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PubMed2003

Midterm results of routine bilateral internal thoracic artery grafting.

BACKGROUND: Skeletonized dissection of the internal thoracic artery (ITA) decreases the occurrence of sternal devascularization, thus decreasing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting. METHODS: From April 1996 to July 1999, 1000 consecutive patients underwent bilateral skeletonized ITA grafting. Of the 770 male and 230 female patients, 420 were older than 70 years, and 312 had diabetes. RESULTS: Operative mortality was 3.3%. Follow-up (40-78 months) revealed 79 late deaths, and the Kaplan-Meier 6-year survival rate was 88%. Cox regression analysis revealed increased overall mortality (early and late) in patients with preoperative congestive heart failure (risk ratio [RR], 2.13; 95% confidence interval [CI], 1.31-3.45), in patients with peripheral vascular disease (RR, 5.52; 95% CI, 3.31-9.19), and in patients older than 70 years (RR, 2.18; 95% CI, 1.37-3.47). Early postoperative morbidity included sternal infection (2.2%), cerebrovascular accident (1.6%), and perioperative myocardial infarction (1%). Multiple regression analysis showed repeat operation (odds ratio [OR], 7.5; 95% CI, 1.77-31.6) and chronic obstructive pulmonary disease (OR, 3.6; 95% CI, 1.27-10.75) to be independent predictors of sternal infection. During follow-up, angina returned in 95 patients, 24 of whom required reintervention (20 cases of percutaneous balloon angioplasty and 4 reoperations). Postoperative coronary angiography performed in 87 patients revealed an ITA patency rate of 91%. CONCLUSIONS: Bilateral skeletonized ITA grafting is associated with satisfactory early and midterm results. We do not recommend the use of this surgical technique in patients with chronic obstructive pulmonary disease.

Aged↗

PubMed1999

Spontaneous recanalization of postoperative severe graft stenosis. What is the cause and prognosis of the "string sign" in the internal thoracic artery?

A 68-year-old female with unstable angina was treated surgically. She was referred to the surgical ward by cardiologists because of a diagnosis of unstable angina with three vessel disease. On a coronary angiogram (CAG), 90% stenoses were found in the left anterior descending coronary artery (LAD), circumflex (CX), and right coronary artery (RCA). She received elective coronary artery bypass grafting (CABG), in which the left internal thoracic artery (LITA) was anastomosed to the LAD and reversed saphenous vein grafts (SVG) were made to segment 12 of the CX, and segment 4PD of the RCA, respectively. The postoperative course was uneventful, but postoperative early graftgraphy revealed distal narrowing of the LITA graft as the so-called "string sign". However, one year post surgery, the LITA string sign was not found and its patency had markedly improved on the second graftgram. It is reported that the LITA "string sign" might cause late graft occlusion. However, this LITA graft evidently enlarged the size and increased the flow of the artery in proportion to myocardial blood demand. To our knowledge, it has not been reported that an in situ LITA string sign on postoperative early graftgram has disappeared in the late phase. We hypothesize that the LITA string sign might be caused by several different factors such as flow competition, spasm, and/or technical problems. In any event, the LITA string sign does not cause graft occlusion in the late postoperative period in every case.

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PubMed2005

Endovascular control of patent internal thoracic artery graft in aortic valve surgery.

Aortic valve replacement in patients who underwent previous coronary artery bypass with a patent internal thoracic artery is often a challenge because of the risk of graft injury during dissection or difficulties to obtain optimum myocardial protection. Different approaches to myocardial protection or internal thoracic graft dissection and control have been described. Endovascular control of the internal thoracic graft by an angioplasty balloon catheter positioned in the operating room before the operation can be a safe and simple alternative. We report the case of a patient who underwent this technique for aortic valve replacement.

Angioplasty, Balloon↗

PubMed1989

Bilateral internal thoracic artery surgery: 17-year experience.

