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At least 217 records · Page 12Linked to original sources
PubMed1999

Myocardial revascularization with modified T-graft using bilateral internal thoracic arteries.

OBJECTIVE: By using a T-graft configuration, the myocardium may be completely revascularized with bilateral internal thoracic arteries. This study aimed to evaluate the perioperative morbidity and mortality in a single surgeon's early experience with a modified T-graft using bilateral internal thoracic arteries. METHODS: Between October 1994 to April 1997, 200 consecutive patients mostly selected per protocol, received a T-graft with bilateral internal thoracic arteries for stable angina pectoris (n = 157) or unstable angina pectoris (n = 43). The mean age of patients was 56 years (range of 36 to 78 years). There were 171 males and 29 females. Forty-three patients had diabetes. Concomitant procedures were performed in 8 patients. RESULTS: In 190 patients (95%), total arterial revascularization of the myocardium was achieved solely by the use of bilateral internal thoracic arteries in a T-graft configuration and the number of anastomoses per patient averaged 4.2. Ten patients (5%) received supplemental saphenous veins in addition to T-grafts for low cardiac output (n = 3), intraoperative regional ischaemia (n = 2), postoperative myocardial ischaemia (n = 2) and inadequate conduits (n = 3). The 30-day mortality was 0.5%. Perioperative myocardial infarct occurred in 2 patients (1.0%). Reasons encountered for early re-operation included bleeding (n = 7), sternal dehiscence (n = 5), suppurative sternitis (n = 3) and myocardial ischaemia (n = 2). Twelve patients received inotropes and intraaortic balloon counterpulsation was employed in 3 patients. CONCLUSION: When bilateral internal thoracic arteries were used in a T-graft configuration, total arterial revascularization of the myocardium was achieved with an acceptably low morbidity and mortality.

Adult↗
PubMed1997

Semiskeletonization of internal thoracic artery: alternative harvest technique.

A simple technique of harvesting the internal thoracic artery is described. Harvesting the internal thoracic artery as a thin pedicle without the endothoracic fascia is advantageous in terms of obtaining its maximum length, dissecting a narrow space, avoiding pleural opening, and facilitating handling of the internal thoracic artery during the coronary anastomoses. This alternative-technique requires almost the same skill and time as the conventional wide pedicle technique.

Humans↗
PubMed2001

Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling.

OBJECTIVES: We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization. BACKGROUND: Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity. METHODS: We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms. RESULTS: There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were < or =70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66). CONCLUSIONS: Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.

Aged↗
PubMed2001

Innate diversity of adult human arterial smooth muscle cells: cloning of distinct subtypes from the internal thoracic artery.

Vascular smooth muscle cells (SMCs) perform diverse functions and this functional heterogeneity could be based on differential recruitment of distinct SMC subsets. In humans, however, there is little support for such a paradigm, partly because isolation of pure human SMC subsets has proven difficult. We report the cloning of 12 SMC lines from a single fragment of human internal thoracic artery and the elucidation of 2 distinct cellular profiles. Epithelioid clones (n=9) were polygonal at confluence, 105+/-9 micrometer in length, and had a doubling time of 39+/-2 hours. Spindle-shaped clones (n=3) were larger (267+/-18 micrometer long, P<0.01) and grew slower (doubling time 65+/-4 hours, P<0.01). Both types of clones expressed smooth muscle (SM) alpha-actin, SM-myosin heavy chains, h-caldesmon, and calponin, but only spindle-shaped clones expressed metavinculin. Epithelioid clones displayed greater proliferation in response to platelet-derived growth factor-BB and fibroblast growth factor-2 and were more responsive to the migratory effect of platelet-derived growth factor-BB. Spindle-shaped clones showed more robust Ca(2+) transients in response to angiotensin II, histamine, and norepinephrine, crawled more quickly, and expressed more type I collagen. On serum withdrawal, spindle-shaped clones differentiated into a contraction-competent cell. A regional basis for diversity among SMCs was suggested by stepwise arterial digestion, which liberated small, SM alpha-actin-positive cells from the abluminal medial layers and larger SMCs from all layers. These results identify inherent SMC diversity in the media of the adult internal thoracic artery and suggest differential participation of SMC subsets in the regulation of human arterial behavior.

Actins↗
PubMedDate not supplied

A simple method to prevent internal thoracic artery tension: a single pericardio-thoracic suture technique.

