Re: True death rate from Coronary Bypass?

Discussion in 'Health and medical' started by Hawki63, Aug 23, 2003.

  1. Hawki63

    Hawki63 Guest

    >Subject: Re: True death rate from Coronary Bypass?
    >From: [email protected] (M. Schwartz)
    >Date: 8/23/2003 6:03 AM Pacific Daylight Time


    >What do you mean by "statistically...a well done cabg MIGHT mean some
    >kind of repeat intervention"?
    >
    >Mel, thinking about maxing his credit cards
    >
    >
    >
    >
    >
    >


    exactly that...no cardiac surgeon will shake your hand and say "you are cured
    for life"

    coronary artery disease CAD,,is not like appendicitis..ya takes out the bad
    organ and it can never bother you again..

    CABG as you know is the grafting of vessels from one part of your body to
    another..to "bypass" the narrowed coronary arteries...

    veins are NOT arteries..thus they CAN re narrow over time...also..other
    arteries in your heart could be narrowing as we speak...

    thus ....CABG does not come with a lifetime guarantee...you should know this...

    more recently done surgeries..where the internal mammary artery (IMA) is used
    as one of the grafts DO have a much better success rate...supposedly they can
    last for the rest of your life (because the IMA is an artery...the things in
    your legs are veins)..

    CAD is something you need to treat forever...you know the drill...

    I would be surprised if your surgeon or cardiologist didn't tell you this
    stuff...if not..they should have..

    sorry

    hawki


    hawki
     
    Tags:


  2. On Sat, 23 Aug 2003 16:34:59 +0000, Hawki63 wrote:

    SNIP

    > veins are NOT arteries..thus they CAN re narrow over time...also..other
    > arteries in your heart could be narrowing as we speak...
    >
    > thus ....CABG does not come with a lifetime guarantee...you should know
    > this...
    >
    > more recently done surgeries..where the internal mammary artery (IMA) is
    > used as one of the grafts DO have a much better success
    > rate...supposedly they can last for the rest of your life (because the
    > IMA is an artery...the things in your legs are veins)..



    Even the IMAs, radials, gastroepiploics and other arterial grafts develop
    stenoses over time. Arterial grafts are not immune (pardon the pun for
    the immunologists in the crowd) to the development of occlusive disease.

    Your coronary arteries are arteries, not veins... :)

    Arterial grafts do tend to last notably longer then vein grafts, which
    provides a superior outcome over time. In the case of an IMA graft to the
    LAD, an outcome superior to angioplasty and/or stents over time. For this
    reason, there is some use of hybrid procedures where an IMA to the LAD
    will be done in the O.R., in conjunction with stent placement in the cath
    lab to other coronary arteries in the case of multi-vessel disease. This
    will likely increase as the use of robotic techniques enable better
    technical approaches to minimally invasive off pump CAB surgery.

    There is even a short term benefit to the use of IMA grafts in terms of a
    documented reduction in 30 day mortality after CAB surgery. This finding
    has been published in several papers. As a result, over the past decade
    or so, the use of the IMA has increased to >80% of CAB procedures.

    There are surgeons around the country who are doing an increasing
    proportion of their CAB procedures using all arterial grafts, rather than
    a mix of arteries and veins, with superior outcomes. However, there are
    patient selection issues that can impact the ability to engage in this
    aggressive approach.

    HTH,

    Marc Schwartz
     
  3. 1024Bytes

    1024Bytes Guest

    On Sat, 23 Aug 2003 18:06:28 GMT, Marc Schwartz <[email protected]>
    wrote:

    >On Sat, 23 Aug 2003 16:34:59 +0000, Hawki63 wrote:
    >
    >SNIP
    >
    >> veins are NOT arteries..thus they CAN re narrow over time...also..other
    >> arteries in your heart could be narrowing as we speak...
    >>
    >> thus ....CABG does not come with a lifetime guarantee...you should know
    >> this...
    >>
    >> more recently done surgeries..where the internal mammary artery (IMA) is
    >> used as one of the grafts DO have a much better success
    >> rate...supposedly they can last for the rest of your life (because the
    >> IMA is an artery...the things in your legs are veins)..

    >

    [snip]
    >
    >Your coronary arteries are arteries, not veins... :)
    >


    >Marc Schwartz


    One question. My cardiac surgeon, who will be opening me for fun and
    profit next month, plans to use an artery from my arm (along with
    beating heart surgery) for a double bypass. What is the life
    expectency of the donor arm artery? What will be affect be on the arm
    he takes it from? Will my golf swing be just as bad as it was before
    or will I be weaker than heck on that side?
     
