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PubMed2006

A rare form of communication between the left internal thoracic artery and the left anterior descending artery.

Extracardiac collaterals generally from bronchial and internal thoracic arteries to coronary circulation have been described in the literature. In this report, we present a case of 59-year-old male patient with collaterals from the left internal thoracic artery to the left anterior descending artery developed after coronary artery bypass grafting and aneurysmectomy surgery. It is likely the collaterals developed as a result of the postoperative adhesions.

Cardiopulmonary Bypass↗

PubMed2005

Results of myocardial revascularization by two internal thoracic arteries using a Y-shaped conduit.

MATERIAL AND METHODS: Between August 2002 and September 2004, 276 patients with coronary artery disease underwent surgical treatment using a Y-shaped conduit formed from two internal thoracic arteries (ITA). In 268 (97.1%) patients, myocardial revascularization required exclusively bi-mammary bypass grafting. In creation of the Y-shaped conduit in the capacity of a free transplant, the intercepted right ITA was connected to the left internal thoracic artery (LITA). In the remaining 7 (2.5%) patients, venous bypasses together with the internal thoracic arteries were employed: in one patient (0.36%), the radial artery was used. RESULTS: Three patients (1.08%) died after operation. The survival rate accounted for 98.4%. CONCLUSION: The use of two internal thoracic arteries for complete myocardial revascularization provided beneficial results in the short- and long-term postoperative periods.

Adult↗

PubMed1994

[A case report of disappearance of free internal thoracic artery graft stenosis].

We have experienced an interesting case of spontaneous disappearance of stenosis of the injured free internal thoracic artery graft six months after coronary artery bypass grafting. A 61-year-old male underwent coronary bypass surgery with in situ left internal thoracic artery (LITA)-left anterior descending (LAD) and free right internal thoracic artery (RITA)-first diagonal branch (D1) bypass at our hospital. Postoperative angiogram showed the stenosis of the distal portion of the free RITA. We judged it was the injury by the electrocautery when dissecting the RITA. He was admitted to our hospital and received repeat angiography because of recurrence of angina six months after surgery. Repeat angiogram showed the good patency of LITA and complete disappearance of the stenosis of the free RITA. We consider that this case proved the free ITA can be a living graft.

Coronary Artery Bypass↗

PubMed1999

Cardiac surgery in patients with previous carcinoma of the breast and mediastinal irradiation: is the internal thoracic artery graft obsolete?

BACKGROUND: The increasing number of patients of more advanced age undergoing cardiac surgery means the number of those with previous curative (relapse free) mastectomy and irradiation of the chest is also increasing. A higher incidence of postoperative complications such as sternal infection in these patients is considered possible. Furthermore the question of whether mediastinal irradiation leads to a relevant internal thoracic artery (ITA) gaft damage remains unclear. In this context the benefit of arterial revascularization (CABG) using one or both ITAs is not sufficiently proven by data available from clinical studies. METHOD: 70 patients (49-85 years) with previous mastectomy or Hodgkin/non-Hodgkin's disease and mediastinal irradiation underwent CABG (n = 59) or an aortic valve replacement (AVR, n = 11). 20 patients received bilateral internal thoracic artery grafts, 34 a single internal thoracic artery graft, and in 16 patients an internal thoracic artery was not used. Perioperative data and data concerning postoperative complications such as mortality, myocardial infarction, and sternal infection or refixation was gathered and compared with all other patients receiving CABG (n = 5102). An histological investigation of ITA segments was done in 12 patients. RESULTS: There was no significant enhancement of the perioperative risk in comparison with other patients of a corresponding age group. Internal thoracic artery damage induced by irradiation was not present. There was no increased incidence of sternal instability requiring refixation observed. CONCLUSION: In the patient cohort investigated there is in general no need for restrictive use of the ITA in CABG.

Aged↗

PubMed1992

[Clinical experience of sternal retractor for dissection of internal thoracic artery].

