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PubMed2004

Aortic valve replacement in a patient with a patent internal thoracic artery graft.

Myocardial protection in patients requiring a second open-heart surgical procedure after coronary artery bypass grafting, especially when there is a patent left internal thoracic artery graft to the left anterior descending coronary artery, remains controversial. We present the case of a patient in whom aortic valve replacement was undertaken 18 months after coronary artery revascularization. Unusual features included beating-heart aortic valve replacement with continuous retrograde coronary sinus perfusion and avoidance of dissection of the patent grafts, including the left internal thoracic artery and a saphenous vein graft.

Aged↗

PubMed2007

Progressive improvement of myocardial perfusion after off-pump revascularization with bilateral internal thoracic arteries: comparison of early versus 1-year postoperative myocardial single photon emission computed tomography.

OBJECTIVE: We evaluated the time course of myocardial perfusion improvement after off-pump revascularization. METHODS: Seventy-six patients who underwent off-pump coronary bypass with bilateral internal thoracic arteries for revascularization of the left coronary territory were studied. Myocardial single photon emission computed tomography was performed preoperatively and at 3 months and 1 year postoperatively. Myocardial perfusion was quantified with automatic software, and the left coronary territory was divided into 16 segments. As an indicator of the ischemic myocardium, the reversibility score was defined as a measure of rest minus stress perfusion values. A total of 403 segments that showed a reversibility score of 7 or greater preoperatively were included. RESULTS: The reversibility score was improved significantly at 3 months postoperatively (P < .001) and further improved 1 year after the operation (P < .001). When the patients were divided into 2 groups based on the type of bilateral internal thoracic arteries used (group Y: Y-composite graft, n = 39; group I: bilateral in situ grafts, n = 37), the reversibility score was improved significantly 3 months after the operation (P < .001) and further improved 1 year after the operation (P < .001) in both groups. There were no significant differences in the reversibility scores between groups Y and I at postoperative month 3 (P = .463). The scores approached zero in both groups at 1 year postoperatively (group Y, -1.7% +/- 7.9%; group I, 1.3% +/- 7.2%). CONCLUSIONS: The myocardial reversibility score improved greatly during the first 3 months after the operation and further improved until 1 year postoperatively. Perfusion improvement was similar between the Y-composite and bilateral in situ internal thoracic artery grafts in terms of the reversibility score.

Coronary Artery Bypass, Off-Pump↗

PubMed2000

Left internal thoracic artery harvesting in pleural symphyses under minimally invasive direct vision.

In minimally invasive direct coronary artery bypass grafting (MIDCAB), the internal thoracic artery (ITA) is harvested under a direct-vision or videothoracoscopic techniques. However, whatever the technique used, dense pleural adhesions hamper ITA harvesting. We describe the case of a patient who underwent MIDCAB 40 years after a pulmonary resection for tuberculosis. The parietal pleura adhered to the left lung so firmly that we could not enter the intrapleural cavity. Therefore, the ITA was harvested creating an extrapleural tunnel Although this approach resulted in more operating time and bleeding, an anastomosis between the ITA and left anterior descending coronary artery was performed successfully. We believe that MIDCAB can be carried out even in patients with dense pleural adhesions.

Aged↗

PubMed1994

Percutaneous transluminal coronary angioplasty of the left internal thoracic artery graft: a case report in a child.

A 9-year-old girl who had undergone previous coronary artery bypass surgery at the age of 3.5 years for stenoses of the left anterior descending and right coronary arteries resulting from Kawasaki disease presented with recurrent exertional angina. Stenosis was found at the anastomosis of the left internal thoracic artery to the left anterior descending artery. Percutaneous transluminal coronary angioplasty was successfully performed. This is the first reported case of percutaneous transluminal coronary angioplasty of an internal thoracic artery graft in a child.

Angioplasty, Balloon, Coronary↗

PubMed2006

Tandem pedicled internal thoracic artery conduit for sequential grafting of multiple left anterior descending coronary artery lesions.

