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Democratizing The Use Of Bilateral Internal Thoracic Artery Grafts In Coronary Bypass Surgery: The Value Of A Robotic Approach
Yazan AlJamal1, Sarah Nisivaco
2, Riya Bhasin
1, Hiroto Kitahara
1, Gianluca Torregrossa
3, Husam H. Balkhy
1.
1University of Chicago, Chicago, IL, USA,
2University of northwestern, Chicago, IL, USA,
3Lankenau Medical Center, Wynnewood, PA, USA.
Introduction: Bilateral internal thoracic artery (BITA) grafting is associated with superior long-term outcomes in CABG. However, its use has been limited in high-risk populations— advanced age, morbid obesity, IDDM, COPD, or ESRD. Robotic off-bump beating-heart totally endoscopic coronary artery bypass (TECAB) offers a sternal-sparing, least invasive alternative, potentially overcoming these barriers. We reviewed our TECAB series and identified patients who underwent robotic BITA grafting but would have been excluded for BITA, with traditional sternotomy because of their higher risk. We compared their peri-operative and long-term outcomes with patients who had TECAB with BITA grafts without these risk factors.
Methods: Of 927 consecutive TECAB patients at our institution between 8/2013-11/2024, 429 patients had BITA grafting. Patients were categorized into two groups: 308 low-risk patients (without significant comorbidities) and 121 high-risk patients (with one or more of the following: age >80, BMI >40, IDDM, COPD, or on dialysis). Perioperative and long-term data were compared between groups.
Results: High-risk patients had significantly higher rates of hypertension, dyslipidemia, PVD, smoking history, previous MI, previous PCI, lower ejection fraction and higher STS score (2.5 vs 0.9; p<0.05) compared to low-risk patients. TECAB was successfully performed in all patients without conversions and there were no wound infections. 88% of high-risk patients had TECAB x2, 10.7% had TECAB x3. There were no significant differences in mean operative time (326 vs 322 minutes; p=0.52) or blood transfusion (14% vs 10%; p=0.19). Mean length of ICU (1.4 vs 1.1 days; p=0.02) and hospital stay (2.6 vs 2.3 days; p=0.001) were longer in the high-risk patients. In-hospital mortality was 1% (5/486) with nonsignificant difference between groups (p=0.55). At mean follow-up of 52.5 months cardiac-related mortality, repeat revascularization, and freedom from MACCE were similar between groups (3% vs 1.9%; 5.7% vs 6%; and 88.4% vs 87% respectively).
Conclusion: In patients who had traditional risk factors for increased morbidity with BITA grafting, the application of a robotic endoscopic approach resulted in similar outcomes to patients without such risk factors. By eliminating the traditional risks of open surgery, this technique can enable a broader adoption of BITA utilization in patients previously considered non candidates.
Table | BITA in patients with no RFs | | BITA in patients with (+) RFs | | |
| Number of patients | % | Number of patients | % | P Value |
| Mean Follow up (months) | 52.56 | | 47.35 | | 0.188 |
| Prior Myocardial infarction | 64 | 20% | 43 | 35.5% | 0.0014 |
| STS score | 0.9 | | 2.511 | | 0.00001 |
| Conversion to CPB | 3 | 0.9% | 1 | 0.8% | NS |
| OR Time (minutes) | 322.8 | | 326 | | 0.52 |
| Intraoperative blood transfusion | 14 | 4.5% | 10 | 8% | 0.13 |
| LOS (days) | 2.37 | | 2.58 | | 0.02 |
| Freedom from MACCE | 269 | 87% | 107 | 88.4% | 0.57 |
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