We performed dissection of internal thoracic artery using sternal retracor for I.T.A. made by Delacroix Chevalier in France. This retractor composed of 5 elements i.e. arms, cranking axe, two assymetric claws and assymetric valve. This retractor is entirely reversible, so the same apparatus is used for left and light dissections. We concluded that this retractor has minimal risk to internal organs and the best position for exposure of I.T.A.

Dissection↗

PubMed2004

Skeletonization does not influence internal thoracic artery innervation.

BACKGROUND: This study was designed to compare the effect of surgical harvesting on internal thoracic artery innervation and to assess the eventual presence of denervation supersensitivity in skeletonized grafts. METHODS: Nineteen patients who underwent primary isolated coronary artery bypass grafting were randomly assigned to receive a skeletonized (n = 9) or pedicled (n = 10) internal thoracic artery graft. Immunohistochemical nerve localization using anti-S-100 protein, anti-160-kd neurofilament polypeptide and anti-tyrosine hydroxylase antibodies was performed on distal specimens of arteries to study vascular innervation. Moreover, endovascular vasoactive challenges using serotonin and methylergometrine were performed at early angiographic control to evaluate the eventual presence of denervation supersensitivity. RESULTS: Quantitative analysis of immunohistochemical specimens revealed lack of difference in the number of positive cells between skeletonized and pedicled arteries for all the antibodies used. No difference in the reaction to serotonin and methylergometrine was found between skeletonized and pedicled arteries. CONCLUSIONS: Skeletonization does not influence internal thoracic artery innervation.

Aged↗

PubMed2005

Sternal wound complications in bilateral internal thoracic artery grafting: a comparison of the off-pump technique and conventional cardiopulmonary bypass.

BACKGROUND: Sternal wound complication is a major concern in bilateral internal thoracic artery grafting. The purpose of this study was to assess whether avoiding cardiopulmonary bypass has beneficial effects with fewer wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS: Retrospective review was performed using prospectively gathered data of 69 patients who had undergone elective coronary artery bypass grafting and received conventional pedicled bilateral internal thoracic artery grafting from December 2002 through April 2004 by the same surgical team. The patients were divided into 2 groups: those who underwent coronary artery bypass grafting without cardiopulmonary bypass (off-pump group, n = 41), and those who underwent coronary artery bypass grafting with cardiopulmonary bypass (CPB group, n = 28). Chart review and 3-month follow-up were obtained for all patients. These 2 groups were compared for sternal wound complications and preoperative, intraoperative, and postoperative variables. RESULTS: Deep sternal wound infection (SWI) was seen in 1 patient (2.4%), superficial SWI in 2 patients (4.8%), and sternal dehiscence in 1 patient (2.4%) in the off-pump group. Deep SWI was seen in no patients, superficial SWI in 2 patients (7.1%) and sternal dehiscence in 2 patients (7.1%) in the CPB group. No statistically significant difference in the frequency of occurrence of sternal complications was detected between the 2 study groups. CONCLUSIONS: The results suggest that the avoidance of CPB has no beneficial effect on the number of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. However, further prospective, randomized studies on large patient groups are required to assess this finding.

Aged↗

PubMed1995

Is median thoracic artery a target organ artery for estradiol and progesterone? A comparison with uterine artery.

PURPOSE: The aim of this study was to show the parallel evolution of the pulsatility index of the uterine artery and the one of the median thoracic artery. STUDY DESIGN: The study involved seven volunteer women, below 38, suffering from premature ovarian failure, who received E2 and progesterone replacement therapy. Plasma levels of E2, progesterone, follicle stimulating hormone and luteinizing hormone were measured and PI were studied and compared before treatment and on Days 13, 27 and 41. RESULTS: Before treatment, a high-resistance vascular for both arteries is uniformly found. The curves show with the increasing of the E2 plasma levels, a decrease in the PI of UA and MTA with a fall at Day 13. We compared the mean values in MTA and UA PI. No statistical difference between the three mean values in PI obtained at Day -1, Day 13 and Day 41 was demonstrated. CONCLUSION: The results suggest that median thoracic artery is a target organ artery. Such as the UA, the MTA vascular resistance is according to the variations of plasma levels of E2. In consideration of it rectilinear and superficial type, this led us to study this artery when we use different sorts of replacement therapy, and particularly in the oocyte donation program.

