Coronary-artery bypass surgery with internal-thoracic-artery grafts.
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Coronary Artery Bypass↗
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Effect of normothermic papaverine to relieve intraoperative spasm of the internal thoracic artery.
BACKGROUND: After mobilization, vasospasm often reduces flow through the internal thoracic artery. An established method of relaxing the artery and increasing flow is to use papaverine at ambient temperature (20 degrees to 22 degrees C) as a topical vasodilator. However, the pharmacologic actions of papaverine generally have been assessed at 37 degrees C. METHODS: In 60 patients in whom the left internal thoracic artery was used for myocardial revascularization, we investigated the effects of normal saline solution at 20 degrees C (group I), papaverine at 20 degrees C (group II), and papaverine at 37 degrees C (group III). Under controlled hemodynamic conditions, free flow was measured before any pharmacologic intervention and a median of 16 minutes after the pedicle had been sprayed with one of the agents. RESULTS: Normal saline solution at 20 degrees C produced a small increase in flow from 37.5 +/- 8.1 mL/min to 50 +/- 10.2 mL/min. A significant increase occurred with papaverine at 20 degrees C, from 38.05 +/- 6.5 mL/min to 78.75 +/- 21.2 mL/min (p < 0.0001). Papaverine at 37 degrees C, however, produced an increase in flow from 36.9 +/- 12.6 mL/min to 103.3 +/- 44.6 mL/min (p < 0.0001) and proved to be more effective than papaverine at room temperature (p = 0.0174). CONCLUSIONS: We recommend topical use of papaverine at 37 degrees C to relieve intraoperative spasm of the internal thoracic artery.
Administration, Topical↗
The role of the internal thoracic artery in the sternal blood supply.
The altered arterial supply to the sternum after use of the internal thoracic artery in coronary bypass surgery was studied by delineation of the sternal arterial system with plastic material and by injection of ink/barium contrast for radiography and microscopy. The study was performed on 17 anterior chest walls from human cadavers. The total arterial supply was charted before and after 'harvest' of the internal thoracic artery. The dominant blood supply to the sternum was found to be periosteal and derived almost exclusively from branches of the internal thoracic artery. Following harvest of that artery, the arterial supply to the upper part of the corpus sterni was compromised, and based only on sparse ramifications to the periosteal membrane from the thoracoacromial artery via branches from the pectoralis major muscle.
Aged↗
Role of physiological state 'normothermia' in internal thoracic artery spasm after harvesting.
OBJECTIVE: Vasospasm is often faced after the operative preparation of internal thoracic artery. Different vasodilating pharmacological agents are being used to eliminate this problem. During the preparation of internal thoracic artery, normal, local, and systemic temperatures are lost. We aimed to find out the effect of this decrease in temperature on the free flow of internal thoracic artery. METHODS: We investigated the effects of normal saline solution at 20 degrees C (group I), papaverine at 20 degrees C (group II) and normal saline solution at 37 degrees C (group III). Each group contained 20 patients undergoing coronary bypass. Free flow of the left internal thoracic artery was measured after mobilization. After approximately 18 min the graft had been sprayed with one of the agents, and the second free flow was measured (t-interval was 18.2+/-2.1 for group I, 18.3+/-1.8 for group II, and 17.5+/-1.9 for group III). RESULTS: Normal saline solution at 20 degrees C did not cause a significant change. Topical papaverine at 20 degrees C increased the flow from 42.1+/-10.7 ml/min to 77.5+/-17.9 ml/min (p < 0.0001). A significant increase also occurred with normal saline solution at 37 degrees C from 41+/-11.9 ml/min to 75.3+/-18.9 ml/min (p < 0.0001). CONCLUSIONS: After harvesting the graft, regaining physiological normothermic state is enough for vasodilatation. Even using one of the most potent vasodilating agent papaverine at 20 degrees C is not superior to normothermia.
Adult↗
Flow analysis of left internal thoracic artery in myocardial revascularization surgery using y graft.
In order to evaluate the left internal thoracic artery flow pattern, when the vessel is used as a graft to supply the left coronary artery system, we evaluated flow by Doppler measurement, both at rest and under dobutamine stress. There were 2 groups of 20 patients each: group A patients received only a left internal thoracic artery graft to the left anterior descending artery, and group B patients received a pedicled left internal thoracic artery graft associated with a vein graft, which together supplied the left anterior descending artery and another branch of the left coronary artery. Angiography showed patent grafts in all patients from both groups. The following characteristics were evaluated: systolic flow, diastolic flow, total flow, total flow under stress/total flow at rest ratio, systolic peak velocity, diastolic peak velocity, and systolic peak velocity/diastolic peak velocity ratio. In group A, the total flow was 45.5 +/- 21.6 mL/min at rest and 68.3 +/- 32.9 mL/min under stress. In group B, the total flow was 98.2 +/- 50.4 mL/min at rest and 175.7 +/- 79.2 mL/min under stress. Comparison between groups showed a total flow increase in group B of 115.8% (P=0.0002) at rest and 157.2% (P <0.0001) under stress. The other characteristics were also statistically significant, except systolic flow, total flow under stress/total flow at rest ratio, and systolic peak velocity. Our results showed that the left internal thoracic artery sufficiently supplies regional myocardium at rest and during exercise (stress), demonstrating its great adaptability in response to demand.