Tension on the internal mammary artery is a major risk for anastomosis in patients with severe emphysematous lungs. For this reason, it can be necessary to harvest the internal thoracic artery to its origin, to skeletonize it, or as a last resort to use it as a free graft. Sometimes, these maneuvers cannot be enough to solve the problem. A simple suture technique to hang up the pericardium to the chest wall is described that eliminates herniation of emphysematous lungs across mediastinum and reduces tension on the left internal mammary artery.

Anastomosis, Surgical↗
PubMed2004

Bilateral internal thoracic artery grafting in diabetic patients: short-term and long-term results of a 515-patient series.

BACKGROUND: Despite potential long-term benefits, bilateral internal thoracic artery grafting in diabetics remains controversial because of the risk of sternal infection. We sought to assess the short- and long-term outcome after left-sided bilateral internal thoracic artery grafting and to determine the configuration of choice in diabetic subsets. METHODS: Between 1996 and 2001, 515 diabetics underwent isolated left-sided skeletonized bilateral internal thoracic artery grafting. The outcome of 468 consecutive oral-treated diabetics and 47 selective insulin-treated patients was analyzed. Patients undergoing T-grafting were compared with those undergoing in situ bilateral internal thoracic artery arrangements. RESULTS: The respective rates for early mortality and sternal infections were 2.4% and 1.9% in oral-treated diabetics and 6.3% and 4.3% in insulin-treated diabetics. Multivariate correlates of sternal infection were chronic lung disease (odds ratio, 10), obesity (odds ratio, 7), reoperation (odds ratio, 22), and a creatinine level of 2 mg/dL or more (odds ratio, 8). Five-year survival was 82%. The T-graft (n = 437) and in situ (n = 162) subgroups had comparable baseline profiles. Freedom from cardiac mortality at 6.5 years was 95.6% and 87.6% (P =.277), and freedom from repeat revascularization was 91.5% and 92.7% (P =.860), respectively. The choice of bilateral internal thoracic artery configuration did not appear as a correlate of mortality, cardiac mortality, or major adverse cardiac events. Complementary right-sided gastroepiploic artery (hazard ratio, 0.36) and sequential (hazard ratio, 0.55) grafting were identified as protective factors against the occurrence of major adverse cardiac events. CONCLUSIONS: Routine skeletonized bilateral internal thoracic artery grafting can be implemented safely in oral-treated diabetics. This strategy is associated with a favorable late cardiac outcome and is thus recommended. Both left-sided bilateral internal thoracic artery configurations provide comparable short- and long-term outcomes.

Administration, Oral↗
PubMed1996

Use of color Doppler imaging in assessment of preoperative and postoperative flow characteristics of internal thoracic artery in myocardial revascularization.

Between January 1993 and February 1993, the left internal thoracic arteries of 40 consecutive patients scheduled for aortocoronary bypass operation were examined by transthoracic B-mode imaging. Perioperative measurements correlated well with preoperative noninvasive measurements (r = 0.914). In the postoperative period, B-mode images could not be obtained in 17 (44.7%) of 38 patients. Adequate Doppler spectra of the internal thoracic artery were obtained in all patients preoperatively and in 36 (94.7%) of 38 patients postoperatively. Preoperatively a triphasic wave form was obtained with a large systolic peak followed by small reversed and diastolic components in all patients. Postoperatively this triphasic wave form had been converted into a combined systolic-diastolic wave form. In all patients peak systolic velocity of the internal thoracic artery decreased (96.4 +/- 15.3 vs 64.2 +/- 18.9 cm/sec., P < 0.05), and peak diastolic velocity increased (21.7 +/- 8.8 vs 28.3 +/- 11.2 cm/sec., P < 0.05) significantly in the postoperative period as compared with the preoperative values. A slight decrease in peak systolic and diastolic velocities was detected at twelve months postoperatively. This study indicates that transthoracic B-mode imaging and Doppler spectrum analysis are reliable techniques in the preoperative and postoperative assessment of the internal thoracic artery in myocardial revascularization.

Blood Flow Velocity↗
PubMed1997

Instrumentation for minimally invasive internal thoracic artery harvest.

The anterior fourth interspace minithoracotomy is our current choice for exposure of the anterior myocardial wall for minimally invasive coronary bypass grafting procedures. This approach provides direct access to the left anterior descending coronary artery for anastomosis, and good exposure of the midsegment of the internal thoracic artery. We describe the use of instrumentation that facilitates the harvest of the left internal thoracic artery under direct vision. The use of this retractor system, which elevates the third and fourth and depresses the second and first ribs, permits better visualization of the internal thoracic artery and allows for proximal internal thoracic artery harvest without rib resection.

