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PubMed2004

[Changes in tissue plasminogen activator and plasminogen activator inhibitor during administration of nitroglycerine into internal thoracic artery in dogs with acute myocardial ischemia].

OBJECTIVE: To study the changes in tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI) in a model of acute myocardial infarction reproduced in the dog with administration of nitroglycerin into internal thoracic artery under pressure. METHODS: Sixty healthy cross-breed dogs were randomly divided into experimental and control group with 30 dogs in each group. The animal model of acute myocardial ischemia was reproduced by ligating the left anterior descending coronary artery. Internal thoracic artery in the experimental group was ligated, and a tube was introduced into the proximal end. Nitroglycerine was infused under pressure into the internal thoracic artery in experimental group. The drug was given intravenously in control group. t-PA and PAI were measured before anterior coronary artery ligation and at 0.5, 2 and 6 hours after coronary artery ligation. RESULTS: The t-PA levels in two groups were increased at 0.5 hour after coronary artery ligation, and gradually declined in control group, while no obvious change was found in experimental group. There was significant difference between experimental group and control group at 6 hours after coronary artery ligation(P<0.05). PAI levels were increased after coronary artery ligation, peaking at 6 and 2 hours after coronary artery ligation in both groups. Significant difference in PAI level was observed between two groups at 6 hours after coronary artery ligation(P<0.05). CONCLUSION: Introduction of nitroglycerine through internal thoracic artery under pressure is effective to accelerate release of t-PA from the endothelium while inhibit secretion of PAI, therefore it is useful to modulate the balance of fibrinolysis.

Animals↗
PubMedDate not supplied

Double supply to left anterior descending artery by additional saphenous vein graft in internal thoracic artery malperfusion syndrome.

OBJECTIVE: Internal thoracic artery (ITA) grafting to the left anterior descending artery (LAD) may have catastrophic consequences and can be fatal due to "ITA malperfusion syndrome." We have investigated the efficacy of a second graft in this syndrome. METHODS: A total of 35 patients, 29 males (82.9%) and 6 females (17.1%), with a mean age of 53.0 +/- 8.7, (range: 38 to 70) undergoing coronary artery bypass grafting required a second supply to LAD due to ITA malperfusion syndrome. This was performed using a saphenous vein graft. The mean number of distal anastomosis was 2.7 +/- 0.45 per patient (range: 1 to 5). The decision for an additional grafting procedure was made in the first operation for 18 patients (51.4%) (Group I). For the remaining 17 patients (48.6%) (Group II), the additional grafting procedures were performed during a reoperation after the development of ischemic complications in the intensive care unit (ICU). RESULTS: The early mortality rate was 8.6% (3 of 35). Two patients had perioperative myocardial infarction (MI) (5.7%). The second vein graft proved to dramatically reduce the incidence of postoperative MI. Malignant refractory arrhythmias were recorded in 17 patients (48.6%). Twelve patients (34.3%) required inotropic support and seven patients (20%), all in Group II, required intra-aortic balloon pump (IABP) support. The average duration of IABP was 5 days +/- 1.8 days (range: 3 to 7). The necessity of IABP support was found to be statistically higher in the second group compared to the first one. CONCLUSIONS: Double supply to LAD using an additional saphenous vein graft is the treatment of choice for ITA malperfusion syndrome. The time interval between the first and the second grafts appears to be crucial for postoperative patient outcome.

Adult↗
PubMed1994

Duplex sonography of the internal thoracic artery. Preoperative assessment.

Ultrasonic duplex scanning was used to examine 211 internal thoracic arteries. The investigating vessels were classified as normal, abnormal, and occluded. The results of the duplex examination were compared with angiography as the reference method. The diameter measurements showed virtually no differences between the two methods. Normal internal thoracic arteries showed a continuous decrease of the systolic flow velocities from proximal to distal and a narrow to moderate spectral flow curve, whereas arteries classified as abnormal showed a velocity profile distinct from that--in particular, no decrease of the systolic peak velocities and an increased spectral broadening during systole with peak frequencies greater than 4 kHz at 60 degrees (> 1.2 m/sec). In occluded vessels no flow could be detected. The majority of changes were found in the proximal part of the internal thoracic artery. All lesions were detected by duplex sonography. Six normal vessels were misjudged as abnormal by the duplex method. The sensitivity, specificity, and accuracy of duplex sonography compared with angiography as the reference method were 100% (95% CI, 74.4% to 100%), 96.9% (95% CI, 93.2% to 98.8%), and 97.2% (95% CI, 93.6% to 98.8%), respectively. Duplex sonography is a reliable, noninvasive technique for the preoperative assessment of the internal thoracic artery. It allows the detection of potential atherosclerotic changes in the internal thoracic artery and the assessment of adequacy of caliber and flow.