Adult↗
Effect of flow competition on internal thoracic artery graft: postoperative velocimetric and angiographic study.
OBJECTIVES: To assess the effects of competitive blood flow on internal thoracic artery grafts, we investigated postoperative flow velocity characteristics and angiographic findings of the grafts with various grades of native coronary artery stenosis. METHODS: Fifty patients who had an internal thoracic artery graft to the left anterior descending artery underwent intravascular Doppler graft velocimetry during postoperative angiography. Patients were divided into 3 groups according to the grade of native coronary stenosis: group H (28 patients), 80% stenosis or greater; group M (16 patients), 60% to 79% stenosis; and group L (6 patients), 40% to 59% stenosis. Phasic flow velocity of the grafts was measured with an intravascular Doppler ultrasound-tipped guide wire during angiography. Graft flow volume was calculated from the diameter and the average peak velocity. RESULTS: Average peak velocity (group H, 27.1 +/- 8.6 cm/s; group M, 16.9 +/- 3.9 cm/s; group L, 7.2 +/- 3.7 cm/s), distal graft diameter (group H, 2.27 +/- 0.23 mm; group M, 2. 00 +/- 0.28 mm; group L, 1.07 +/- 0.27 mm), and calculated graft flow volume (group H, 33.1 +/- 12.0 mL/min; group M, 16.2 +/- 5.8 mL/min; group L, 2.3 +/- 2.0 mL/min) significantly differed among the 3 groups. Graft flow in diastole and systole also differed among the 3 groups. CONCLUSIONS: Competitive blood flow reduces internal thoracic artery graft flow and diameter according to the grade of the native coronary artery stenosis. These data suggest that grafting the internal thoracic artery to the coronary artery with stenosis of a low grade can cause graft atrophy and failure.
Aged↗
Composite bilateral internal thoracic artery grafts via standard sternotomy for lateral wall revascularization in conscious patients.
BACKGROUND: A new technique has been developed that permits complete arterial revascularization of the lateral wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, performed without cardiopulmonary bypass or mechanical ventilation, creates the least invasive revascularization method for the lateral wall of the heart yet described. METHODS: In 4 patients, double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started 1 hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique via standard median sternotomy. Circumflex branches were anastomosed with the left internal thoracic artery via a heart positioner. RESULTS: All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in only 1 patient and did not hinder the procedure. There were no hemodynamic changes during lateral wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses. CONCLUSIONS: Complete arterial revascularization via median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach allows for complete coronary artery revascularization in patients with contraindications for general anesthesia with or without cardiopulmonary bypass.
Anastomosis, Surgical↗
Anatomic feasibility of creating an inferior epigastric arterio-venous fistula to develop the internal thoracic artery with a view to coronary grafting.
Arterio-venous fistulae increase the diameter of their feeding artery. It may be advantageous to increase the diameter of the internal thoracic artery before its use for coronary grafting. A fistula applied directly to the internal thoracic artery may compromise its subsequent use as a coronary graft and is technically difficult and invasive. However, in view of the continuity between the internal thoracic artery and the inferior epigastric artery, it is possible to achieve the same effect by constructing a fistula on the latter. The purpose of this work was to determine, in a cadaveric study, the feasibility of carrying out an arterio-venous fistula on the inferior epigastric artery so as to increase the caliber of the internal thoracic artery before coronary grafting. A morphologic study of the inferior epigastric artery and its vein and their relations as well as the feasibility of such a fistula was carried out on 10 cadavers. The epigastric artery measured 12.35+/-1.2 cm in length. Its diameter decreased from its origin towards it termination from 3.16+/-0.26 cm to 1.76+/-0.18 cm. There was a constant connection between the inferior and superior epigastric arteries. This connection was single in 30% of cases, double in 50% and through an anastomotic plexus of more than two vessels in 20%. The mean number of anastomotic connections was 1.8. The epigastric vein was constant with a diameter of 0.75+/-0.06 mm at its origin and only sufficiently large to carry out a fistula at its termination (2.6+/-0.9 mm). In conclusion, this study indicates that it should be relatively simple to create a fistula between the inferior epigastric artery and either the inferior epigastric vein or the external iliac vein.
Aged↗
Flow reserve capacity of left internal thoracic artery 23 years after Vineberg procedure.
