“ “ Multiple Multiple Arterial Graft Arterial Graft CABG” CABG” Where do we Where do we stand? stand? Mohammad Shihata Mohammad Shihata
““Multiple Multiple Arterial Graft Arterial Graft
CABG”CABG”Where do we Where do we
stand?stand?
Mohammad ShihataMohammad Shihata
CABGCABG
• The most performed operation in the developed world.
• Enjoying a re-established role as a gold standard for severe CAD.
• The best treatment for LM and 3 vessel CAD.
Changing DemographicsChanging Demographics
• Aging population: > 20% over the age of 70 by 2030.
• CAD combined with other cardiac pathology (e.g. / Aortic stenosis ) will be more frequent.
• Treatment standards for the elderly need to be defined better.
LIMA to LAD + RSVGs is a very LIMA to LAD + RSVGs is a very good operationgood operation
but ....
can we make it better ?can we make it better ?
Why MAG?Why MAG?
Literature Literature ReviewReview
Probability of saphenous vein graft patency
Age GroupAge Group 5y5y 10y10y
50 - 5950 - 59 93%93% 78%78%
60 – 6960 – 69 92%92% 80%80%
70 – 7970 – 79 94%94% 76%76%
>80>80 80%80% 58%58%
University of Melbourne Database 1986 – 2007;University of Melbourne Database 1986 – 2007;18,588 CABG patients18,588 CABG patients
Buxton B, et al . 23rd EACTS , 2009
3000 patients. At 18 months the portion of occluded or severely diseased SVG was 47% and 38% for endoscopic and open harvesting respectively.
Over 3000 reports 1978 – 1999; 10 analyzed.Over 3000 reports 1978 – 1999; 10 analyzed.
Adjusted 12 y survivalAdjusted 12 y survival
1984 - 1987 ; 1087 patients
Composite Outcome:Composite Outcome:All cause death, non – fatal MI,All cause death, non – fatal MI, PCI, Redo CABGPCI, Redo CABG
Limitations to MAGLimitations to MAG
Patient Factors:• Obese Diabetics (BIMA)• Severe COPD (BIMA)• Immunosuppressants
Technical Factors:• Inadequate IMA or Radial (uncommon)• Large target with moderate stenosis
MAG still stubbornly low!!!MAG still stubbornly low!!!
In North America & UK
• 95% receive a single IMA• < 20% receive 2 arterial grafts (more radial
than BIMA)• STS Database < 5% receive BIMA• < 3% receive 3 arterial grafts.
142 consultant adult cardiac surgeons; 90 replies. 142 consultant adult cardiac surgeons; 90 replies.