A patient presented with severe triple-vessel coronary artery disease, including multiple lesions on the left anterior descending coronary artery (LAD), which supplied a well-contracting myocardium. In approaching our patient, we judged that a pedicled left internal thoracic artery (LITA) would not provide enough length for sequential grafting of the multisegment-diseased LAD. We also considered that a pedicled right internal thoracic artery (RITA) conduit would not be long enough to provide a free segment that would form a tandem graft with a LITA and then arrive at the marginal branch, unless it was detached at its origin. Consequently, we decided to form a composite graft that would connect a free, short segment (6-7 cm) of pedicled LITA to the in situ pedicled RITA, in an end-to-end fashion. This new composite conduit enabled us to perform sequential grafting (3 sequential anastomoses, 2 with the LITA segment) of the multisegment-diseased LAD, following the route anterior to the aorta. The in situ remnant of the LITA was grafted to the marginal branch. Although many large series have reported resourceful solutions, to the best of our knowledge, tandem arterial sequential grafting (an in situ pedicled RITA plus a free, short segment of a pedicled LITA) has not heretofore been reported in application to the multisegmented-diseased LAD artery. We strongly believe that this technique is an attractive variation on bilateral pedicled ITA left-sided revascularization in cases of multivessel coronary artery disease, including LADs with multiple lesions.

Coronary Angiography↗

PubMed1997

Suitability and durability of multiple internal thoracic artery coronary artery bypasses.

OBJECTIVE: The authors evaluate operative and extended outcomes of coronary artery bypass surgery using the bilateral internal thoracic arteries (ITAs) as bypass grafts. The authors conclude that the procedure is viable and of long-term benefit to most patients. SUMMARY BACKGROUND DATA: Multiple ITA grafting was met with early enthusiasm by the surgical profession, but skepticism and controversy arose with reports of increased operative morbidity, insufficient graft blood flow, a high incidence of failure of the right ITA, and uncertainty about durability and long-term benefits. METHODS: To assess the actual incidence and impact of these complications and long-term results, the authors prospectively studied 500 consecutive patients with multiple ITA bypasses, constituting the closely observed and carefully documented experience of one surgeon over an 11-year period. RESULTS: Operative mortality in the series of 500 patients was 1.8%, perioperative myocardial infarction (new Q wave) rate was 0.6%, and deep sternal wound infection occurred in 1%. Six patients (1.2%) had strokes, and nine patients (1.8%) were returned to the operating room to control bleeding. One hundred ninety-eight patients who had abnormal stress test results before surgery were retested within 3 months of surgery. Ninety-four percent of these were normal, 3% were nondiagnostic, and 3% were abnormal. After a mean follow-up of 7.1 years (mode, 7.2 years), 87.5% of patients in the sample were alive, and 93.2% of this group have experienced continuing good clinical results (New York Heart Association class I or II). Eighty-nine patients who underwent an angiogram had 90.8% patency rates of ITA bypasses and 84.5% patency of vein grafts. Only two patients required repeat operations. CONCLUSIONS: The operative results did not support the contention that the coronary artery bypass using ITA procedure produces higher than acceptable mortality and morbidity rates. Multiple ITA bypasses can be performed without excessive morbidity, with low reoperation rates and long-term outcomes that should encourage skeptics to reconsider the procedure's clinical value.

Aged↗

PubMed1992

Multivessel coronary revascularization with bilateral internal thoracic artery grafts.

Sixteen patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts between 1988 and 1989 at the Okayama University Hospital. A total 39 coronary grafts were performed, being an average of 2.4 grafts per patient. Each patient received bilateral ITA grafts, and in 5 patients an additional 7 grafts were constructed with 5 autologous veins and 2 gastroepiploic arteries. The right ITA was grafted as a free graft in 4 patients. The ITA graft patency rate was 96.8 per cent (31/32) at the time of hospital discharge. The postoperative morbidity included one reoperation for bleeding and one myocardial infarction. Coronary artery bypass grafting with bilateral ITA grafts can be safely performed and its application facilitates complete revascularization with arterial grafts.

Aged↗

PubMed1993

Mid-term results of bilateral internal thoracic artery grafting.

Forty patients underwent coronary revascularization using bilateral internal thoracic artery (ITA) grafts between 1988 and 1992. A total of 111 coronary grafts were performed, or an average of 2.8 grafts per patient. Each patient received bilateral ITA grafts, and in 20 patients an additional 29 grafts were constructed with 18 autologous veins and 11 gastroepiploic arteries. The right ITA was grafted as a free graft in 20 patients. The ITA graft patency rate was 96 per cent (67/70) at the time of hospital discharge. The operative morbidity included 3 reoperations for bleeding, 1 perioperative myocardial infarction, 1 renal failure, 2 postcardiotomy shock, and 1 colon perforation. Two hospital deaths occurred; one due to colon perforation and the other due to postcardiotomy cardiogenic shock. One patient died of cerebral infarction 6 month after the operation. Thirty-four patients were in New York Heart Association functional class I, 2 were in class II and 1 was in class III. Cardiac function evaluated by echocardiography and scintigraphy showed significant improvement postoperatively. These data suggest that the use of bilateral ITA grafts is associated with an acceptable mortality and increases the versatility of arterial grafting.