Graft flow volume and flow reserve were assessed by Doppler echocardiography 23 years after Vineberg left internal thoracic artery implantation. Angiography showed good patency of the left internal thoracic artery, and the flow velocity profile was as biphasic as that of the coronary circulation. Drug-stressed test showed a physiologic reactivity of the Vineberg left internal thoracic artery but less response than that of a directly anastomosed left internal thoracic artery.
Blood Flow Velocity↗
[Characteristics of porcine thoracic arteries fixed with polyepoxy compound].
OBJECTIVE: To investigate the characteristics of porcine thoracic arteries fixed with ethylene glycol diglycidyl ether (EX-810) and to provide the proper scaffold materials for tissue-engineered blood vessel. METHODS: The porcine thoracic arteries were respectively treated with 40 ml/L EX-810 and 6.25 g/L glutaraldehyde, and then they were examined with naked-eye, light microscope and scanning electron microscope. The fixation index determination, the amino acid analysis and the biomechanics test were also performed. RESULTS: The antigenicity of vascular tissues can be diminished by EX-810 through getting rid of cell in the vascular tissues or reducing the level of free amino groups in the vascular tissues. The structural integrity of vascular tissues can be preserved after treatment with EX-810. It was also found that the EX-810-fixed porcine vascular tissues appeared more similar to the natural vascular tissues in color and mechanical properties, and were more pliable than the glutaraldehyde-fixed tissues. CONCLUSION: The EX-810-fixed porcine thoracic arteries with low cytotoxicity and low antigenicity showed favorable characteristic similar to those of natural vessel, and it should be a promising material for fabricating scaffold of tissue-engineered blood vessel.
Animals↗
All internal thoracic artery composite graft revascularization.
The aim of this study was to determine the most efficient design of composite grafts and clarify the technical feasibility rate of composite grafting using internal thoracic artery exclusively in patients undergoing triple-vessel revascularization. Retrospective analysis of 104 consecutive patients was carried out. An in situ left internal thoracic artery graft for the left anterior descending artery area, with attachment of the right internal thoracic artery to the side of the left internal thoracic artery to revascularize the circumflex and right coronary vessels, was the most efficient graft design. The technical feasibility rate was 80% (83/104 patients). The mean number of distal anastomoses for the entire group was 3.8+/-0.8 per patient. Intraoperative left internal thoracic artery flow rate was 91.6+/-37.8 mL.min-1. With more experience, it is thought that the technical feasibility rate could be increased.
Adult↗
Minimally invasive internal thoracic artery harvest: the hybrid approach.
BACKGROUND: Safe harvesting of the left internal thoracic artery is a difficult problem during minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. A complete internal thoracic artery dissection through a limited approach is technically demanding and time consuming and different techniques have been proposed. METHODS AND RESULTS: Based on our experience, the different surgical approaches and technical considerations are reviewed. CONCLUSIONS: A hybrid technique using dissection under direct vision and completed by thoracoscopy is discussed and proposed as our preferred technique of internal thoracic artery harvesting.
Aged↗
Results of internal thoracic artery grafting over 15 years: single versus double grafts.
One hundred consecutive patients who had coronary artery bypass grafting using both internal thoracic arteries (ITAs) and saphenous veins, operated on during a 3-year period between 1972 and 1975, have been compared retrospectively with a series of 100 patients operated on during the same period who had one ITA graft along with saphenous vein grafts. The two groups were similar with respect to age, sex, risk factors for coronary artery disease, angina class, extent of coronary artery disease, left ventricular function, number of coronary bypass grafts performed, and completeness of revascularization. Single ITA operative mortality was 2% and double ITA, 9% (p = NS). The mean follow-up of hospital survivors was 14.4 +/- 2.7 years; all but 7 patients had follow-up for at least 10 years. At 13 years, the actuarial patency of the right ITA was 85% and the left ITA, 82%. These data strongly suggest a survival benefit for patients with double ITA grafts among hospital survivors (74% versus 59%; p = 0.05). Patients receiving two ITA grafts had a significant freedom from subsequent myocardial infarction (75% versus 59%, p less than 0.025), recurrent angina pectoris (36% versus 27%, p less than 0.025), and subsequent total ischemic events (32% versus 18%, p less than 0.01). These data also suggest improved freedom from coronary artery interventional therapy (percutaneous transluminal coronary angioplasty and reoperation) when two ITA grafts were used. These results support the use of bilateral internal thoracic artery grafting in selected patients.
Actuarial Analysis↗
Does it make sense to use two internal thoracic arteries?