Adult↗

PubMed2004

Angioplasty of the internal thoracic artery bypass-graft an alternative to reoperation.

BACKGROUND: This review presents an overview of interventional revascularization procedures of the internal thoracic artery after prior implantation as a coronary-artery bypass graft. METHODS: Our search was concentrated on the MEDLINE-database to identify all articles on internal thoracic artery-graft-angioplasties and reoperation after internal thoracic artery bypass grafting published between 1968 and 2000. RESULTS: Surgical revascularization and reoperation were reported in five papers including a total of 785 patients. The overall mortality of these patients was 4.2%. The presence of a patent internal thoracic artery-graft at the time of reoperation was not a risk factor for higher morbidity and mortality. Revascularization with percutaneous transluminal coronary angioplasty of the internal thoracic artery or the native left anterior descending artery via the internal thoracic artery-graft used as a conduit was performed in 327 patients. The primary success rate was 87%, the angiographically assessed rate of restenosis was 30% and the rate of complications approximately 1%. CONCLUSIONS: In spite of technical problems the percutaneous transluminal coronary angioplasty in or via internal thoracic artery-graft presents a safe and feasible option to be recognized before a potential reoperation.

Angioplasty, Balloon↗

PubMed2000

Importance of preoperative marking for minithoracotomy and for internal thoracic artery harvesting in minimally invasive direct coronary artery bypass grafting.

Minimally invasive direct coronary artery bypass has the potential to cause an anastomotic failure because of a limited exposure of the operative field and the difficulty of internal thoracic artery harvesting. In the present study, the importance of preoperative marking for an accurate minithoracotomy location and a successful internal thoracic artery harvest was assessed. A paperclip was placed on the left nipple and a chest X-ray was performed in the supine position. By aligning the position of the paperclip to the location of the left anterior descending coronary artery from a coronary arteriogram frontal view, the intercostal space for the minithoracotomy was thus determined. Marking the incisional intercostal space during preoperative left internal thoracic arteriography revealed the number and location of the internal thoracic artery branches at the beginning of the harvest. This preoperative marking technique allowed for a more adequate exposure of the operative field and an easier internal thoracic artery harvest which therefore contributed to an improvement in the operative results.

Aged↗

PubMed1996

Bilateral and unilateral use of internal thoracic artery for myocardial revascularization. Comparison of extubation outcome and duration of hospital stay.

The left internal thoracic artery is usually used as arterial conduit for myocardial revascularization; however, there is an increasing popularity of bilateral use of this artery for grafting. We examined 180 patients with both types of arterial conduits to answer whether bilateral use of the internal thoracic artery makes the difference in postoperative extubation outcome and duration of hospital stay in comparison to the unilateral use of this conduit. Ninety-three patients with bilateral conduit and 87 patients with unilateral conduit, with comparable age, cardiopulmonary bypass, and aortic cross-clamp time have been studied. On the basis of statistical and retrospective analysis, we conclude that bilateral use of internal thoracic artery for myocardial revascularization prolongs required postoperative respiratory support (12.0 h against 7.6 h) not affecting the duration of the mean hospital stay.

Humans↗

PubMed1990

Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft.

Although use of the internal thoracic artery (ITA) for coronary artery bypass grafting results in superior graft patency and improved patient survival, our initial clinical observations suggested an increased incidence of pleuropulmonary morbidity with its use. One hundred consecutive patients with left ITA grafts were studied prospectively and compared with a consecutive retrospective group of 100 patients undergoing coronary artery bypass grafting with saphenous vein grafts only. Preoperative, postoperative day (POD) 2, POD 6, and postoperative week 8 chest roentgenograms were analyzed for atelectasis and effusion. Postoperative left lower lobe atelectasis was common in both groups on both POD 2 (saphenous vein, 43%, versus ITA, 53%; not significant) and POD 6 (saphenous vein, 40%, versus ITA, 41%; not significant). There was a significantly higher incidence of pleural effusion on POD 6 in the ITA group (84% versus 47%; p less than 0.05) but most of these were small. There was more chest tube drainage (1,413 versus 1,028 mL; p less than 0.01) and a greater need for secondary thoracostomy or thoracentesis (4% versus 0%) in the ITA group. The left pleural space was opened in 67 of the 100 ITA patients but pleurotomy did not appear to influence postoperative morbidity. We conclude that use of the internal thoracic artery for coronary artery bypass grafting results in a small but significant increase in pleuropulmonary morbidity.