  4. M. Schwartz

    M. Schwartz Guest

    Marc Schwartz <[email protected]> wrote in message news:<[email protected]>...
    > On Sat, 23 Aug 2003 16:34:59 +0000, Hawki63 wrote:
    >
    > SNIP
    >
    > > veins are NOT arteries..thus they CAN re narrow over time...also..other
    > > arteries in your heart could be narrowing as we speak...
    > >
    > > thus ....CABG does not come with a lifetime guarantee...you should know
    > > this...
    > >
    > > more recently done surgeries..where the internal mammary artery (IMA) is
    > > used as one of the grafts DO have a much better success
    > > rate...supposedly they can last for the rest of your life (because the
    > > IMA is an artery...the things in your legs are veins)..

    >
    >
    > Even the IMAs, radials, gastroepiploics and other arterial grafts develop
    > stenoses over time. Arterial grafts are not immune (pardon the pun for
    > the immunologists in the crowd) to the development of occlusive disease.
    >
    > Your coronary arteries are arteries, not veins... :)
    >
    > Arterial grafts do tend to last notably longer then vein grafts, which
    > provides a superior outcome over time. In the case of an IMA graft to the
    > LAD, an outcome superior to angioplasty and/or stents over time. For this
    > reason, there is some use of hybrid procedures where an IMA to the LAD
    > will be done in the O.R., in conjunction with stent placement in the cath
    > lab to other coronary arteries in the case of multi-vessel disease. This
    > will likely increase as the use of robotic techniques enable better
    > technical approaches to minimally invasive off pump CAB surgery.
    >
    > There is even a short term benefit to the use of IMA grafts in terms of a
    > documented reduction in 30 day mortality after CAB surgery. This finding
    > has been published in several papers. As a result, over the past decade
    > or so, the use of the IMA has increased to >80% of CAB procedures.
    >
    > There are surgeons around the country who are doing an increasing
    > proportion of their CAB procedures using all arterial grafts, rather than
    > a mix of arteries and veins, with superior outcomes. However, there are
    > patient selection issues that can impact the ability to engage in this
    > aggressive approach.
    >
    > HTH,
    >
    > Marc Schwartz


    Where are they getting the arteries? I know about the mammary artery
    and that was one of my grafts. But you say they are using all arteries
    and where do they all come from? And what kind of arteries?

    I know the vein grafts aren't the same quality as the arteries they
    replace, but I like to think positively, although reading this stuff
    is making me downright nervous.

    Mel, counting the days...
     
  5. Hawki63

    Hawki63 Guest

    >Subject: Re: True death rate from Coronary Bypass?
    >From: [email protected] (M. Schwartz)


    >Where are they getting the arteries?


    Mel

    Marc was talking about the "radial" artery..from your lower forearm...not
    exactly sure why they would use that artery and not the brachial ..upper
    arm..but obviously there is a good reason!!

    >I know the vein grafts aren't the same quality as the arteries they
    >replace, but I like to think positively, although reading this stuff
    >is making me downright nervous.
    >


    you may...or may know ...know that veins have tiny valves in them..thus to use
    them as "conduits" so to speak..they are turned sorta "upside down"...which
    somewhat mimics the non valves in the arteries..also..the diameter of these
    veins is usually smaller than MOST arteries...thus perhaps the increased re
    occlusion over time

    ya know...it just occurred to me WHY my hubby "changed his time
    line"...originally after the cath that indicated that his LAD stents had re
    occluded..he was scheduled 3 weeks or so out...within 24 hours of exactly the
    kind of stress you are now experiencing...he waltzed into the house and
    announced "I don't want to wait...call Sue...cardiac surgeon's nurse back..and
    find our HOW SOON we can reschedule!!! By the end of the afternoon he was
    scheduled for 6 days later...best decision he ever made!!! (assuming of course
    that one CAN wait!! which apparently you both could...)

    don't count the days...go out and count the flowers!!! you need to be as
    destressed as possible...

    keep in touch..

    hawki


    hawki
     
  6. On Sat, 23 Aug 2003 23:26:02 +0000, Hawki63 wrote:

    >>Subject: Re: True death rate from Coronary Bypass?
    >>From: [email protected] (M. Schwartz)

    >
    >>Where are they getting the arteries?

    >
    > Mel
    >
    > Marc was talking about the "radial" artery..from your lower forearm...not
    > exactly sure why they would use that artery and not the brachial ..upper
    > arm..but obviously there is a good reason!!



