Cabg with lima rima

Cabg with lima rima

1. CABG with LIMA RIMA

2. CABG Performed for patients with coronary artery disease (CAD) to improve quality of life and reduce cardiac-related mortality . Indications Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows [1, 2] : Left main coronary artery stenosis >50% Stenosis of proximal LAD and proximal circumflex >70% 3-vessel disease in asymptomatic patients or those with mild or stable angina 3-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function 1- or 2-vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina >70% proximal LAD stenosis with either ejection fraction < 50% or demonstrable ischemia on noninvasive testing

3. Sites of conduit harvesting Saphenous vein Radial artery Left internal thoracic (mammary) artery (LITA) Right internal thoracic (mammary) artery (RITA) Right gastroepiploic artery Inferior epigastric artery Splenic artery Ref: http ://emedicine.medscape.com/article/1893992-overview

4. Consequence of conduit Saphenous vein grafts Declining patency with time At 10 years after surgery, only 50-60% of saphenous vein grafts are patent, and only half of these are free of angiographic atherosclerosis Internal Thoracic Artery grafts Exhibit stable patency over time At 10 years, more than 90% of internal thoracic artery grafts are patent

5. Total A rterial G rafting(TAG) Definition TAG was defined as the use of any arterial conduit ( LIMA, RIMA , RA or GEPA), either alone or in combination, without concomitant use of SVG Légaré JF 1 , Hassan A, Buth KJ, Sullivan JA . The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting . J Cardiothorac Surg. 2007 Oct 23;2:44.

6. LIMA Pedicled + RIMA skeletonized in situ LIMA + RIMA skeletonized in situ LIMA in situ + RIMA (Y grafted ) Types of TAG

7. Why is TAG not popular? Perceived ‘lack of evidence’ in their favour Increased sternal morbidity Increased operative time Reluctance to perform it in elderly as they would not be conferred the survival benefits as in younger patients Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

8. The burning question: Is it really better than conventional CABG?

9. The Evidence

10. Studies comparing BIMA with SIMA

11. More evidence… Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

12. Sternal wound infection Increase in Sternal wound dehiscence in BIMA group but mortality unchanged at 1 yr as compared to SIMA Vallely MP, Edelman JJ, Wilson MK. Bilateral internal mammary arteries: evidence and technical considerations. Ann Cardiothorac Surg 2013;2(4):570-577

13. Conclusions Using TAG & BIMA is time consuming & technically difficult But it is justified by the Increased long term survival rates Less incidence of MACCE Overall improved patient outcomes

14. Thank You