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PubMed1993

[A right internal thoracic artery graft to the left anterior descending artery].

From 1987 to 1991, 48 patients received a right internal thoracic artery (RITA) to the left anterior descending artery (LAD). No operative death occurred, but two patients (4.2%) died during hospitalization due to graft versus host disease, and congestive heart failure. Graft patency of the RITA was 100%. After a 17.2 month mean follow-up, the 4 year actuarial survival rate (including all causes of death) was 85.3%, and the 4 year cumulative cardiac event free rate (including all cardiac deaths, myocardial infarction, reoperation, and PTCA) was 87.6%. The length of the RITA graft to the LAD, 15.6 +/- 1.1 cm, was significantly longer than that of the left internal thoracic artery (LITA) to the LAD, 12.9 +/- 1.1 cm. However, the flow of the RITA-LAD graft, 42.3 +/- 21.1 ml/min, was same as the flow of the LITA to the LAD, 42.1 +/- 19.6 ml/min. These findings justify wider use of the RITA to the LAD as a second arterial graft.

Adult↗
PubMed1999

Mediastinal irradiation: A risk factor for atherosclerosis of the internal thoracic arteries.

Previous radiotherapy to the thorax is a risk factor for coronary artery disease. Patients with radiation-induced atherosclerosis tend to be young and frequently have lesions involving the coronary ostia and left anterior descending artery. Bypass is often the most suitable method of revascularization, and given the young age of the patient, arterial conduits would be considered superior to vein grafts. However, the internal thoracic arteries can lie within the radiation field and may not be free of atherosclerosis. A 40-year-old man who required coronary artery bypass grafting for multivessel coronary artery disease 11 years following radiotherapy for Hodgkin's lymphoma is reported. Preoperative angiography showed that the right internal thoracic artery had significant atherosclerosis and was unsuitable as a conduit.

Adult↗
PubMedDate not supplied

Free right internal thoracic artery in a "horseshoe" configuration: a new technical approach for "in situ" conduit lengthening.

Severe chronic obstructive pulmonary disease with large lung volumes may prevent both the "in situ" internal thoracic arteries to reach coronary anastomoses sites. We present a method to revascularize the left antero-lateral myocardial wall using the right internal thoracic artery as a "free graft" anastomosed side to end to the "in situ" left internal thoracic artery, in a "horseshoe" fashion. The two ends of the "free graft" were anastomosed to the left anterior descending coronary artery and the second obtuse marginal branch, respectively. This method was successfully used in a 74-year-old patient with severe chronic obstructive pulmonary disease.

Aged↗
PubMed1996

Internal thoracic artery graft function during exercise assessed by transthoracic Doppler echography.

BACKGROUND: Noninvasive quantitative assessment of internal thoracic artery (ITA) graft function at rest and during exercise is important in patients who have undergone coronary artery bypass grafting. METHODS: Blood flow in the ITA graft was measured using transthoracic color Doppler echography before and after operation in 50 patients who underwent coronary artery grafting using an ITA to the left anterior descending artery. The patients were divided into three groups according to the degree of coronary stenosis and previous anterior myocardial infarction: Group 1 included 12 patients with severe (90% or more) coronary stenosis accompanied by anterior infarction. Group 2 included 26 patients with severe coronary stenosis without anterior infarction. Group 3 included 12 patients with moderate (75% or less) coronary stenosis without anterior infarction. Transthoracic echographic images of the ITA were obtained through the first intercostal space using a 7.5-MHz probe, and the diameter and cross-sectional area of the ITA were measured on B-mode imaging. Systolic, diastolic, and mean blood flow velocity and volume were measured by the Doppler method. RESULTS: Internal thoracic artery diameter increased significantly from 2.2 mm to 2.4 mm after operation. The ITA flow patterns in both flow velocity and volume changed from systolic-dominant to diastolic-dominant after operation. Postoperative ITA graft flow was 82 +/- 24 mL/min, 53 +/- 30 mL/min, and 31 +/- 15 mL/min (p < 0.01, group 1 versus 3; p < 0.05, group 1 versus 2) and percent diastolic fraction of ITA flow was 72%, 68%, and 62% (not significant) in groups 1, 2, and 3, respectively. Compared with intraoperative ITA flow, which was measured using an ultrasound transit-time flowmeter, postoperative ITA graft flow was increased in group 1, but not changed in group 2 or 3. The ITA graft flow was measured before and after exercise in 19 patients and was compared with ITA flow in 10 normal control subjects. The ITA graft flow increased significantly with exercise in all patients in the three groups. Percent diastolic fraction of ITA flow increased significantly with exercise in patients with severe coronary stenosis (groups 1 and 2), but decreased significantly in patients with moderate stenosis (group 3). CONCLUSIONS: Changes in native coronary artery and ITA graft may be predicted by assessing ITA flow pattern during exercise. Transthoracic color Doppler echography is a clinically useful noninvasive method of assessing ITA graft function at rest and during exercise.