Humans↗
PubMed2002

Bilateral internal thoracic artery grafting: midterm results of composite versus in situ crossover graft.

BACKGROUND: Two common techniques of bilateral internal thoracic artery grafting are the composite T graft and in situ crossover graft. The superiority of one method over the other has not yet been established. METHODS: From April 1996 to July 1999, bilateral skeletonized internal thoracic arteries were used as T grafts (composite group, n = 649) and in situ grafts (cross group, n = 351) in 1,000 consecutive patients. In the cross group, in situ right internal thoracic artery was routed anterior to the aorta across the midline for grafting to the left anterior descending artery, and the left internal thoracic artery was used for the circumflex branches. RESULTS: The two groups had comparable preoperative risk profiles. Bypass time and aortic cross-clamping time were longer in the composite group (80 +/- 38 and 67 +/- 29 minutes versus 66 +/- 43 and 55 +/- 34 minutes, respectively). Number of anastomoses per patient was similar (3.1 versus 3.2). However, more sequential anastomoses were performed in the composite group (62% versus 53%), and the gastroepiploic artery was used more often in the cross group (30% versus 19%). Thirty-day mortality was 3.9% in the composite and 2.3% in the cross group (not significant). Occurrence of postoperative complications (sternal infection, myocardial infarction, cerebrovascular accident, and bleeding) was similar. Late follow-up (2 to 56 months) showed increased return of angina (6% versus 3.1%; p = 0.046) and decreased 4-year survival (Kaplan-Meier; 86% +/- 2.7% versus 92.4% +/- 1.5%; p = 0.07) in composite patients. CONCLUSIONS: Early results of bilateral internal thoracic artery grafting with composite T graft are comparable with those of in situ grafts. However, increased angina return and decreased midterm survival led us to recommend in situ grafting whenever technically possible.

Aged↗
PubMed2004

Arterial thoracic outlet syndrome.

Arterial vascular complications resulting from thoracic outlet compression, although rare, can be substantial and potentially limb threatening. Bony abnormalities such as cervical ribs can lead to chronic trauma to the subclavian artery. Early on, the clinical symptoms can be subtle and confusing, causing potential delay in diagnosis.

Arterial Occlusive Diseases↗
PubMed1990

[Long-term results of coronary artery bypass grafting: comparison of angiographic evaluation of internal thoracic artery and saphenous vein grafts].

The long term (10 to 15 years) results of coronary artery bypass grafting (CABG) were studied in 20 patients. The duration of follow-up was ranged from 130 to 170 months with mean 146.4 months. Ten out of 20 patients underwent coronary angiography (CAG), which disclosed that the late patency of saphenous vein (SV) grafts was 68.8% (11/16), but 54.5% (6/11) of patent SV grafts showed atherosclerotic changes such as irregularity and localized narrowing. On the other hand, internal thoracic artery (ITA) grafts were all patent without any atherosclerotic luminal changes. We recognized that ITA grafts were superior to SV grafts from an angiographic standpoint of view in the long term in Japan.

Adult↗
PubMed1996

Coronary bypass surgery with internal-thoracic-artery grafts--effects on survival over a 15-year period.

BACKGROUND: Aortocoronary bypass surgery has been performed most often with the patient's saphenous vein as the conduit. The internal-thoracic-artery graft, which has superior patency rates, has been shown to have clinical advantages, but it is not known how long these advantages persist. METHODS: We identified all the patients in the registry of the Coronary Artery Surgery Study who had undergone first-time coronary-artery bypass grafting. Those with internal-thoracic-artery bypass grafts (749 patients) were compared with those with saphenous-vein bypass grafts only (4888 patients) with respect to survival over a 15-year follow-up period. RESULTS: In a multivariate analysis to account for differences between the two groups, the presence of an internal-thoracic-artery graft was an independent predictor of improved survival and was associated with a relative risk of dying of 0.73 (95 percent confidence interval, 0.64 to 0.83). This improved survival was also observed in subgroups including patients 65 years of age or older, both men and women, and patients with impaired ventricular function. The survival curves of the two groups showed further separation over the years of follow-up, with a more marked downsloping after eight years in the curve for the group with saphenous-vein grafts only than in that for the group with internal-thoracic-artery grafts. CONCLUSIONS: As compared with saphenous-vein coronary bypass grafts, internal-thoracic-artery grafts conferred a survival advantage throughout a 15-year follow-up period. The survival advantage increased with time, suggesting that the initial selection of the conduit was a more important factor in survival than problems appearing long after surgery, such as the progression of coronary disease.