Retrospectively, the first 143 patients who were operated on with bilateral internal thoracic arteries (BITA group) were matched with 143 patients operated on with only one left internal thoracic artery anastomosed on the left anterior descending artery and additional vein grafts (LITA group) and followed up for a maximum of 8 years. At 5 years follow-up there were no significant differences in event-free survival between the groups. After 8 years, the overall survival was 96% and 92% (not significant [NS]), cardiac survival 99% and 97% (NS), angina-free cardiac survival 51% and 35% (NS), infarction-free cardiac survival 95% and 78% (NS), reintervention-free cardiac survival 87% and 88% (NS), and all cardiac event-free survival 49% and 31% (NS) for the BITA and LITA groups, respectively. The incidence of late pulmonary, wound, and other complications was comparable. Cox proportional hazards analysis showed that a higher left ventricular end-diastolic pressure and female sex were predictors of recurrent angina and late cardiac events. During this intermediate-term follow-up, the use of one or two internal thoracic arteries was of no value in predicting angina-free or cardiac event-free survival.
Adult↗
Anatomy of superficial thoracic artery related to subpectoral augmentation mammoplasty.
The aim of this study is to elucidate the anatomic details of superficial thoracic artery related to transaxillary subpectoral augmentation mammoplasty.Thirty-three breasts of Korean cadavers (11 males, 6 females) were dissected. The superficial thoracic artery was found at the lateral part of the pectoralis (P.) major muscle in all cases. It originated mostly from the lateral thoracic artery (42%), thoracoacromial artery (38%), and partly from axillary artery (19%). Most of (82%) the muscle entering point was included in the circle of 2.5-cm radius. The center was located 2.5 cm superior from the intersection of the lateral border of the P. major and inferior border of the fourth rib. It was distant from 12 cm lateral to the midline and 6 cm below the sternal notch. We think that the superficial thoracic artery might be the culprit of bleeding and severe hematoma in transaxillary subpectoral mammoplasty.
Adult↗
Age-related changes of mineral contents in the human aorta and internal thoracic artery.
To elucidate accumulations of minerals in the human aorta and internal thoracic artery, their relative contents (RCs) of minerals were analyzed by inductively coupled plasma atomic emission spectrometry. Aortas from 47 men and 24 women subjects were examined. The ages of these subjects ranged from newborn to 99 yr. After the age of 40 yr, RCs of calcium and phosphorus began to increase, and thereafter increased stepwise in the 50s and 70s. In the 70s, their accumulations were markedly increased. Internal thoracic arteries from 16 men and 7 women subjects were examined. These subjects ranged in age from 65-93 yr. It was found that all the RCs of calcium were low, <5.0 mg/g dry wt, and there was no age-dependent increase of calcium contents in internal thoracic arteries.
Adolescent↗
Feeding artery of a recurrent pheochromocytoma from the left internal thoracic artery demonstrated by multislice computed tomography.
A 53-year-old female presented to our hospital because of an abnormal shadow on chest X-ray. She had previously undergone surgical removal of a pheochromocytoma. Enhanced multislice CT was performed and three-dimensional volume rendered images revealed two tumors in the thorax and neck, suggesting pheochromocytoma. There was an aberrant artery originating from the left internal thoracic artery (ITA) leading to the tumor, which we identified as the feeding artery of the pheochromocytoma. We planned to eliminate the tumors surgically, and based on the multislice CT findings, we also planned to simultaneously eliminate the feeding artery from the left ITA.
Female↗
Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery.
BACKGROUND: With the rapid advance of catheter intervention, the direction taken by surgeons is not only to make conventional CABG less invasive but also to pursue better long-term results by using more arterial conduits. METHODS AND RESULTS: Between July 1989 and April 2000, 239 patients (218 men, 21 women) with a mean age of 59.7 (range 39 to 79) years underwent CABG with exclusive use of both internal thoracic arteries (ITAs) and the right gastroepiploic artery (RGEA). ITA grafts were harvested by using the skeletonization technique. Most patients (96%) had either triple-vessel or left main disease. Fifty percent of the patients were diabetic, and 16 were being treated with insulin. The left ventricular ejection fraction was </=40% in 46 patients (19%). Eleven patients (5%) had chronic renal failure and were on hemodialysis. Follow-up was completed in 235 patients (98%). Postoperative follow-up averaged 43 (range 1 to 129) months. Sequential grafting was performed in 64 patients, and the mean number of anastomoses was 3.3. One patient (0.4%) died of mediastinitis on the 53rd postoperative day. Graft patency was confirmed angiographically in 230 patients (96%) 2 to 3 weeks after surgery. The patency rate was 97.1% for the left ITA, 99.6% for the right ITA, and 95.5% for the RGEA. Five-year actuarial survival rate was 92.9%, and the cardiac death-free rate was 97.8%. CONCLUSIONS: Complete arterial grafting with both ITAs and RGEA was associated with minimal operative risk, a high early graft patency rate, and excellent long-term results.
Adult↗