1 lung cancer, 1 gangrenous cholecystitis)
• No reintervention.
CCS
NYHA
No pain
90
1
42
2
10
3
0
I
126
II
14
III
2
IV
0
Angiographic control by MSCT
46 pts, 164 grafts, 24 months post-op
Grafts
Target
vessels
Patent
String
sign
Obstructi
ve
Stenotic
Patency
rates
0
1/70
0
1/47
0
98,6%
Diagonal
LAD
69/70
23/23
46/47
4/94
1/4
0
3/29
0
14/94
0
9/51
3/29
1/3
1/94
0
0
1/29
0
84%
Ramus
OM
PDA
RCA
75/94
3/4
42/51
22/29
2/3
ĐMV trái
117/129
1/129
11/129
0
90,1%
ĐMV phải
27/35
3/35
4/35
1/35
77,1%
144/164
4/164
15/164
1/164
90,3%
LIMA
RIMA
Total
Early and mid-term outcomes
• Inhospital mortality 2%, RAMR: 0,68
• AMI 3,3%, ARF 2,6%, SWI 0,7%
• Patency rate 24 months: LIMA-LAD 98,6%, overall 90,3%
• 2/142 mortality at follow-up (non-cardiac)
• No patient with CCS > 2
• No reintervention
Author
Year
Method
Method
LCA system
RCA system
Barra
1995
Angiography
1 year
96.4%
80%
Calafiore
2000
Angiography
2 week
96.4%
3 year
98.8%
Before
98.9%
90% functional
97.2%
97%
A.Azmoun
2007
Angiography
discharge
D Glineur
2008,
Angiography
6 mo
2009
74.7% functional
D Glineur
2011
Angiography
3 year
HY Hwang
2011
Angiography
BD
99.5%
1 year
95.9%
5 year
92.3%
Nakajima
2011
Angiography
68% functional
2 week
98%
10 year
79,9% (symptomatic pts)
FACTORS RELATED TO FLOW COMPETITION
Nakajima 2011
• 852
pts/3263
anastomoses
• T-graft arterial
conduits
• 10 year followup
Nakajima H., et al. (2011). Eur J Cardiothorac Surg 40:399-404
TTFM: FLOW COMPETITON RIMA TO RCA
Before RCA ligation
After RCA ligation
HOW TO AVOID FLOW COMPETITION
• Sequential anastomoses (side-to-side) should be used
only if target vessels are significantly stenotic (≥ 70%).
• The last anastomosis (end-to-side) is preferably on the
most severely stenotic vessel (90 – 100% stenotic is
ideal).
Martin Misfeld, JCTS 2011
BIMA skeletonisation
• Preparation:
• Harvest, divide distally and clip
• Wrab in papaverine swab + increase BP to 150 for 5mins
• No need to inject
• Artery
• Longer
• Wider
• See full length
• Easier composites
• Easier sequential
BIMA skeletonisation: when not to use
• Diabetes especially if insulin dependent AND obese
• Bad lungs (prolonged ventilation)
• Patients on steroids and immunosuppressives
• Elderly?
Figure 3. A, Representative SPECT Image of postoperative sternal perfusion in a patient who
received a left skeletonized and a right nonskeletonized ITA. Differences in sternal perfusion are
discernible in the manubrium and middle third of the sternum.
Munir Boodhwani et al. Circulation. 2006;114:766-773
Copyright © American Heart Association, Inc. All rights reserved.
RISK FACTORS OF DSWI
• BIMA harvesting (RR 2.18)
• Medically treated diabetes (RR 1.73)
• Female sex (RR 1.8)
• Higher BMI (7% increased risk per kg/m2)
• Previous MI (RR 1.58)
• Peripheral arterial diseases (RR 1.73)
•
Raza S, Sabik III JF et al. Surgical revascularization techniques that minimize surgicak risk
and maximize late survival after coronary artery bypass grafting in patients with diabetes
mellitus. J Thorac Cardiovasc Surg 2014;148:1257-66
HOW TO AVOID DSWI IN BIMA GRAFTING
• Patient selection
• Skeletonized IMAs harvesting
• Sternal closure techniques
• Topical antibiotic: vancomycin, gentamycin?
ITAs HARVESTING AND IABP SUPPORT
Vohra:
IABP
help
facilitate
ITAs harvesting,
decrease renal
failure
and
hospital stay in
unstable angina,
low EF and left
main patients.
•
Vohra, H. A. (2006). J Card Surg, 21(1), 1-5.
Summary and conclusions
1. CABG using BITA T-graft is safe with long-term survival
benefits and should be encouraged in daily practice.
• Strong angiographic evidence of >90% long-term patency of
both IMAs.
• Meta-analyses and large registries show benefit of BIMA
• ART trial phase 1: BIMA does not increase 1 year mortality,
risk of stroke, MI, revascularization
Summary and conclusions
2. Composite arterial graft with no-touch technique
reduces risk of stroke
3. Use of BIMA slightly increase risk of SWI, can reduce
risk with skeletonization technique
Thank you for your kind attention!