Aged↗

PubMed1998

Morphometry of the internal thoracic arteries.

The surgical significance of the internal thoracic arteries (ITA's) in procedures such as coronary artery bypass grafting, transverse rectus abdominis myocutaneous flaps and minimal incision direct coronary artery bypass surgery is well recognised. However, the detailed morphometry of these vessels is not well documented. This study aimed to detail the morphometry of the ITA's. Morphometric analysis of these vessels from post mortem en-bloc specimens, consisting of aortic arch, great vessels and ITA's with anterior chest wall was conducted on 62 adults. The mean lengths and diameters of the ITA's at the origin, costal cartilage levels and termination were: length of the right ITA, 18.05 +/- 0.6 cm and the left, 18.085 +/- 0.6 cm. The average diameters recorded at the origin, first costal cartilage, fourth costal cartilage and termination were: right: 3.24 +/- 0.5 mm; 2.85 +/- 0.4 mm; 2.33 +/- 0.6 mm; 1.98 +/- 0.2 mm and left: 3.05 +/- 0.4 mm, 2.67 +/- 0.3 mm; 2.22 +/- 0.3 mm; 1.92 +/- 0.2 mm respectively. Morphometry of the ITA's are detailed. There was no significant difference in length between right and left ITA's although differences between the race groups were demonstrated. Significant differences in diameters in sides and race exist.

Adult↗

PubMed2002

Free right internal thoracic artery composite graft: an option in left anterior descending artery grafting?

Myocardial revascularization using bilateral internal thoracic arteries (ITA) decreases the risk of reinterventions and provides potential survival benefit. From May 1996 to April 2000, 1,057 patients underwent myocardial revascularization using skeletonized bilateral ITAs. A free right ITA as a composite graft was used for the left anterior descending artery grafting in 38 (3.6%) cases when the left ITA was not long enough to reach the left anterior descending artery. Operative mortality was 2.6% (1 patient). There was no observable reversible myocardial ischemia on the postoperative thallium single-photon emission computed tomography study. Myocardial revascularization with the use of a skeletonized free right ITA as a composite graft to the left anterior descending artery is an alternative option in cases when an in situ ITA cannot be used.

Humans↗

PubMed2002

Changing pattern in beating heart operations: use of skeletonized internal thoracic artery.

BACKGROUND: The use of skeletonized internal thoracic artery (ITA) was reported to be technically and hemodynamically beneficial in conventional coronary artery bypass grafting with cardiopulmonary bypass assistance. The purpose of this study is to evaluate the impact of changing from conventional to skeletonized ITA harvesting on early off-pump coronary artery bypass grafting outcome. METHODS: Between 1996 and 2001, 640 patients underwent systematic off-pump coronary artery bypass grafting (single surgeon experience). The ITA was pedicled (P) in the first consecutive 440 patients and skeletonized (S) in the subsequent 200 consecutive patients. Mean age, preoperative risk factors, sex, number of involved territories, and incidence of reoperations were similar in both groups. RESULTS: In group S, number of ITAs per patient (1.7 +/- 0.08 versus 1.2 +/- 0.05; p < 0.001), bilateral ITA (46% versus 27%; p < 0.001), ITA sequential grafts (27% versus 1%; p < 0.001), and T grafts (16% versus 3%; p < 0.001) were higher. Deep sternal infections were comparable in both groups (group S: 1%, group P: 1.2%; p = 0.38). Perioperative myocardial infarction, maximal creatinine kinase-MB level, and requirement for more than 24 hours of inotropic support were comparable in both groups. Thirty-day mortality was also similar (S: 1.7%, P: 1.6%). CONCLUSIONS: Changing to routine use of skeletonized ITA in off-pump coronary artery bypass grafting is a safe alternative to routine pedicled ITA. In our experience, this procedure has facilitated the use of ITA anastomosis without increasing sternal wound complications.

Aged↗

PubMed2005

Impact of ostial stenosis on the Doppler flow profiles in internal thoracic artery graft.