    If they used the brachial, there is no other major artery in the arm to
    provide blood flow to the lower arm and hand. The brachial then
    bifurcates into the radial and ulnar. Using the radial artery, there is
    then the ulnar artery to provide an essentially parallel route for the
    blood flow to the lower arm and hand. The docs will then check to be
    sure, using certain tests, that if the radial artery were to be tied off
    for use as a graft, there is sufficient blood flow to the hand. If not,
    they will not use the radial or you of course risk damage to the hand.

    Other arteries that have been or are used are the gastro-epiploic artery
    and the inferior epigastric artery. As was mentioned, there is also the
    possibility of using both the right and left internal mammary arteries.
    Thus, there are several choices that can be used, depending upon the
    extent of native coronary disease and the availability of the above
    arteries. Also remember, that is it possible to use a single artery
    conduit to bypass more than one narrowing, by using what is called a
    "jump" graft technique. This depends upon the length of the artery and the
    locations of the narrowings.


    >>I know the vein grafts aren't the same quality as the arteries they
    >>replace, but I like to think positively, although reading this stuff is
    >>making me downright nervous.
    >>


    Mel, no reason to be nervous. The use of combinations of arteries and
    veins represents the overwhelming majority of CAB procedures performed.
    That is the present standard of care.

    As with any technology, in this case medical, there is always a
    distribution of new leading edge techniques and mainstream techniques. If
    the leading edge techniques demonstrate benefit, they are eventually
    adopted by the mainstream. That is the way it is done and for good reason.
    You don't make wholesale changes in the system until there is a clear
    benefit demonstrated to justify the change.


    > you may...or may know ...know that veins have tiny valves in them..thus
    > to use them as "conduits" so to speak..they are turned sorta "upside
    > down"...which somewhat mimics the non valves in the arteries..also..the
    > diameter of these veins is usually smaller than MOST arteries...thus
    > perhaps the increased re occlusion over time



    There also tends to be more side branching in the veins.

    All of these things provide irregularities in the interior surface of the
    vein, which results in turbulent blood flow. This type of flow can result
    in pooling and eddies in the vein, which can accelerate the accumulation
    of platelets and therefore narrowing.

    This is one of the key advantages of using the IMA over time. There is
    better flow, which results in better long term patency.


    > ya know...it just occurred to me WHY my hubby "changed his time
    > line"...originally after the cath that indicated that his LAD stents had
    > re occluded..he was scheduled 3 weeks or so out...within 24 hours of
    > exactly the kind of stress you are now experiencing...he waltzed into
    > the house and announced "I don't want to wait...call Sue...cardiac
    > surgeon's nurse back..and find our HOW SOON we can reschedule!!! By the
    > end of the afternoon he was scheduled for 6 days later...best decision
    > he ever made!!! (assuming of course that one CAN wait!! which apparently
    > you both could...)
    >
    > don't count the days...go out and count the flowers!!! you need to be
    > as destressed as possible...
    >
    > keep in touch..
    >
    > hawki



    Agreed.

    Marc
     
  7. Hawki63

    Hawki63 Guest

    >Subject: Re: True death rate from Coronary Bypass?
    >From: Marc Schwartz [email protected]


    >If they used the brachial, there is no other major artery in the arm to
    >provide blood flow to the lower arm and hand. The brachial then
    >bifurcates into the radial and ulnar. Using the radial artery, there is
    >then the ulnar artery to provide an


    >The docs will then check to be
    >sure, using certain tests, that if the radial artery were to be tied off


    ahhh...of course...Alllen's test!! I am an np!! tho obviously a bit rusty on
    some anatomy!!

    >There also tends to be more side branching in the veins.
    >


    hmmm...that I hadn't thought of...

    good info Mark


    hawki
     
  8. On Sun, 24 Aug 2003 16:55:02 -0400, 1024Bytes wrote:

    > Marc, you are right. The comment was tongue in cheek. It's probably the
    > result of the fact that the whole concept of bypass is driving me nuts
    > and I have been searching for virtually any alternative and have found
    > none. I do also believe that a little humor now and again isn't a bad
    > thing. I do understand, however, that surgeons still make a fine
    > living--a thing I am strongly in favor of. I believe talented people
    > should be well compensated for their good work. It's the purest form of
    > capitalism, a concept I strongly endorse.



    I can certainly appreciate your anxiety and apprehension. For as much as I
    can claim to know and for as many years as I have been in health care
    (which includes being married to a cardiovascular nurse for 22+ years), I
    can only attempt to anticipate my own state of mind if confronted with the
    decisions you face.