Adult↗
PubMed1997

Effect of altered blood flow on the caliber and morphology of the internal thoracic artery in the dog.

OBJECTIVE: The purpose of this study was to evaluate in dogs the effect of blood flow alteration on caliber and morphology of in situ internal thoracic arteries. METHODS: Six dogs underwent creation of a unilateral distal arteriovenous fistula between the internal thoracic artery and vein at the sixth rib to create high flow, and in six others the internal thoracic artery was unilaterally skeletonized and dissected. For both groups the contralateral internal thoracic artery served as the control; sides were alternated among cases. Blood flow was measured for shear stress calculation before and after surgical alteration. After 2 months, internal thoracic arteries were harvested with the entire anterior chest plate, which was dynamically inflated and fixed with 10% formalin at a controlled pressure of 120 mm Hg after angiography had been done at the same pressure. The luminal diameters were then measured at eight levels on the angiograms. Arterial tissue samples were taken at three levels and embedded, sectioned, and treated with hematoxylin-eosin and Verhoeff-van Gieson stains. Digital imaging analysis was used for quantitative morphometric studies. RESULTS: All fistulas remained patent. In comparison with control arteries, high-flow internal thoracic arteries dilated and low-flow internal thoracic arteries narrowed, which was associated with significant change in shear stress for both groups. There were no substantial structural changes in the walls of either group. CONCLUSION: In the dog, the luminal diameter of the internal thoracic artery responds to altered blood flow without intimal thickening or other undesirable wall changes.

Animals↗
PubMed1996

Changing flow pattern of the internal thoracic artery undergoing coronary bypass grafting: continuous-wave Doppler assessment.

Surgeons have limited ability to evaluate intraoperatively the patency of internal thoracic artery graft as a bypass for coronary artery revascularization. We used continuous-wave Doppler ultrasonography to study the velocity of the internal thoracic artery before harvesting and after grafting (scanning probe, 8 MHz). Systolic and diastolic frequency shift (in kilohertz) and systolic frequency/diastolic frequency index were analyzed. Twenty four internal thoracic artery grafts in 15 patients were studied. Fourteen internal thoracic artery grafts were anastomosed to the left anterior descending artery, one to a diagonal artery, and nine to the circumflex artery. The mean systolic frequency before harvesting was 1.19 +/- 0.40 KHz and no significant differences were found between the right and the left internal thoracic artery (right, 1.17 +/- 0.37; left, 1.19 +/- 0.42 KHz). There was a 40% drop in systolic frequency related to the harvesting. Mean systolic frequency decreased after grafting (1.19 +/- 0.40 versus 0.87 +/- 0.32 KHz; p < 0.01) whereas mean diastolic frequency doubled (0.32 +/- 0.12 versus 0.83 +/- 0.4 KHz; p < 0.001) and mean diastolic frequency/systolic frequency index increased from 28% +/- 11% to 101% +/- 39% (p < 0.001), indicating an increased myocardial vascularization during diastole. No significant difference was found between grafted arteries (left anterior descending versus circumflex). All patients had an uneventful postoperative course and no perioperative myocardial infarction was reported. Doppler flow quantification of internal thoracic artery bypasses may give the surgeon an opportunity to evaluate intraoperatively the physiologic features and patency of the internal thoracic artery before and after coronary artery bypasses.

Aged↗
PubMed2004

Should the internal thoracic artery be skeletonized?

Traditionally, the internal thoracic artery is harvested as a pedicle. In contemporary cardiac surgical practice, however, certain surgeons practice the internal thoracic artery-skeletonization technique. A systematic review of clinical studies reporting on the use of skeletonized internal thoracic arteries (SKT-ITA) has not yet been performed. The primary aim of this review article is to examine comprehensively the entire body of evidence regarding the use of SKT-ITA. In particular, we aimed to analyze the effects of skeletonization on sternal blood supply, wall damage and blood flow in the harvested vessel, postoperative graft patency, and clinical outcome. Advantages and disadvantages of the skeletonization technique are highlighted and discussed.