Adult↗
PubMed2004

Reactivity of the human internal thoracic artery to vasodilators in coronary artery bypass grafting.

OBJECTIVE: The internal thoracic artery (ITA) is a useful conduit for coronary artery bypass grafting (CABG) and the patency rate is indispensable. Recently we have developed a method for increasing ITA blood flow during surgery by directly injecting phosphodiesterase III inhibitor (PDE III-I) into the left ITA (LITA) to prevent its contracture. In this study, we compared the reactivity of LITA blood flows before and after injection of four drugs: saline, papaverine hydrochloride, isosorbide dinitrate (ISDN), and PDE III-I. METHOD: 80 patients who were undergoing the first primary CABG, were randomly separated into four groups. Each group consisted of 20 patients. LITA graft free flow (GFF) and systemic mean blood pressure (MBP) were measured before and 1 min after direct intra LITA drug administration and blood vessel resistance (R) was calculated. RESULT: The saline group showed no significant changes in GFF, R value, and MBP. Significant increase in GFF was observed in the PDE III-I and ISDN groups. Except the saline group, each group exhibited a significant decrease in both the R value and MBP. A comparison of the change rate of MBP showed no significant differences among the four groups. The PDE III-I significantly increased the change rate of GFF and decreased the change rate of R value, when compared to the saline and papaverine hydrochloride groups. The PDE III-I showed a tendency to increase the change rate of GFF and to decrease the change rate of the R value compared to the ISDN group. CONCLUSION: The results of this study suggested that the PDE III-I is the most effective for increasing the blood flow of a LITA graft for CABG during surgery.

3',5'-Cyclic-AMP Phosphodiesterases↗
PubMed2002

Bilateral pedicled internal thoracic artery grafting.

BACKGROUND: Pedicled bilateral internal thoracic artery grafting (BITA) has been discouraged in historical high-risk groups such as diabetes mellitus (DM), renal failure, old age, and obesity because of reported high incidence of mediastinitis. However, considering the fact that there are abundant short and long-term results including angiography study about the conventional pedicled grafts, it might be worthwhile reassessing the results of pedicled BITA grafting with modern techniques by a disciplined surgical team before abandoning the method. METHODS: Between September 1989 and September 1999, 1371 patients underwent isolated coronary artery bypass grafting (CABG) in Kumamoto central hospital. Of these patients, 558 patients who had bilateral ITA strategy (mean age 63.0+/-9.2 years, 13-79) were studied. The method of harvest of ITAs is consistently the use of conventional pedicled grafts. The use of bone wax and unnecessary electrocautery injury to the periostium or cartilage were avoided as much as possible. The only change in the surgical technique in the study period is the application of the pinpoint hemostasis for the presternal tissues from August 1997 (late period). RESULTS: In late period, there were significantly more patients with sternal sepsis risk factors such as diabetes mellitus (early: late; 19.3% vs. 34.8%, P<0.00003), and renal failure (0.3 vs. 9.7%, P<0.0001) as well as patients who had gastroepiploic artery grafting (16.9 vs 48.5%, P<0.0001) and those who required aortic non-touch technique (2.1 vs. 7.9%, P<0.001). The percentage of the patients receiving BITA grafting among the isolated CABG patients increased in the late period from 31.7% (331/1043) to 69.2% (227/328) (P<0.001), reflecting that a more aggressive approach towards bilateral ITA and arterial grafting has been taken in the late period. Overall operative mortality was 1.1% (n=6). Mediastinitis occurred in seven patients (1.3%). Of these, only one mediastinitis occurred in late period (0.4%). No mediastinitis occurred in 23 chronic renal dialysis patients. Among the 143 DM patients, there were three mediastinitis (2.1%). Of three, only one occurred in late period, yielding 1.3% mediastinitis rate. There was one mediastinitis (0.7%) among 134 elderly patients more than 70 years of age. Univariate analysis identified obesity as a risk factor for mediastinitis. And there was a trend of decreasing mediastinits in late period but did not reached a statistical significance (P<0.2). Multivariate analysis identified obesity and arteriosclerosis obliterates as independent risk factors. Neither diabetes mellitus, dialysis, female gender, nor old age were significant independent predictors of mediastinitis. Despite the significantly high percentage of high-risk patients in late group, there were no significant difference in mortality and morbidity between the two groups. CONCLUSION: Pedicled BITA grafting is feasible with acceptable morbidity and shouldn't be abandoned even in high-risk patients such as DM, old age, and dialysis, especially combined with pinpoint-hemostasis, avoiding excessive use of bone wax, and strict aseptic technique. These point require a surgical team familiar with these techniques to maintain adequate skills in conduit procurement.