    Ultimately, given my nature, I would seek as much information as I could,
    explore all options and then, in consultation with my physicians and
    family, come to an informed decision. Having the knowledge base that I do,
    I also recognize that there are no absolutes. There is no option,
    including doing nothing, that has a 0% risk associated with it. Much of
    the decision making is based upon probabilities and those probabilities
    are based upon both scientific fact and assumptions. There are things that
    we know, things that we think we know and things that we clearly don't
    know. Thus, the "art" as well as the science of medicine and the basis for
    a spectrum of opinions in the field.

    Last evening, I watched "Failure Is Not An Option" on The History Channel.
    It is about the NASA ground based flight controllers and related personnel
    during the early days of the space program (Mercury, Gemini and Apollo). I
    recall many of those episodes and names from my childhood. Indeed it was
    the awe inspiring, heady nature of those days that led me to major in
    astrophysics and biochemistry in college. Now as an adult with a more
    educated appreciation for what these folks experienced, the challenges
    they faced and the risks that they took, you get a feel for how much they
    knew and how much they did not yet know. Doing all of this with slide
    rules and relatively primitive technology and computers relative to what
    we have today. With all of the expertise available, risks were taken,
    formulas and calculations were tested and validated, accountability
    assumed and decisions made.

    In many respects, it is the same here. In the end, information and
    communication are critical to enabling an appropriate decision. Once that
    decision is made, commit to it, believe in it, have faith and move
    forward. You have to go in believing "Failure is not an option". I know
    that your surgeon and the rest of the team will, because that is who they
    are.

    I do sincerely wish you and your family a successful outcome.

    Best regards,

    Marc
     
  9. 1024Bytes

    1024Bytes Guest

    Your kind encouragement is much appreciated.



    On Mon, 25 Aug 2003 07:57:08 -0500, Marc Schwartz
    <[email protected]> wrote:

    >On Sun, 24 Aug 2003 16:55:02 -0400, 1024Bytes wrote:
    >
    >> Marc, you are right. The comment was tongue in cheek. It's probably the
    >> result of the fact that the whole concept of bypass is driving me nuts
    >> and I have been searching for virtually any alternative and have found
    >> none. I do also believe that a little humor now and again isn't a bad
    >> thing. I do understand, however, that surgeons still make a fine
    >> living--a thing I am strongly in favor of. I believe talented people
    >> should be well compensated for their good work. It's the purest form of
    >> capitalism, a concept I strongly endorse.

    >
    >
    >I can certainly appreciate your anxiety and apprehension. For as much as I
    >can claim to know and for as many years as I have been in health care
    >(which includes being married to a cardiovascular nurse for 22+ years), I
    >can only attempt to anticipate my own state of mind if confronted with the
    >decisions you face.
    >
    >Ultimately, given my nature, I would seek as much information as I could,
    >explore all options and then, in consultation with my physicians and
    >family, come to an informed decision. Having the knowledge base that I do,
    >I also recognize that there are no absolutes. There is no option,
    >including doing nothing, that has a 0% risk associated with it. Much of
    >the decision making is based upon probabilities and those probabilities
    >are based upon both scientific fact and assumptions. There are things that
    >we know, things that we think we know and things that we clearly don't
    >know. Thus, the "art" as well as the science of medicine and the basis for
    >a spectrum of opinions in the field.
    >
    >Last evening, I watched "Failure Is Not An Option" on The History Channel.
    >It is about the NASA ground based flight controllers and related personnel
    >during the early days of the space program (Mercury, Gemini and Apollo). I
    >recall many of those episodes and names from my childhood. Indeed it was
    >the awe inspiring, heady nature of those days that led me to major in
    >astrophysics and biochemistry in college. Now as an adult with a more
    >educated appreciation for what these folks experienced, the challenges
    >they faced and the risks that they took, you get a feel for how much they
    >knew and how much they did not yet know. Doing all of this with slide
    >rules and relatively primitive technology and computers relative to what
    >we have today. With all of the expertise available, risks were taken,
    >formulas and calculations were tested and validated, accountability
    >assumed and decisions made.
    >
    >In many respects, it is the same here. In the end, information and
    >communication are critical to enabling an appropriate decision. Once that
    >decision is made, commit to it, believe in it, have faith and move
    >forward. You have to go in believing "Failure is not an option". I know
    >that your surgeon and the rest of the team will, because that is who they
    >are.
    >
    >I do sincerely wish you and your family a successful outcome.
    >
    >Best regards,
    >
    >Marc
     
  10. M. Schwartz

    M. Schwartz Guest

    Marc Schwartz <[email protected]> wrote in message news:<[email protected]>...
    > On Sat, 23 Aug 2003 23:26:02 +0000, Hawki63 wrote:
    >
    > >>Subject: Re: True death rate from Coronary Bypass?
    > >>From: [email protected] (M. Schwartz)

    >
    > >>Where are they getting the arteries?