Aged↗
PubMedDate not supplied

[The internal thoracic blood vessels (internal thoracic arteries and veins) and their practical significance].

Internal thoracic blood vessels (A. et Vv. thoracicae internae) are parietal vessels of the thoracic anterior wall. Because of their position, they are often exposed to injuries during the fracture of the ribs and the sternal bone. These facts require a general knowledge about the anatomical variations of these vessels, specifically the knowledge concerning their mutual relationship, their anastomoses and their distance from the lateral margins of the sternal bone. Due to the poor and different data in the available literature, we directed our investigations towards the study and confirmation of the described anatomical variations of the internal thoracic blood vessels. In this study we investigated the distance between the internal thoracic artery and the lateral margins of the sternal bone, the level of its bifurcation, the number of the internal thoracic veins and anastomoses between them. The investigation was carried out on 300 formalin specimens consisting of the anterior wall of the thorax (persons of different ages and sexes) by using the method of dissection and the method of contrast injection. In adults (200 specimens), the distance between the arterial trunk and the lateral margin of the sternal bone was not equal in the first fifth or sixth intercostal spaces, but in children up to five years of age (100 specimens), the distance was almost the same. In adults, the internal thoracic artery was nearest to the sternal bone in the first intercostal space, but going downward the artery was gradually more and more distant from the sternum and in the sixth intercostal space the distance measured approximately from 11 mm to 13 mm. In children, the distance of the artery from the lateral margin of the sternal bone, just in the above mentioned intercostal spaces, was from 5 mm to 10 mm. There was no difference according to sex in any of the two groups. Most frequently, the internal thoracic artery gave off its terminal branches at the level of the sixth costal cartilage (adults--35% and children--45%), and most rarely, the bifurcation of the artery was at the level of the seventh costal cartilage (adults--10% and children--8%). The internal thoracic vein that accompanies the same named artery, could be either single or double, on one or both sides. In cases of double veins-the artery was situated between the two of them, but in cases of single vein-the vein was located medially to the artery. In 82% of cases in the adult group, and in 69% of cases in the children-group, there were two veins accompanying the artery. The right and the left internal thoracic veins were connected in the region of the sternal bone by the retrosternal venous net (specifically in the region of the manubrium) and by one venous vessel lying in front of the xiphoid process. According to the position and the course of that venous vessel it could be called "arcus venosus prexiphoideus". The internal thoracic blood vessels were enclosed by the unique fascial sheath. They were superiorly separated from the costal pleura by the endothoracic fascia and inferiorly by the transversal thoracic muscle (m. transversus thoracis). The safest approach to the internal thoracic artery was at the level of the second and the third intercostal space. During the approach through some of the lower intercostal spaces it was necessary to be very careful because they could be narrowed at their anterior ends.

Adult↗
PubMed2000

Functional integrity and aging of the left internal thoracic artery after coronary artery bypass surgery.

OBJECTIVE: To study the endothelial function in the left internal thoracic artery after coronary artery bypass surgery and to identify predictors of early dysfunction, we performed a provocative test with acetylcholine in 23 male patients who underwent routine postoperative coronary angiography. METHODS: The change in mean diameter of the proximal thoracic artery was assessed by quantitative angiography after selective injections of acetylcholine and nitroglycerin. RESULTS: The thoracic artery showed a 6.8% (P <. 001) and 9.0% (P <.001) increase in mean diameter after acetylcholine and nitroglycerin administration, respectively. Vasodilative responses to acetylcholine and nitroglycerin administration were strongly correlated (R: 0.88; P <.001). Among the common risk factors, only age was associated with an impairment in the vasodilative response of the arterial graft (P =.001), and acetylcholine-induced vasodilation was inversely correlated to the age of the patient (R: 0.69; P <.001). CONCLUSIONS: Endothelium-dependent vasodilative response to acetylcholine administration seems well preserved in the left internal thoracic artery after surgery. Common risk factors, except for age, do not affect the functional integrity of the arterial graft. The vasodilative properties of the graft depend on the age of the patient and do not deteriorate over time after operation.

Acetylcholine↗
PubMed2004

Early and mid-term angiographic assessment of internal thoracic artery grafts anastomosed to non-stenotic left anterior descending coronary arteries.