Coronary Artery Bypass↗
PubMed2003

In situ retrocaval skeletonized right internal thoracic artery anastomosed to the circumflex system via transverse sinus: technical aspects and postoperative outcome.

BACKGROUND: The aim of this study was to investigate whether, by using the in situ right internal thoracic artery via the transverse sinus (eventually retrocaval), both the proximal and distal major branches of the circumflex system could be grafted and to evaluate the early and late outcome in these patients. METHODS: Between January 1997 and March 2002, 452 consecutive patients underwent grafting of the circumflex system with the in situ skeletonized right internal thoracic artery routed via the transverse sinus. The mean age was 62.4 +/- 10.3 years. A mean of 2.2 +/- 0.3 arterial grafts per patient were used, and 271 (60%) patients underwent total arterial myocardial revascularization. At 3 months after surgery, 86 patients (right Y or T graft) underwent echo color Doppler imaging before and after an adenosine provocative test. The mean follow-up was 27 +/- 8 months. RESULTS: The success rate of skeletonized right internal thoracic artery grafting to the circumflex system branch was 100%. There were 15 (3.4%) hospital deaths. In 116 patients who underwent postoperative angiography, the total patency rates of the right and left internal thoracic arteries were 94% and 96.6%, respectively. Strong predictors for nonfunctional internal thoracic artery grafts were a small internal thoracic artery caliber (P <.001), recipient coronary artery diameter less than 1.5 mm (P =.012), stenotic lesions of less than 60% (P =.016), and diffuse stenotic lesions (P =.015) of the recipient coronary artery. In 86 patients who underwent postoperative echo color Doppler imaging, the flow reserves at the main stem of the left and right internal thoracic arteries were 2.24 +/- 0.5 and 2.48 +/- 0.6, respectively. Cumulative actuarial survival at 3 years was 96.3%, and event-free cumulative survival was 93%. The Cox model revealed a left ventricular ejection fraction of less than 35% (P =.016), age greater than 70 years (P =.025), New York Heart Association grade greater than III (P =.0019), nontotal arterial myocardial revascularization (P =.002), and the preoperative presence of more than 1 ischemic area (P <.001) as strong predictors for poor overall cumulative event-free survival. CONCLUSIONS: The skeletonized right internal thoracic artery, placed via the transverse sinus and eventually retrocaval, can reach most branches of the circumflex system and is associated with an excellent patency rate. The predictors for poor overall event-free survival seem to be similar to those of the general population undergoing conventional coronary artery bypass grafting. Use of bilateral internal thoracic arteries and in situ right internal thoracic artery grafting via the transverse sinus offers the possibility of various configuration constructions, making possible total arterial myocardial revascularization with a minimum number of arterial conduits.

Adult↗
PubMed1997

Prevention of internal thoracic artery spasm.

Perioperative spasm of the internal thoracic artery is a common experience in coronary artery bypass grafting. We describe a simple method of harvesting the internal thoracic artery with improved ease of dissection that helps to prevent the arterial spasm.

Coronary Artery Bypass↗
PubMed2000

Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older.

OBJECTIVES: Higher patency rates of the internal thoracic artery have led myocardial revascularization with bilateral internal thoracic arteries to be a procedure designated primarily for young patients. Fewer leg wound complications and sternal collateral flow preservation with the skeletonizing dissection technique can make bilateral internal thoracic artery grafting attractive also for elderly patients. METHODS: Between May 1996 and May 1998, 303 consecutive patients aged 70 years or older (mean age 75.5 years; range 70-92 years) underwent coronary artery bypass grafting with double skeletonized internal thoracic arteries. Forty-four (14.5%) patients were 80 years or older, and 89 (28%) had diabetes. The mean number of grafts was 3.1 per patient (2-6). RESULTS: Operative mortality was 2.6% (n = 8): it was higher for octogenarians (6.8%) than for younger patients (1.9%) (P =.06). The only significant preoperative predictors of early mortality were complicated percutaneous transluminal coronary angioplasty (P =.03) and preoperative use of intra-aortic balloon pumping (P =.03). Six patients (2%) had sternal wound infections for which chronic lung disease (P =.02) and emergency operation (P =.006) were the only significant predictors. Twenty-two (7.2%) late deaths occurred, and 1- and 3-year survivals were 93% and 90%, respectively. The 3-year survival of patients 80 years old or older was 92%. CONCLUSIONS: Bilateral grafting of the skeletonized internal thoracic artery carries relatively low morbidity and mortality in elderly patients and can be recommended for selected patients including octogenarians.