Adolescent↗
PubMedDate not supplied

Transthoracic colour Doppler ultrasonography in the evaluation of internal thoracic artery bypass graft patency.

The internal thoracic artery (ITA) is the most important conduit for coronary artery bypass grafting. The quality of the anastomosis joining the ITA to the left anterior descending coronary artery has a major impact on left ventricular perfusion. The rapid detection of flow disturbances due to sub-optimal anastomosis is, therefore, of great prognostic significance. In this study, 47 coronary bypass patients were examined using colour Doppler ultrasonography peri-operatively and 4-6 months post-operatively. Findings were correlated with clinical observations and a treadmill exercise test. The pre-operative ITA flow pattern was normally triphasic, but changed post-operatively to simulate the normal biphasic flow pattern of left anterior descending coronary artery. A 35-case-control group was used to compare pre-operative ITA flow characteristics. The authors conclude that Doppler parameters, clinical findings and the treadmill test can be used in combination for the routine evaluation of graft patency, and to select cases that require more invasive coronary angiography.

Adult↗
PubMed1994

[The complex grafting of the internal thoracic artery to the coronary arteries].

Among the 34 complex internal thoracic artery (ITA) to coronary artery grafts, there were bilateral (in 20 patients), bifurcated (in 8), sequential (in 4), "free" (in 1), left ITA and right radial artery (in 1). It was performed with the "no-touch" technique to the ascending and transverse aorta, cardiopulmonary bypass with an arterial inflow cannulation to the left common femoral artery, with a beating, warm, and vented heart and severe bradycardia induced by a short acting beta 1-blocker. Two latter factors were used to decrease myocardial oxygen consumption and facilitate construction of the ITA to coronary artery anastomoses. There were no operative mortality.

Adult↗
PubMed1996

Complete revascularization with internal thoracic artery grafts.

Saphenous vein graft atherosclerosis continues to be the major cause of late failures of coronary artery bypass operations (CABG). The internal thoracic artery (ITA) is an ideal bypass graft because it remains free of atherosclerosis at late follow-up in most patients. Myocardial revascularization with only ITA grafts has developed in an incremental manner from single grafts of the left ITA to the left anterior descending coronary artery (LAD), to use of bilateral, free and sequential ITAs, and now recently to the use of preconstructed grafts that attach the free right ITA to the left ITA. The microanatomy and vascular reactivity of the ITA have been recently defined, and they explain why the ITA remains free of obstruction. Our techniques and results of ITA grafting developed over the past 25 years are presented.

Anastomosis, Surgical↗
PubMed1990

[Internal thoracic artery in coronary surgery].

The authors emphasize advantages of using the internal thoracic artery for mammary-coronary shunts in patients with ischemic heart disease. 257 operations have been performed in the clinic since 1964. Among them there were operations of mammary-coronary anastomosis (after V. I. Kolesov) and mammary-coronary shunts. Long-term results were followed-up which evidence high effectiveness of operative treatment. In 109 patients control angiographic examinations were fulfilled at different terms (up to 12 years). Patency of mammary-coronary shunts was 83.5% as compared with ACSh where it was about 63%.

Coronary Disease↗
PubMed2001

Free right internal thoracic artery as a second arterial conduit: modification of proximal anastomosis for improvement of graft patency.