Chest Tubes↗

PubMed2005

Off-pump, in situ internal thoracic artery grafting: a durable treatment for single-vessel coronary artery disease.

BACKGROUND: The value of off-pump in situ left internal thoracic artery to left anterior descending coronary artery bypass grafting in single-vessel coronary artery disease was assessed by long-term angiographic and clinical data. METHODS: One-hundred three randomly selected patients (87 male, 16 female; mean age, 57.4 +/- 10.5 years) underwent postoperative angiographic control after an average postoperative period of 4.8 +/- 2.9 years (up to 8.2 years; a total of 490 patient-years). RESULTS: Fifty-five patients (52%) were asymptomatic, whereas 31 (30%) had anginalike chest pain. Ninety-seven patients (94.2%) were in New York Heart Association class I or II. Five-year angina-free survival was 81% +/- 5%. Of 103 left internal thoracic arteries assessed, 99 were patent (overall patency, 96.1%). All four cases having occluded grafts had mild native vessel stenoses (<80%) before operation. The patency rate was 99% +/- 1% at 3 years, and 93% +/- 4% at 5 years. The left ventricular segmental wall motion score of the left anterior descending coronary arterial distribution improved from 4.1 +/- 1.1 to 3.7 +/- 0.9 (p = 0.001). Consequently, 15 patients (15%) underwent secondary revascularization (11 interventional and 4 surgical) 4.8 +/- 2.1 years after the primary operation. The most frequent indication for interventional revascularization was atherosclerotic progression in systems other than left anterior descending artery. The cases with graft occlusion were treated surgically. Five-year freedom from interventional or surgical repeat revascularization was 91% +/- 4%. CONCLUSIONS: In addition to the well-documented safety and reliability, off-pump in situ left internal thoracic artery grafting is also a durable treatment for isolated left anterior descending artery disease, in both clinical and angiographic terms.

Adult↗

PubMedDate not supplied

Internal thoracic artery as main blood supply to the lower limbs. Case report.

A 70-year-old male patient was admitted with symptoms of unstable angina pectoris and claudication. He presented critical left main and right coronary artery disease and juxtarenal aortic occlusion at the same time. Internal thoracic artery increased in diameter with many collateral branch arteries distally. Coronary artery bypass graft operation was performed immediately. Saphenous veins were used for conduit. Internal thoracic artery was let intact to avoid any ischemic problem of the lower extremities. DSA performed postoperatively showed that the internal thoracic artery was the unique blood supply to the leg. In the absence of emergency of peripheral revascularization two staged surgical approach (CABG first and aortobifemoral bypass some months later) was considered. However, in patients with severe peripheral vascular disease or even in patients whom intraaortic balloon-pump indicated postoperatively, combined surgical approach is necessary. In all coronary artery disease patients with Leriche syndrome, ITA dependent lower extremity circulation should be thought preoperatively. Extra-anatomic peripheral bypass is a reasonable alternative choice in combined procedures with low morbidity, especially in elderly patients having coexisting disease.

Aged↗

PubMed2004

Right internal thoracic artery remodeling 18 years after circumflex system grafting.