Aged↗
PubMed1994

Fifteen- to twenty-one-year angiographic assessment of internal thoracic artery as a bypass conduit.

Fifteen patients who had coronary artery bypass grafting with the left internal thoracic artery (2 also had in situ right internal thoracic artery grafts placed) underwent catheterization for recurrent angina 15 to 21 years later. Angiographic assessment revealed widely patent conduits without evidence of conduit atherosclerosis. Translocation of the internal thoracic artery to the coronary circulation does not appear to be associated with accelerated atherosclerosis of the conduit, and freedom from serious conduit atherosclerosis can be anticipated for at least 20 years.

Angina Pectoris↗
PubMed2006

Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PM) flap is supplied by three arterial systems. The lower chest skin of the PM flap is mainly supplied by the branches of lateral thoracic artery and internal mammary artery. The conventional harvesting technique for head and neck reconstruction utilizes single arterial supply from the pectoral branch of thoracoacromial artery. The distal skin island of PM flap is therefore compromised and requires indirect blood supply by communicating vessels. In harvesting the PM flap, the pectoralis minor muscle is divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of PM flap without compromising the pedicle length for head and neck reconstruction. Six PM flaps were harvested for reconstruction of head and neck defects with preservation of both the pectoral artery and lateral thoracic artery. The focal pint of swing of all six flaps was at the same point just below the mid-point of clavicle for both pectoral artery and lateral thoracic artery. The flaps can reach the oral cavity, tonsil or hypopharynx without limitation and there is no flap necrosis. In conclusion, the lateral thoracic artery can be preserved without compromising the pedicle length of PM flap. It is a recommended technique to improve the blood supply to the distal skin of PM flap.

Head and Neck Neoplasms↗
PubMed1999

Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery.

OBJECTIVE: This study prospectively evaluates the effect on sternal vascularity of harvesting the left internal thoracic artery. METHODS: Twenty-four consecutive patients undergoing primary coronary artery bypass grafting were studied. One patient's procedure was altered during the operation, and he was eliminated from the study. The patients were prospectively randomized to receive a skeletonized internal thoracic artery (group I, n = 11) or a pedicled internal thoracic artery (group II, n = 12) graft. Each patient underwent a preoperative technetium 99 methylene diphosphonate bone scan using single photon emission computed tomography. The ratio of the mean counts per pixel on the left side of the sternum was compared with the mean counts per pixel on the right side. Postoperatively, all patients had a second scan, and sternal uptake was compared with the preoperative uptake. RESULTS: No significant differences in preoperative and operative variables were observed between the groups. A statistically significant reduction in blood flow to the left side of the sternum was shown postoperatively in group II compared with group I (0.61 +/- 0.11 vs 0.85 +/- 0.09; P <.001). Multivariable logistic regression analysis of preoperative and operative variables revealed only a pedicled left internal thoracic artery to be associated with a 20% or more reduction in left-to-right sternal activity ratio (odds ratio, 100; 70% confidence limits, 22-465; P =.002). CONCLUSION: A pedicled left internal thoracic artery graft to the left anterior descending artery reduces blood flow to the left side of the sternum during the acute postoperative period. This does not occur when the left internal thoracic artery is skeletonized.

Aged↗
PubMed1992

Internal thoracic artery grafting for congenital coronary malformations.

We report 2 patients with congenital coronary anomalies (atresia of left main coronary artery and anomalous origin of the left coronary artery from the pulmonary artery) successfully treated with single or double internal thoracic artery grafting. Because the internal thoracic artery has a potential for circumferential as well as longitudinal development, and because of the uncertainty of ultimate vein graft function, we believe that the internal thoracic artery is the best graft material for the treatment of congenital coronary malformations requiring bypass operation in children, adolescents, or even in adults.