BACKGROUND: Mild to moderately stenotic coronary arteries present a major problem as the progression of atherosclerosis is unpredictable. In addition, residual flow from the native coronary artery has been proposed as a mechanism that reduces blood flow in bypass grafts resulting in failure of the graft. PATIENTS AND METHODS: The internal thoracic artery was anastomosed to the left anterior descending coronary artery for different reasons in three patients who underwent coronary arterial surgery, with stenosis of this coronary artery changing from none to 30%. Patients were monitored by coronary arteriography at different intervals postoperatively (from 6 days to 25 months) to assess the patency of the internal thoracic artery graft. RESULTS: Internal thoracic artery grafts were found to be patent in all coronary arteriographies during the follow-up period. Twenty-five months after surgery, one patient showed total occlusion of the native coronary artery which was previously normal. CONCLUSIONS: Competitive flow from the native coronary artery does not seem to influence internal thoracic artery patency when grafted to a normal or mildly stenotic left anterior descending coronary artery. This information could be of help in some patients undergoing coronary artery bypass surgery with non-critical stenosis of this coronary artery. If the non-critical lesion is located proximally and if the patient has additional risk factors for coronary artery disease progression, prophylactic grafting of the left anterior descending coronary artery to the internal thoracic artery should be considered to prevent any future cardiac event, keeping in mind that this procedure may accelerate the progression of the native coronary artery disease.

Anastomosis, Surgical↗
PubMed2001

Adequacy of flow capacity of bilateral internal thoracic artery T graft.

BACKGROUND: With the T graft configuration, multiple arterial revascularization can be accomplished using bilateral internal thoracic arteries. However, concern remains about the flow capacity of the main stem of the left internal thoracic artery (LITA). METHODS: Forty patients who underwent multiple revascularization of the entire territory of the left coronary system with a T graft were investigated. Six months after the operation, they were examined angiographically. During the same period, dobutamine stress echocardiography was performed to evaluate the adequacy of the myocardial blood supply from the T graft. The T graft revascularized two branches in 5 patients, three branches in 23, four branches in 11, and five branches in 1 of the left coronary system. Other conduits were used if revascularization was required for the right coronary system. RESULTS: Complete revascularization was achieved in the left coronary territory in all patients. The LITA main stem showed a wide lumen in all patients. Luminal narrowing was present in the distal segment of the LITA in 3 patients. The right internal thoracic artery (RITA) was patent in all patients, whereas luminal narrowing was observed in the distal segment of the RITA in 5 patients. No patient exhibited ischemic wall motion abnormality in the anteroseptal, lateral, or posterolateral region of the left ventricle where the T graft revascularized. Eight patients showed ischemic response in the inferoposterior region, that is, the territory of the right coronary artery. CONCLUSIONS: The LITA main stem, forming a T-graft configuration with the free RITA, has an adequate flow reserve to supply at least the entire left coronary arterial system with sufficient blood. Therefore, multiple coronary revascularization using the T-graft technique is feasible.

Aged↗
PubMed2006

Human gastroepiploic artery has greater chymase activity than the internal thoracic artery.

OBJECTIVE: Recent reports have demonstrated that long-term patency of the gastroepiploic artery (GEA) in coronary artery bypass grafting (CABG) is less satisfactory compared with the internal thoracic artery (ITA). However, the reason has not been fully elucidated. Angiotensin II is known to play an important role in the development of intimal hyperplasia, we hypothesized that the GEA is different from the ITA with respect to angiotensin II-forming ability. Accordingly, we measured activities of angiotensin II-forming enzymes, angiotensin-converting enzyme (ACE) and chymase, in human GEA and ITA. METHODS: Remnant of the GEAs and ITAs were obtained from 24 patients who underwent CABG in which both conduits were used simultaneously. Activities of ACE and chymase were measured by using the extract form the GEA or ITA. Sections of the GEA or ITA were immunohistochemically stained with anti-human chymase antibody. RESULTS: The ACE activity of the GEA (0.28+/-0.16 mU/mg protein) was greater than that of the ITA (0.18+/-0.11, p < 0.001). The chymase activity of the GEA (11.11+/-7.15 mU/mg protein) was also greater than that in the ITA (7.13+/-4.89, p < 0.001). The density of chymase-positive cells in the GEA (3.8+/-4.2 cells/mm2) was greater than that in the ITA (1.1+/-1.2, p < 0.01). CONCLUSION: Activities of both ACE and chymase were significantly greater in the GEA compared with the ITA. The GEA may be different from the ITA with respect to potential ability of angiotensin II-formation.

Aged↗