A 64-year-old man with left main coronary artery disease underwent myocardial revascularization. The left internal thoracic artery (LITA) was sutured to the left anterior descending artery, and the right internal thoracic artery (RITA) was sutured to the obtuse marginal artery. Eighteen years later, angina reoccurred. Catheterization revealed that both the coronary and the left subclavian arteries were occluded and that a patent RITA graft was maintaining the cardiac blood supply. The RITA graft evaluation revealed increased lumen diameters, suggestive of remodeling. The LITA was subsequently disconnected and sutured to the aorta as a free graft in order to restore appropriate myocardial blood flow. This case emphasizes the benefits of using a live graft for left coronary system grafting, which include long-term patency and flow-dependent remodeling.

Humans↗

PubMed2000

Long-term clinical and angiographic follow-up of sequential internal thoracic artery grafting.

OBJECTIVE: Sequential internal thoracic artery (ITA) grafting allows a more complete arterial revascularization of the myocardium. We wanted to verify whether the excellent clinical and angiographic short term results reported by us before where maintained over 10 years and more. METHODS: the first consecutive 500 patients having received at least one sequential ITA graft between October 1985 and August 1991 were reviewed. Age averaged 61 years. Fifty-three patients had a left ventricular ejection fraction less than 40%, 117 were not elective, 35 (7%) were reoperations, 56 (11%) had diabetes. In total 2156 anastomoses were constructed (4.3/patient), among them 1367 arterial anastomoses (2.7/patient) and 1150 sequential ITA anastomoses (2.3/patient). The clinical follow-up was 97.4% complete and averaged 9.6 (range 8.6-13.6) years. One hundred and sixty-one patients consented to a late angiographic restudy after a mean interval of 7.4 (range 1-12.2) years. RESULTS: At 5 and 10 years, 89 and 72% of the patients were still alive. At 10 years 82% are still asymptomatic and 71% free of any type of ischaemia. Only four patients (0.8%) needed a repeat surgical revascularization, and 11 (2.3%) a percutaneous coronary angioplasty. At 5 and 10 years, 92.8 and 69% of the patients remained free of any cardiac event. Overall, 95.5% of the arterial anastomoses were patent and 96.1% of the sequential ITA were patent. There was a significant difference between the patency rate of pedicled ITA and free ITA anastomoses: 96.3 vs. 86.5% (P=0.02). There was no difference in patency between left ITA and right ITA anastomoses for the LAD and Cx areas. Sequential ITA anastomoses showed excellent patency rates to all coronary vessels but the very distal circumflex and the distal branches of right coronary artery (85%). There was no significant difference between the patency of the proximal and the distal sequential ITA anastomoses. The sequential anastomoses constructed in the length tend to remain more patent than the diamond-shaped ones: 97.2 vs. 91.5% (P=0.004). CONCLUSIONS: Sequential ITA grafting optimizes arterial revascularization. The long-term patency is excellent, is identical to that of single ITA grafting, and appears not much different from postoperative patency. The need for repeat surgical and interventional revascularization has been extremely low: 3.1% over the whole follow-up.

Adult↗

PubMed2000

[Myocardial revascularization using the internal thoracic artery: pro and con].

Internal thoracic artery (ITA) has superior histological, physiological and pharmacological properties over the venous grafts, and it is considered to be the graft of choice for myocardial revascularization. It has low incidence of late atherosclerotic lesions, and excellent long-term patency. Usage of ITA yields improved clinical results in all subgroups of patients with coronary artery disease, including patients with poor left ventricular function (EF%), left main stenosis, diffuse coronary artery disease and octogenarians. Since superior long-term results (to be expected only 10-15 years after the operation) may be outweighed with slightly higher incidence of early morbidity and mortality, many cardiac surgeons are reluctant to use it routinely. However, this attitude is difficult to justify, since early operative results in patients that have received ITA graft are superior as well, compared to patients that have received vein grafts only.

Humans↗

PubMed1999

[Coil embolization of an AV-fistula between the left thoracic artery and vein after coronary artery bypass surgery].

We report a case of an artificial fistula between the internal thoracic artery and vein after coronary artery bypass surgery, anastomosing the left internal thoracic artery to the LAD. Because of symptomatic anterior wall ischaemia due to coronary steal a treatment was mandatory. Instead of surgical correction, this shunt was closed by coil embolization of the venous limb.

Arteriovenous Fistula↗