Child↗
PubMed1996

Randomized comparison of ultrasonic aspiration versus conventional electrocautery for dissection of the human internal thoracic artery.

The most common technique currently employed to harvest the internal thoracic artery for coronary artery bypass grafting is conventional electrocautery. This study compared an alternative method, electrocautery with an ultrasonic aspirator, for harvesting the internal thoracic artery. Patients were randomly assigned to one of six experimental groups (conventional electrocautery, ultrasonic aspirator at settings of 60%, 80%, and 100% power output, and ultrasonic aspirator in 100% CAVI-Pulse modes 1 and 3). Ring segments of internal thoracic artery were studied in an organ bath. Contraction responses were elicited with 123 mmol/L potassium physiologic salt solution, KPSS, KPSS solution containing noradrenaline, and a cumulative noradrenaline dose-contraction curve. Relaxation studies were performed with the vasodilators acetylcholine, bradykinin, and sodium nitroprusside. Forty percent of the electrocauterized vessels were traumatized or damaged and failed to respond to contractile stimuli, whereas only 10% of the vessels in ultrasonic aspirator groups 60%, 80%, and 100% failed to respond. All vessels in the group harvested by ultrasonic aspirator in 100% CAVI-Pulse mode 1 responded, whereas 20% of the vessels in the group harvested by ultrasonic aspirator in 100% CAVI-Pulse mode 3 failed to respond. All settings of electrocautery with an ultrasonic aspirator produced a greater contractile response to KPSS and noradrenaline. Acetylcholine and sodium nitroprusside produced similar relaxations in all groups, but the bradykinin responses were significantly improved in all groups undergoing 100% electrocautery with an ultrasonic aspirator. These results suggest that 100% electrocautery with an ultrasonic aspirator, particularly in 100% CAVI-Pulse mode 1, resulted in less damage and trauma than conventional electrocautery during harvesting of the internal thoracic artery.

Adult↗
PubMedDate not supplied

[Angiographic characteristics of the internal thoracic artery--anatomic variations and their surgical importance].

INTRODUCTION: The internal thoracic artery is considered the graft of choice for surgical revascularization of the ischemic myocardium. The real incidence of anatomic variations of the internal thoracic artery is not known, although it is an extremely important issue, considering surgical strategy, as well as immediate and long-term outcome. MATERIAL AND METHODS: During a period of three months (Jun. 1st-Aug. 31st 1998) we have evaluated the left internal thoracic artery (ITA) in 80 randomly selected patients (62 men, average age being 57.4 +/- 5.2). RESULTS: Typical take-off, side branches, terminal division and absence of any atherosclerotic lesions were noted in 69 patients (86.25%). Angiographically apparent atherosclerotic lesions were not noted; anomalous take-off from the left subclavian artery was noted in 9 cases (11.25%--including one case of aneurysmatic proximal portion of the ITA); there were two cases where the lateral thoracic artery was present (2.5%) and three cases where the distal division was of a trifurcation type, which is not of surgical importance (3.75%). Average diameter of the left ITA was 2.19 +/- 0.24 mm for the entire group (2.20 +/- 0.19 mm for men, and 2.10 +/- 0.21 mm for women, p = NS). DISCUSSION: Results that we have obtained are in accordance with previously published data. We did not find significant (angiographically visible) atherosclerotic lesions of the ITA, however variations in the take-off and branching were found to be frequent (11.25%). Aneurysmatic left ITA is an extremely rare finding in the literature. Angiographically found variations (capable of causing coronary steal) are impossible to be detected during operation. This raises a question of a need for routine angiographic evaluation of the ITA before operation. For some patients, routine angiographic evaluation of the ITA before myocardial revascularization is mandatory: in pts with previous myocardial revascularization, in whom ITA was not used, but could have been damaged; in pts with atherosclerotic lesions of the supraaortic vessels; in pts with previous irradiation of the anterior mediastinum (ITA could be fibrotic); in pts with actual or corrected coarctation of aorta (ITA could be aneurysmatic). CONCLUSION: The incidence of anatomic variations of the ITA (that may be of surgical importance) is not negligible (13.25%). These data indicate that routine angiographic evaluation of the ITA should be considered in all patients in need for myocardial revascularization.

Aneurysm↗