As ostial stenoses of internal thoracic artery (ITA) grafts rarely occur after coronary artery bypass grafting, little is known about their Doppler flow profile. This report describes changes in the Doppler flow of ITA grafts with ostial stenosis after surgical repair of the stenosis. A 54-year-old male underwent coronary artery bypass grafting (CABG) in which the left ITA was anastomosed to the left anterior descending coronary artery. The follow-up coronary angiography revealed an ostial 90% stenosis of the ITA. The patient underwent elective surgery during which the radial artery was interposed between the left subclavian artery and the ITA. Intraoperative ultrasonography was performed immediately before cut down of the ITA graft and again immediately after completion of all anastomoses. Both diastolic and systolic velocities and the velocity time integral increased more than 2-fold after the repair. Neither the diastolic-to-systolic peak velocity ratio nor the diastolic velocity time integral fraction showed remarkable change. These profiles were different from those reported previously for distal stenosis.

Constriction, Pathologic↗

PubMed2006

Y configuration of the internal thoracic arteries in myocardial revascularization.

This paper describes the short-term results of surgical myocardial revascularization in 35 patients. Y configuration from one or two internal thoracic arteries was applied for bypass grafting of the left coronary artery. In 4 patients with truncal stenosis of the left coronary artery (LCA) or proximal stenoses of the anterior interventricular artery (AIVA) and circumflex artery, the length of the left internal thoracic artery (LITA) appeared adequate for creation of Y bypass and revascularization of the entire LCA pool. In most cases (28), Y bypass was formed from both ITA, which made it possible to revascularise more distant arteries of the posterolateral wall of the left ventricle. Analysis of bypass-graphies performed in 10 patients after 7 months on the average has demonstrated that occlusion (2) and stenosis of one of the branches (2) of Y bypass were most probably caused by underestimation of the degree of stenosis of the target coronary arteries.

Aged↗

PubMed1999

Intraoperative application of power Doppler imaging: visualization of myocardial perfusion after anastomosis of left internal thoracic artery to left anterior descending coronary artery.

The purpose of this study was to determine the role of power Doppler imaging in assessing patency of coronary artery bypass graft (CABG) anastomosis. Twelve consecutive patients referred for CABG with the use of anastomosis of the internal thoracic artery to the left anterior descending coronary artery (LAD) were studied. A linear 6.5-MHz wide-band transducer was used during cardioplegic administration and reperfusion. Baseline power Doppler signals were obtained in the LAD in 11 patients, and post-CABG signals were obtained in 11 patients. In one patient the LAD was poorly visualized because of extensive calcification. In another patient the flow after bypass worsened and the graft was revised. Visualization of the LAD and internal thoracic artery grafts by epicardial intraoperative power Doppler imaging is feasible in almost all patients and allows rapid and simple intraoperative assessment of graft patency. In addition, myocardial perfusion is limited by heavily calcified coronaries.

Aged↗

PubMed2002

A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft.

We present a complex graft for total arterial revascularization based on bilateral skeletonized internal thoracic arteries (ITA). The lower two-thirds of the free right ITA is anastomosed to the proximal segment of the left in situ ITA using the T-graft technique (Tector-Barner-Calafiore). The free, transected distal part of the left ITA is then anastomosed end-to-side on free right ITA (T-on-T anastomosis). In addition, the technique may use another graft extending the proximal third of the in situ right ITA with the free radial artery for right-sided revascularization. The entire operation can be performed off-pump to avoid any procedure on the ascending aorta.

Anastomosis, Surgical↗

PubMed2006

Prostaglandin E2 EP4 receptor-selective agonist facilitates sternal healing after harvesting bilateral internal thoracic arteries in diabetic rats.

OBJECTIVE: Sternal wound complications are devastating events occurring in coronary artery bypass surgery, particularly in patients with diabetes. Prostaglandin E2 receptors have 4 subtypes, and the activation of the EP4 receptor induces bone regeneration. The present study investigated the utility of a prostaglandin E2 EP4 receptor-selective agonist in sternal healing after median sternotomy with the removal of the bilateral internal thoracic arteries in diabetic rats. METHODS: Diabetic Wistar rats with blood glucose levels of greater than 400 mg/dL were established by means of a single intraperitoneal injection of streptozotocin. After median sternotomy and bilateral internal thoracic artery removal in 16 diabetic rats, 8 rats were administered the EP4 agonist (300 microg) on the posterior table of the sternum (EP4 group), whereas 8 did not receive any treatment (control group). Sternal healing and incidence of sternal wound complications were evaluated 4 weeks after the operation. RESULTS: Sternal wound complications developed in 5 rats in the control group but in only 1 rat in the EP4 group (P < .01). Histologic examination revealed an almost completely healed sternum filled with regenerated bone tissue only in the EP4 group. Both bone mineral content and bone mineral density, as assessed with dual-energy x-ray absorptiometry, were higher in the EP4 group than in the control group (71.7 +/- 12.1 vs 48.9 +/- 11.7 mg for bone mineral content [P < .01] and 66.8 +/- 14.6 vs 47.9 +/- 6.3 mg/mm2 for bone mineral density [P < .05]). CONCLUSIONS: The prostaglandin E2 EP4 agonist accelerated the sternal healing and decreased the incidence of sternal wound complications in the diabetic ischemic sternum. This method might help in decreasing sternal necrosis in high-risk patients or permit wider application of bilateral internal thoracic arteries in coronary artery bypass surgery, even in patients with diabetes.