The applicability of the right internal thoracic artery (RITA) for coronary artery bypass grafting is higher when used as a free graft than as a pedicled graft. However, the technical difficulty of directly connecting the proximal end of the free RITA to the much larger aorta leads to poor patency. To overcome this technical limitation, we have used a modification that places the proximal end of this artery onto the hood of an accompanying vein graft at the aortic anastomosis instead of directly onto the aorta. We performed isolated coronary artery bypass grafting on 43 patients using the free RITA as a second arterial graft following pedicled left internal thoracic artery grafting. The mean patient age was 60 years and 38 patients were male. There was no mortality and no incidence of morbidity related to free RITA use. Postoperative coronary angiography performed in all patients revealed that all proximal anastomoses were widely patent, making the patency rate of the free RITA 100%. With these encouraging results, the free RITA graft with the described modification is thought to be a more promising second arterial graft with greater versatility than the pedicled graft. The long-term evaluation of a large patient population will determine the significance of this modification.

Adolescent↗
PubMed2005

The difference between nicardipine and its enantiomers on inhibiting vasoconstriction of isolated rabbit thoracic artery.

The present study was designed to study the difference effects between nicardipine and its two enantiomers on thoracic artery of rabbit. A high-performance liquid chromatographic method was used to prepare the two enantiomers of nicardipine. The thoracic artery of rabbit was removed. The vessels were cut into 3 mm in width and 15 mm in length spiral strips and immersed into tissue baths. The concentration-response curves of nicardipine and its enantiomers were obtained by cumulative administration of the vasoconstrictors. Nicardipine and the enantiomers could shift the dose-response curves of NE, KCl or CaCl2 to right in a nonparallel manner and decrease the maximum effective in a concentration-depended manner, respectively. The pD2' value of R-(-)-nicardipine showed significantly effective than that of nicardipine and S-(+)-nicardipine (P<0.01). There was not obviouse difference between the pD2' value of nicardipine and S-(+)-nicardipine (P>0.05). The results demonstrate that the stereoselective interaction between R-(-)-nicardipine and L-calcium channel receptor is more stronger than that of S-(+)-nicardipine.

Animals↗
PubMed2000

Biochemical assessment of myocardial injury after cardiac surgery: effects of a platelet activating factor antagonist, bilateral internal thoracic artery grafts, and coronary endarterectomy.

OBJECTIVE: Platelet activating factor antagonists reduce ischemia-reperfusion injury in experiments, but there is no supportive clinical evidence. METHODS: A single-center, double-blind, minimized, placebo-controlled, randomized trial of low-dose (10 mg) or high-dose (100 mg) platelet activating factor antagonist was conducted in 150 patients undergoing coronary artery bypass grafting. Myocardial injury was determined by serial measurements of the MB isoenzyme of creatine kinase and cardiac troponin T. The effects of single or bilateral internal thoracic artery grafting and coronary endarterectomy on myocardial injury were also assessed. RESULTS: The placebo and platelet activating factor antagonist groups were similar with respect to preoperative, intraoperative, and postoperative factors. Four patients (2.7%) died before discharge, 3 from cardiac events. Thirteen patients (9%) had biochemical evidence of myocardial infarction, of whom 3 died. Stepwise multiple regression analysis demonstrated that duration of cardiopulmonary bypass was the most important determinant of elevations in creatine kinase MB isoenzyme and cardiac troponin T up to 6 hours after the operation and that the use of a platelet activating factor antagonist and the number of internal thoracic artery grafts did not influence myocardial injury at any time. Endarterectomy was performed in 11 patients (7%), of whom 6 (55%) had biochemically defined myocardial infarction and of whom 1 died (9%). Endarterectomy was the most important determinant of elevated levels of creatine kinase MB isoenzyme and cardiac troponin T 24 and 48 hours after the operation. CONCLUSION: Platelet activating factor antagonists do not reduce perioperative myocardial injury. Bilateral and single internal thoracic artery grafting results in similar levels of myocardial injury, whereas endarterectomy is frequently associated with biochemical evidence of myocardial injury.

Area Under Curve↗
PubMedDate not supplied

Repeat median sternotomy after prior ante-aortic crossover right internal thoracic artery grafting.

