BITA Grafting: Indian Plus Global Trends by Lokeswara Rao Sajja - STAR Hospitals

BITA Grafting : Indian + Global Trends
Lokeswara Rao Sajja, MD
Star Hospitals,
Sajja Heart Foundation
Hyderabad, India

Introduction
International Coronary Congress 2016, New Delhi , 11-13th ,Nov 2016
As the techniques of surgical and percutaneous coronary
revascularization for coronary artery disease continue to
evolve, reassessing the available data to know the
trends is necessary to inform decision making and
should take place periodically
 to improve quality of care
 optimize individual patient outcomes
 favorably affect costs by focusing resources on
the most effective strategies

 Trends in frequency of BITA usage
 Trends in graft configuration ( Y graft / in situ)
 Trends in conduit harvest techniques -
(skeletonized / pedicled)
 Trends in the techniques of revascularization
(Off-pump / On-pump)
 Trends in incidence of DSWI
 Trends in outcomes of BITA grafting strategy
Trends of BITA grafting strategy

Trends in frequency of BITA usage

Year # of
hosp
LITA
/ SV %
LITA/
RA %
BITA
%
BITA/
RA %
2004 620 85.2 10.5 3.6 0.7
2005 717 86.8 8.6 3.9 0.7
2006 798 88.1 7.3 4.0 0.6
2007 875 88.4 6.8 4.1 0.6
2008 948 89.6 5.8 4.0 0.6
2009 982 89.9 5.7 3.9 0.5
2010 1013 90.8 5.0 3.8 0.4
2011 1030 90.8 4.3 4.4 0.4
2012 1024 91.1 4.0 4.5 0.4
2013 1005 91.5 3.6 4.5 0.4
2014 1005 91.7 3.7 4.3 0.3
USA CABG volumes (STS)
: 2004-2014

Year # of
hosp
LITA/
SV %
LITA/
RA %
BITA
%
BITA/
RA %
2004 6 17.3 65.8 6.3 10.6
2005 6 19.5 68.1 4.8 7.6
2006 6 25.6 63.2 3.5 7.7
2007 10 36.9 51.4 3.6 8.1
2008 16 47.1 43.3 3.8 5.8
2009 21 49.8 38.8 5.5 5.9
2010 24 53.2 36.7 5.3 4.8
2011 24 53.6 36.7 4.8 4.9
2012 24 55.6 35.2 4.6 4.6
2013 24 58.1 34.4 2.9 4.6
2014 24 51.4 39.0 3.6 6.0
AUS/NZ CABG volumes
: 2004-2014

Country Author Year
BITA
Usage
Europe
Kappatein AP 2006 12
Elbardissi AW 2012 10
Falk V 2013 20
Head SJ 2014 30.6
Germany Deutsh O 2015 <20
UK
Taggart DP 2002 10
2011 10
Sweden
Dalen M
1997 45(1.10)
2000 57(1.21)
2001 71(1.49)
2005 35(0.96)
2006 33(0.94)
2007 39(1.15)
2008 16(0.51)

Usage of BITA in SYNTAX trial
CABG (N=897)
Off-pump surgery, % 15.0
Graft revascularization, %
At least one arterial graft 97.3
Arterial graft to LAD 95.6
LIMA+venous 78.1
Double LIMA/RIMA 27.6
Complete arterial revascularization 18.9
Radial artery 14.1
Venous graft only 2.6
Grafts per patient, mean ± SD 2.8  0.7
Distal anastomosis/pt, mean ± SD 3.2  0.9
Serruys PW , Mohr FW
On behalf of the SYNTAX investigators

Country Author Year
Annual number
of CABG for
DM patients
Annual no of
BITA grafting
for DM patients
BITA Usage (%)
Japan
Hirose H
(1,123
patients)
1997 129 30 23
1998 122 41 34
1999 88 34 39
2000 103 44 43
2001 109 62 57
2002 33 20 61
Hirose H et al.Interactive Cardiovascular and Thoracic Surgery 2 (2003) 287–292

Country Author Year Usage
India
Sajja et al 2001-2010 11
BITA Survey 2016 10
The frequency of usage of BITA grafting in India

 Approximately 5% of all primary isolated
CABG cases in the STS database have BITA
 EACTS : 10%
 India : 10%
 A few isolated centers all over the world have
higher frequency of BITA grafting compared
to their national averages
Current Global trends

Trends in graft configuration
( Y graft / in situ)

 1985 to 1988 - the RITA was used as an in situ graft where
possible
 1988 to 1994 - preference was given to using the RITA as a free
graft because of its flexibility
 From 1995 - the RITA was used more frequently as an in situ
graft to the left side (to the LAD or diagonal coronary arteries)
Graft configuration is the second important factor influencing the
functionality equation between graft flow and native coronary
flow and thereby the choice of graft
Glineur D. The choice of the second graft. Rev Esp Cardiol. 2013;66(6):427–431
Trends in graft configuration ( Y graft / in situ)

There are 3 major assembly strategies for revascularizing
the left coronary system with BITA
3) in situ LITA to the left anterior descending territory and
free RITA implanted in a Y or T fashion into the LITA
1) in situ left internal thoracic artery to the left anterior
descending territory and in situ RITA to the circumflex
territory through the transverse sinus
2) in situ RITA to the left anterior descending and in situ
LITA to the circumflex territory

Results from Indian Survey

Bilateral in-situ : RITA - LAD Bilateral in –situ : RITA - RCA
Free RITA : RITA Y -graft Free RITA : RITA to aorta

