Arterial revascularization in primary coronary artery bypass grafting: Direct comparison of 4 strategies—Results of the Stand-in-Y Mammary Study
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Internal thoracic artery
Concomitant
Taggart et al 1 need to be congratulated on their post hoc analysis of their ART (Arterial Revascularization Trial) data.However, their work raises a number of questions.This study involved the nonrandomized use of the radial artery and, unsurprisingly, has demonstrated its superiority, in common with other nonrandomized publications. 2Nonrandomized trials usually involve patient selection as a major source of bias, hence the need for randomized trials.However, the largest randomized studies with regard to radial artery outcomes, performed by Hayward et al, 3 failed to identify any significant difference.ART was initially powered to investigate whether a survival difference between single and bilateral mammary artery use existed at 10 years, 4 drawing the power of the present analysis by Taggart et al into question.Of note, no power calculation was included in the article.The use of composite end points has been criticized widely from statistical, patient, and researcher points of view. 5The finding of no significant difference between myocardial infarction, cardiovascular death, and repeat revascularization when analyzed separately needs to be noted.By way of example, reanalysis of the data provided in Table 3 after matching with regard to death (1.4% versus 0.8%), return to operating room (4.3% versus 3%), renal replacement therapy (7.1% versus 5.7%), and sternal wounds (4% versus 3%) indicates that radial artery use is associated with a significantly worse outcome compared with saphenous vein graft only (16.8% versus 12.5%; P=0.03).Multiple imputation was used to address missing data.However, no mention was made of how much data were missing for this technique being used, potentially introducing a source of error.Taggart et al have to be congratulated in performing the ART trial; however, post hoc underpowered interpretation needs to be cautioned against.
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Nephrology
Uremic Toxins
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Internal thoracic artery
Derivation
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近年, 両側内胸動脈 (ITA) を用いた冠状動脈バイパス手術 (CABG) の良好な遠隔成績が報告されている. 当施設では, 両側ITAの使用を1993年より開始し, 1995年より積極的に行うようになった. そこで95年1月より97年12月までの全CABG 219例のうち両側ITAを使用した119例の手術成績を検討した. 右ITAは, 左前下行枝 (77), 対角枝 (8), 回旋枝 (14), 右冠動脈近位部 (12), 遊離として右冠動脈遠位部 (8) に用いた. 病院死亡は5例 (4.2%) であった. 術後合併症としては, 胸骨感染2例, LOS 2例で, 出血による再開胸はなかった. 同時期の一側ITAを使用したCABGや静脈のみのCABGと比較して, 術後創感染率, 無輸血手術率に差は認められなかった. また, high risk 症例においても, 一側ITAを用いたCABGと比較して手術リスクは同様であった. 両側ITAを用いたCABGの手術成績は満足できるものと考えられた.
Internal thoracic artery
Coronary arteries
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For over 40 years, the left internal thoracic artery has been used as the gold standard for myocardial revascularization and anastomosis over the left anterior descending artery due to its excellent patency rates. However, the right internal thoracic artery behaves in the same manner as the left, also having excellent long-term patency. Hence, no patient should be deprived of the benefits of total arterial revascularization allowed by the bilateral use of both internal thoracic arteries.
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Myocardial Revascularization
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Radial endothelial dysfunction may occur after transradial coronary angiography (CAG). This study aimed to make a comparative evaluation of the radial endothelial functions before and after catheterization between three different radial access sites: left radial (LR) artery, left distal radial (LDR) artery, and right radial (RR) artery.Seventy patients scheduled for elective transradial CAG and intervention from September 6, 2017 to March 6, 2018 were consecutively enrolled. Radial artery endothelial functions of the catheterization arm were measured by flow-mediated vasodilation (FMD) upon admission, at 24 hours, and 2 months following the procedure.LR access was used in 17 patients, whereas the LDR and the RR access were used in 27 and 26 patients, respectively. Basal radial diameters and FMD median values measured on the intervention arm were found to be similar between groups (LR 3.04±0.29 mm, 13.33%; LDR 2.79±0.31 mm; 13.64%; RR 2.74±0.29 mm; 12.52%, p=0.952). The radial vasodilation percentage change expressed as median decreased in all groups 24 hours after the procedure; however, the one with the LDR access was found to be significantly higher than with the LR (9.7% vs. 6.25% p=0.013) and the RR access (9.7% vs. 3.39 p<0.001). A partial recovery of endothelial functions was seen at 2 months after the procedure, approximating to basal values (11.11%; 12%; 10.62%, p=0.079, respectively).Radial artery functions deteriorate early after transradial catheterization. The LDR access seems safer than the other conventional radial access sites in terms of preservation of radial endothelial functions.
Cardiac catheterization
Basal (medicine)
Radial stress
Endothelial Dysfunction
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冠動脈バイパス術(CABG)において,われわれは左内胸動脈(LITA)採取時にphosphodiesterase III (PDE III)阻害剤をLITAへ直接注入し拡張させ,攣縮を予防することで血流量を増加させるよう,工夫している.今回,PDE III阻害剤とともに,塩酸パパベリン,硝酸イソソルビド(ISDN)を用い,LITAの薬剤反応性について比較検討した.CABG 42例を対象とし,各薬剤14例において薬剤投与前後のgraft free flow (GFF)と体血圧を計測し,血管抵抗(R)値を算出した.各薬剤でGFFIは有意に増加し,R値,体血圧は有意に低下した.いっぽう,各薬剤間の体血圧変化率に有意差はなく,PDE III阻害剤はほかの薬剤よりGFF変化率が有意に増加し,R値変化率が有意に低下した.この結果より,動脈グラフトの血流量増加にPDE III阻害剤はより有用であることが示唆された.
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