Animals↗

PubMed2004

Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting.

BACKGROUND: Aortic valve replacement (AVR) after coronary artery bypass using bilateral internal thoracic arteries (ITAs) is a challenge. Management of these patent grafts and myocardial protection are important issues. Moreover the risk and outcome of these complex operations have not been clearly defined. METHODS: Eighteen consecutive patients (all male) who exhibited previous bilateral ITA grafts underwent subsequent AVR surgery from 1990-2001 at the Cleveland Clinic Foundation. Their medical records were retrospectively analyzed. RESULTS: At the time of reoperation, the mean age of the patients was 67 +/- 6.4 years and 33 out of 36 (92%) ITAs were patent. The interval between previous coronary bypass and aortic valve surgery was 10.3 +/- 5.3 years. All patients underwent redo-median sternotomy with aortic cannulation in 12 patients (67%) and femoral or axillary artery cannulation in 6 patients (33%). The patent ITAs were clamped during aortic cross-clamping in 15 patients. In 3 patients the ITAs were not dissected. These 3 patients underwent deep hypothermic arrest for myocardial protection. Concomitant coronary revascularization was performed in 8 patients (44%). There were no hospital deaths. One stroke occurred but there were no other major complications. Average intubation time was 23.1 +/- 27.1 hours, intensive care unit stay was 2.3 +/- 3.1 days, and postoperative hospital stay was 10.3 +/- 7.6 days. CONCLUSIONS: Reoperative aortic valve surgery in the patients with patent bilateral ITA grafts can be performed safely.

Aged↗

PubMedDate not supplied

Differential effect of cerivastatin and L-arginine on the vascular function of human radial and left internal thoracic arteries.

BACKGROUND: There are a number of strategies to restore/preserve endothelial function. We have compared the effects of Cerivastatin (CS) to those of L-arginine (L-ARG) supplementation on the endothelial function of human arterial grafts. METHODS: During coronary artery bypass grafting, specimens of radial artery (RA) and left internal thoracic artery (LITA) were obtained. Specimens were divided into vascular rings, which were incubated with either 10(-6) mol/L CS, 10(-3) mol/L L-ARG, or vehicle (control) for 2 or 24 hours. Endothelial function was examined with acethylcholine (10(-9) to 10(-5) mol/L) following contraction by 3 x 10(-8) mol/L endothelin-1. RESULTS: Although no significant differences were observed in the RA at 2 hours, after 24 hours incubation, endothelium-dependent vasodilatation was significantly higher in CS group (68.4 +/- 5.0%; n = 6) compared to L-ARG group (49.9 +/- 5.4%; n = 7, p < 0.05) and control group (33.8 +/- 2.9%; n = 13, p < 0.0001). In addition, there was a significant increase in L-ARG group compared to control (p < 0.01). After 2 hours incubation of the LITA, CS failed to enhance endothelium-dependent vasodilatation compared to control (44.1 +/- 4.9%; n = 9, vs. 40.0 +/- 5.2%; n = 16, respectively, NS), while L-ARG increased it (64.7 +/- 4.9%; n = 7, p < 0.05 vs. CS and p < 0.01 vs. control). However, this increase disappeared at 24 hours although there was a higher trend of endothelium-dependent vasodilatation in CS group (30.3 +/- 3.7%; n = 8 in L-ARG, 56.5 +/- 8.8%; n = 9 in CS and 41.0 +/- 5.5%; n = 18 in control). CONCLUSIONS: CS preserved endothelium-dependent vasodilatation of RA greater than L-ARG. These findings suggest that the use of statins may be an effective therapeutic strategy to preserve endothelial function in the RA grafts, and could have important implications in the clinical practice.

Acetylcholine↗