M. Schwartz said:Marc Schwartz <[email hidden]> wrote in message
news:<[email hidden]>...
SNIP
Quoted message said:Quoted message said:This is one of the key advantages of using the IMA over time. There is
better flow, which results in better long term patency.
Yes, but how many IMA's can they use? Just one right? So what is left
for the other grafts? Leg veins and ?
Mel
There are two IMA's, a right and a left. In addition, you have the leg
veins and the other arteries that have been mentioned (radial,
gastro-epiploic and epigastric).
In terms of the IMAs, most commonly, the left IMA is used, with the
typical target being the left anterior descending coronary artery (the
LAD).
The right IMA can be and is used, where there may be narrowings on the
right side of the heart (ie. the right coronary artery), given where the
right IMA is in relation to the narrowings.
One contraindication that is common regarding the use of both IMA's is in
insulin dependent diabetic patients. It has been suggested that the
additional surgical dissection involved in using both IMA's can result in
diabetic patients being at an increased risk of sternal wound infection
and other incisional related complications. This is because diabetic
patients have underlying vascular issues that can impede healing. I have
however, also seen papers that suggest that this increased risk is not
directly associated with the use of both IMA's, but is more simply a risk
for insulin dependent diabetics in general. Thus, the use of both IMA's
should be considered. A similar mix of conclusions has been suggested for
obese patients.
There are papers suggesting that the use of both IMA's has a long term
benefit associated with it over a single IMA used in combination with
veins. However, as you may have seen in a prior post, *very* preliminary
data suggest that the combination of the left IMA and the radial artery,
may yet be better. As I pointed out, these results are subject to both
confirmation or refutation, if a proper randomized and long term trial is
done. So, at this point, I would not put a lot of weight behind them.
As you can see, the data are still somewhat inconclusive and indeed can
support a variety of conclusions. This is the problem with some studies,
which are purely observational in nature, have small numbers of patients
involved and where they were not specifically designed around a particular
hypothesis, using randomization to treatment with clear parameters to
minimize bias. The good news about these types of studies is that they
hopefully get somebody in the field interested enough in the question, to
submit a research grant application, to get funding, to do a proper study.
Thus, ultimately, much of this process regarding graft conduit selection
will be up to surgeon preference based upon their own experience and bias.
As I mentioned in a prior post, the most common scenario today is still
the use of the left IMA in combination with veins in the case of multiple
coronary artery disease. Until such time as there is conclusive long term
evidence supporting other alternatives, you are likely to see a range of
techniques utilized.
From one Schwartz to another, the best thing Mel would be for you to sit
and talk with your cardiologist and surgeon to best understand
what was done and the rationale behind it, recognizing that even in the
five years since your surgery, some things have changed on "both sides of
the aisle". Only in that way can you address your specific situation and
questions with physicians who know you and your history closely and are
best in a position to make any disease management decisions with you.
I hope that helps to clarify.
Marc