Trends in conduit harvest techniques
(skeletonized / pedicled)

Trends in pedicled harvest
 The use of pedicled BITA grafts carries increased risk
for DSWI after CABG among diabetic patients
 In non-diabetics still large proportion of the patients
receive pedicled BITA grafts
Author Year Institute Period Harvest BITA # DM(%)
Pick 1997 Mayo Clinic 1984-1986 Pedicled 160 17.5
Buxton 1998 Austin and Repatriation Medical Centre 1985-1995 Pedicled 1269 6.8
Stevens 2004 Mountreal Heart Institute 1985-1995 Pedicled 1808 11.8
Carrier 2009 Montreal Heart Institute 1995-2007 Pedicled 69 20.6
Grau 2012 Valley Heart and Vascular Insititue 1994-2010 Pedicled 928 10.8
Kelly 2012 Queen Elizabeth II Health Sciences centre 1995-2009 Pedicled 1079 25.6

 The use of skeletonized BITA grafts can reduce the risk of
DSWI both in diabetics and non-diabetics
 There is an increasing trend in the usage of skeletonized
BITA grafts in diabetics and also in non-diabetics
Trends in skeletonized harvest
Author Year Institute Period Harvest BITA # DM(%)
Endo 2001 Tokyo Womens Medical University 1985-1998 Skeletonized 443 42.9
Bonacchi 2006 Univeristy of Florence 1997-2003 Skeletonized 320 30.0
Kurlansky 2010 Florida Heart Research Institute 1972-1994 Skeletonized 2215 20.8
Kinoshita 2012
Shiga University of Medical
Sciencs
2002-2010 Skeletonized 217 55.8
Navia 2013
Institute of Cardiovascular of
Buenos Aries
2003-2011 Skeletonized 149 30.8

Results from Indian Survey

Impact of pedicled and skeletonized on
rate of sternal wound infection in diabetics
Raja SG. Bilateral internal mammary artery grafting in diabetics: Outcomes,
concerns and controversies. International Journal of Surgery 2015; 16: 153-157

Trends in the techniques of surgical
revascularization (on-pump/off-pump)

Author Year
Type of
technique
2000-2003 2009-2012 P Value
Kindo M 2016 On-pump 294 (32.7%) 1022 (81.8%) <0.0001
Author Year
Type of
technique
Period % of BITA usage
Joo HC
Ann Thorac
Surg 2012
Off-pump 2000-2009 392 (22.4%)
Author Year
Type of
technique
Period % of BITA usage
Jeong DS
Ann Thorac
Surg 2015
Off-pump 2001-2010 100
Trends in the techniques of surgical revascularization
(on-pump/off-pump)

BITA grafting trends in patient subsets

Year Author No. of
patients
BITA
DM
DSWI
DM
BITA
Non DM
DSWI
Non DM
1999 Hirotani et al 420 74 1.9 78 1.9
2001 Matsa et al 765 231 2.6 534 1.7
2004 Bical et al 712 164 1.1 548 1.2
2007 Martins et al 700 148 1.35 552 0.9
2012 Sajja et al 342 181 0.5 161 0.6
2013 Raja et al 909 390 1.8 519 1.7
Diabetics / Non – diabetics receiving BITA grafting
Raja SG. Bilateral internal mammary artery grafting in diabetics: Outcomes, concerns and
controversies. International Journal of Surgery 2015; 16: 153-157
BITA grafting strategy is increasingly applied in diabetics as the
incidence of DSWI decreases

 Decreased incidence of postoperative MI
 Decreased requirement of IABP support
 Marginal decrease in early mortality
Trends in early outcomes of BITA grafting
Kindo M. Trends in isolated coronary artery bypass grafting over the last decade.
Intractive Cardiovasc Surg. 2016;1-6

 Trends of increasing use of BITA grafting globally
 Increased usage of BITA grafting in diabetics ,
elderly
 In-situ LITA and RITA grafting strategy to the left
coronary system is becoming more popular
 LITA and free RITA ( Y graft ) strategy is preferable
if more number of grafts to be used in LCx and RCA
territories
Conclusions

 Increasing trend in skeletonized harvesting of
bilateral ITA graft in diabetic patients
 Pedicled or skeletonized BITA grafts in non-diabetic
patients
 Modified pedicled harvest with sparing of ITA
bifurcation to the chest wall in all subsets of patients
Conclusions ( Cont…)

 There is a declining trend in the incidence of
DSWI with skeletonization , modified pedicled
harvest and preoperative HbA1c < 7.0%
 Declining trends of postoperative morbidity and
mortality with BITA grafting strategy
 Judicious use of BITA grafting in uncontrolled
diabetics, females and obese patients
Conclusions ( Cont…)

 As an adjunct to LITA, a second arterial graft (RITA or RA) should
be considered in appropriate patients (COR IIa, LOE B)
 Use of BITAs should be considered in patients who do not have an
excessive risk of sternal complications (COR IIa, LOE B)
 To reduce the risk of sternal infection with BITA consider the
following:
 Skeletonized grafts should be considered (COR IIa, LOE B)
 Smoking cessation is recommended (COR I, LOE C)
 Glycemic control should be considered (COR IIa, LOE B)
 Enhanced sternal stabilization may be considered (COR IIb,
LOE C)
Current recommendations for
BITA grafting strategy

BITA grafting : The most effective therapy
still
underutilized
for
Multi-vessel CAD patients
Globally

BITA Grafting: Indian Plus Global Trends by Lokeswara Rao Sajja - STAR Hospitals

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