BACKGROUND: In situ bilateral internal thoracic artery (ITA), with ante-aortic crossover right ITA (RITA) is gaining popularity. However, the retrosternal position of the crossover RITA has raised concerns with regard to its compromise during subsequent resternotomy. METHODS: Ten patients underwent repeat median sternotomy after prior ante-aortic crossover RITA grafting. Specific RITA routing and fixation had been performed in the initial operation. Preoperative imaging, including computed tomography (CT) angiography, was performed to confirm RITA position in relation to the sternum and assess feasibility. RESULTS: Resternotomy was performed 4-48 months after the initial operation (median, 22 months). Nine crossover RITA grafts were functioning at the time of resternotomy. CT angiography was performed in four patients in whom the premarked RITA could not be localized on the plain chest radiograph. The feasibility of conducting a nonmodified resternotomy was determined based on preoperative imaging. All RITA grafts resumed their original position and none was injured during reentry. There was no early mortality, perioperative stroke, or reexploration for bleeding. One patient sustained myocardial infarction, however, not in a RITA-related distribution. CT angiography was predictive in confirming a free retrosternal space. CONCLUSIONS: Resternotomy after prior ante-aortic crossover RITA grafting can be performed at acceptable risk. Confirmation of a free retrosternal space by preoperative imaging may contribute to the safety of the procedure. Maneuvers performed during the first operation are useful in preventing RITA adherence to the sternum.

Aged↗
PubMedDate not supplied

Internal thoracic artery collateral to the external iliac artery in chronic aortoiliac occlusive disease.

OBJECTIVE: To evaluate the incidence and angiographic findings of the collateral pathway involving the internal thoracic artery in patients with chronic aortoiliac occlusive disease. MATERIALS AND METHODS: Between March 2000 and Februrary 2001, 124 patients at our hospital underwent angiographic evaluation of chronic aortoiliac occlusive disease, and in 15 of these complete obstruction or severe stenosis of the aortoiliac artery was identified. The aortograms and collateral arteriograms obtained, including internal thoracic arteriograms, as well as the medical records of the patients involved, were evaluated. RESULTS: In nine patients there was complete occlusion of the infrarenal aorta, or diffuse stenosis of 75% or more in the descending thoracic aorta, and in the other six, a patent aorta but complete occlusion or stenosis of 75% or more of the common iliac artery was demonstrated. Collateral perfusion via hypertrophied internal thoracic arteries and rich anastomoses between the superior and inferior epigastric arteries, reconstituting the external iliac artery, were noted in all fifteen patients, regardless of symptom duration, which ranged from six months to twelve years. CONCLUSION: In patients with chronic aortoiliac occlusive disease, the internal thoracic artery, along with visceral collaterals and those from the contralateral side, is one of the major parietal collateral pathways.

Adult↗
PubMed2004

Serial dobutamine stress echocardiography with Doppler assessment of the left internal thoracic artery graft after minimally invasive bypass for a patient with an orthotopic heart transplant.

Select patients who have undergone orthotopic heart transplantation with proximal left anterior disease may be candidates for minimally invasive direct coronary artery bypass surgery. Combining left internal thoracic artery transthoracic Doppler flow assessment with wall motion assessment during dobutamine stress echocardiography adds to the utility of this test by focusing attention on the graft's status as well as detecting ischemia due to cardiac allograft vasculopathy.

Aged↗
PubMed1996

Extrathoracic arteriosclerotic vascular changes preclude the use of the internal thoracic artery for coronary artery bypass grafting.

During a two-years period we have treated 6 patients where use of the internal thoracic artery for coronary artery grafting was precluded because of extrathoracic arteriosclerotic vascular lesions. In four patients with severe aorto-iliac occlusive disease preoperative digital angiography demonstrated collateralisation of the lower extremity by either the left, right, or both internal thoracic arteries (ITA). In these cases use of the ITA was excluded in order to preserve the collateral supply and coronary bypass grafting was performed using only saphenous vein. In two patients with proximal occlusion of the left subclavian artery the right ITA was used as in-situ bypass to graft the left anterior descending artery. All patients survived the operation without development of a perioperative myocardial infarction, neurological deficit, or peripheral ischemia. Although they rarely do, extrathoracic vascular disorders can exclude the use of the ITA for grafting. Especially in the case of aorto-iliac occlusive disease or proximal arteriosclerotic subclavian lesions angiographic evaluation is mandatory to prevent the development of life-threatening peripheral ischemia by harvesting an ITA and to avoid the use of an inadequate ITA graft with in-flow occlusion.

Aged↗