Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Revascularisation coronaire

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Revascularisation coronaire Veines Saphène interne > saphène externe (v. céphalique) moins adapté à celui des artères coronaires. Perméabilité à 10 ans: -Globale :50%-60%. -IVA: 80%.

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Revascularisation coronaire Artère mammaire interne Prélevée sans incision supplémentaire. Conduit à paroi élasto-musculaire. Fonction endothéliale :ERF+Prost. Perméabilité à 10 ans : ~90%(IVA). Perméabilité à 5 ans: -AMIG :> 95% -AMID :~ 90%

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Revascularisation coronaire Artère radiale Prélèvement facile. Disponibilité 90%. Matériel agréable. Conduit musculaire spasme. Perméabilité :(+ inhibiteur Ca) -1 an :97%. -5 ans :~ 85%.

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Revascularisation coronaire Choix du conduit Age Physiologique ans< 65 ans Conduits veineux - + Facteurs de risque - + Conduits artériels Conduits veineux Conduits mixtes A.mammaires A. mammaire A. radiale A. mammaire A. radiale A.mammaires Allen - + Conduits mixtes > 75 ans

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft C.H.U. de Charleroi

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft 1960 : RITA RCA 1965 : LITA LAD 1973 : RITA + LITA in situ 80s : LITA on LAD improves long-term survival

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Sternal infection risk factors –Univariate analysis : bITA grafting Obesity Diabetes Prolonged mechanical ventilation –Multivariate regressive analysis : bITA grafting p= Obesity p= Prolonged ventilation p= Kouchoukos. Ann. Thorac. surg. 1990

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft ITAs have proved to be the best bypass graft but have an inadequate length to bypass Cx pl and RC arteries to achieve a complete revascularization.

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Material:( jan sept. 97 ) –106 patients, 1 /10 –Age: 51 ys (35-69) –Redo: 8 % –Diabetes: 21% –Obesity: 38 %

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Material: –NYHA: II: 49 % III: 13 % IV: 22 % –Stress test: 58 patients. 90 % –EF: 0.60 ( ) +

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Operative data: –Anastomoses: 4.25 (3-6) 3 (2-4) redo patients. –Aortic cross clamping: 94 ±18 min. –IABP: 1 (EF:0.25) –Exploration for bleeding: 0

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Morbidity: –Transient s-t elevation: 12 (11 %) –Q wave infarction: 3 (3 %) –Sternal infection: 1 (1%) Mortality: 0

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Follow-up(105 patients) –35 months(15-61) –Survival: 99 % –Stress test:80 patients. 90 % –Recurrent angina: 7 NYHA II (7 %) –infarct: 0 –Sternal instability: 2 % rewiring -

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Has the potential to increase event-free survival and reduce the need for reoperation in patients with three- vessel disease. Can be performed with a low mortality and morbidity in a selected population, even in patients requiring reoperation. Good experience in ITA grafting is essential to the success of the procedure, especially in redo operations.

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Is the blood supply sufficient? –clinical results. –Experimental studies. What about subclavian artery atherosclerosis? Extraanatomic bypass or angioplasty. FAQs

Janvier 2000 IOSIOS CENTRE CARDIO-VASCULAIRE REGIONAL Total coronary revascularization with the internal thoracic arteries T graft Follow-up: –Symptoms, stress test, thallium test. –Graft evaluation: Duplex(supraclavicular fossa) :qualitative flow information in 95 % of cases. Spiral CT scan : graft patency sensitivity 85 %& specificity 100% Angiography.