    > >
    > > Mel
    > >
    > > Marc was talking about the "radial" artery..from your lower forearm...not
    > > exactly sure why they would use that artery and not the brachial ..upper
    > > arm..but obviously there is a good reason!!

    >
    >
    > If they used the brachial, there is no other major artery in the arm to
    > provide blood flow to the lower arm and hand. The brachial then
    > bifurcates into the radial and ulnar. Using the radial artery, there is
    > then the ulnar artery to provide an essentially parallel route for the
    > blood flow to the lower arm and hand. The docs will then check to be
    > sure, using certain tests, that if the radial artery were to be tied off
    > for use as a graft, there is sufficient blood flow to the hand. If not,
    > they will not use the radial or you of course risk damage to the hand.
    >
    > Other arteries that have been or are used are the gastro-epiploic artery
    > and the inferior epigastric artery. As was mentioned, there is also the
    > possibility of using both the right and left internal mammary arteries.
    > Thus, there are several choices that can be used, depending upon the
    > extent of native coronary disease and the availability of the above
    > arteries. Also remember, that is it possible to use a single artery
    > conduit to bypass more than one narrowing, by using what is called a
    > "jump" graft technique. This depends upon the length of the artery and the
    > locations of the narrowings.
    >
    >
    > >>I know the vein grafts aren't the same quality as the arteries they
    > >>replace, but I like to think positively, although reading this stuff is
    > >>making me downright nervous.
    > >>

    >
    > Mel, no reason to be nervous. The use of combinations of arteries and
    > veins represents the overwhelming majority of CAB procedures performed.
    > That is the present standard of care.
    >
    > As with any technology, in this case medical, there is always a
    > distribution of new leading edge techniques and mainstream techniques. If
    > the leading edge techniques demonstrate benefit, they are eventually
    > adopted by the mainstream. That is the way it is done and for good reason.
    > You don't make wholesale changes in the system until there is a clear
    > benefit demonstrated to justify the change.
    >
    >
    > > you may...or may know ...know that veins have tiny valves in them..thus
    > > to use them as "conduits" so to speak..they are turned sorta "upside
    > > down"...which somewhat mimics the non valves in the arteries..also..the
    > > diameter of these veins is usually smaller than MOST arteries...thus
    > > perhaps the increased re occlusion over time

    >
    >
    > There also tends to be more side branching in the veins.
    >
    > All of these things provide irregularities in the interior surface of the
    > vein, which results in turbulent blood flow. This type of flow can result
    > in pooling and eddies in the vein, which can accelerate the accumulation
    > of platelets and therefore narrowing.
    >
    > 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
    >
    >
    > > ya know...it just occurred to me WHY my hubby "changed his time
    > > line"...originally after the cath that indicated that his LAD stents had
    > > re occluded..he was scheduled 3 weeks or so out...within 24 hours of
    > > exactly the kind of stress you are now experiencing...he waltzed into
    > > the house and announced "I don't want to wait...call Sue...cardiac
    > > surgeon's nurse back..and find our HOW SOON we can reschedule!!! By the
    > > end of the afternoon he was scheduled for 6 days later...best decision
    > > he ever made!!! (assuming of course that one CAN wait!! which apparently
    > > you both could...)
    > >
    > > don't count the days...go out and count the flowers!!! you need to be
    > > as destressed as possible...
    > >
    > > keep in touch..
    > >
    > > hawki

    >
    >
    > Agreed.
    >
    > Marc
     
  11. On Tue, 26 Aug 2003 10:28:41 -0700, M. Schwartz wrote:

    > Marc Schwartz <[email protected]> wrote in message
    > news:<[email protected]>...


    SNIP

    >> 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
     
  12. Julianne

    Julianne Guest

    "Marc Schwartz" <[email protected]> wrote in message
    news:p[email protected]
    > On Tue, 26 Aug 2003 10:28:41 -0700, M. Schwartz wrote:
    >
    > > Marc Schwartz <[email protected]> wrote in message
    > > news:<[email protected]>...

    >
    > SNIP
    >
    > >> 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.


    I did not know that. Thanks for posting.

    j
    > 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
    >
     
Loading...