Angiographic comparisons of late morphology of internal thoracic artery (ITA) and saphenous vein grafts (SVG) in the same patients established morphologic superiority of the ITA grafts (1983). 15-year clinical follow-up of 748 consecutive patients having ITA and SVGs (532) or SVGs alone (216) established the clinical advantages given to patients by ITA grafts (1986): (1) higher cumulative survival rate (P less than 0.01); (2) less early recurrence of angina (P less than 0.01); (3) fewer late myocardial infarctions (P less than 0.02); (4) lower reoperation rate (P less than 0.001). Benefits to patients having bilateral ITA grafts (38) exceeded even those of single ITA grafts: (1) operative mortality = 0%; (2) cumulative survival (10 years) = 89.0%; (3) annual recurrence of angina = 1.5%; (4) annual late myocardial infarction = 1.1%; (5) mortality rate = 0%; (6) annual reoperation rate = 0%. These data prompted routine use of bilateral ITA grafts for all patients requiring multiple bypasses, and use of each ITA for as many bypasses as seemed feasible. Since 1986, ITA anastomoses have accounted for two thirds of anastomoses in all patients requiring multiple bypasses (average 3.2 anastomoses/patient). Results have been gratifying. Potential technical pitfalls are emphasized, and means of avoiding them described.

Adult↗

PubMed2000

Neurogenic vasoreactivity of human internal thoracic artery is unaffected by endothelial cell integrity.

BACKGROUND: The role of internal thoracic artery (ITA) nervous supply has not been previously considered as a potential factor influencing excellent long-term patency of an ITA graft. To define the interaction between the primary afferent neurons and endothelial cells of ITA, we investigated the effects of acute capsaicin administration in vitro on the isometric tension of human ITAs. METHODS: Vessels were obtained from patients undergoing coronary bypass or from multi-organ transplant donors. Thirty-three ITA segments (5 mm wide) were suspended as rings between two stainless-steel stir-ups in water-jacketed (37 degrees C) tissue baths. The tissue baths contained 10 ml physiological salt solution (PSS) of the following composition (mM/L): NaCl 119, KCl 4.7, NaH2PO4 1.0, MgCl2 0.5, CaCl2 2.5, NaHCO3 25, and glucose 11, aerated continuously with 95% O2 and 5% CO2. Peptidase inhibitors, phosphoramidon (1 microM) and captopril (1 microM), were added to PSS to decrease peptide degradation. Mechanical responses were measured isometrically and recorded on a polygraph via isometric force transducers. Vessels were preconstricted with submaximal concentrations of norepinephrine. After the tension had stabilized, capsaicin was added cumulatively to the tissue bath. The viability of ITA was verified by its responses to endothelial-dependent (acetylcholine, 1 microM) (n=20) and endothelial-independent (sodium nitroprusside, 10 microM) (n=13) vasodilators. RESULTS: The exposure of capsaicin (3 microM) to human ITA produced varied effects on ITA irrespective of its endothelium. Capsaicin induced contraction of the ITA smooth muscle in 13 endothelium-intact ITA segments while it produced vasoconstriction in 9 endothelium-denuded ITAs (p=0.6437). In response to capsaicin, relaxation of ITA smooth muscle was observed in 7 ITA rings with endothelium, while vasodilation was present in 4 ITA segments without endothelium (p=0.4099). CONCLUSIONS: Capsaicin-sensitive neurons encircling human ITA produce a neurogenic vasoreactive response independent of ITA endothelial cell integrity.

Adult↗

PubMed1999

Effect of distal stenosis of internal thoracic artery bypass grafts on longitudinal phasic blood flow velocity characteristics.

BACKGROUND: Left internal thoracic artery (LITA) bypass conduits show gradual longitudinal transition in their phasic flow velocity patterns from the proximal to distal segments, but little is known about the influence of distal stenosis, particularly early after surgery, on that characteristic. The purpose of this study was to evaluate the influence of distal stenosis on these flow velocity patterns. METHODS: We examined 24 LITAs within 1 month (7 to 30 days) after surgery with a Doppler-tipped guide wire at the proximal, mid, and distal segments. Maximum peak velocities (MPV), time averaged peak velocities (APV), and velocity-time integrals (VTI) were measured. RESULTS: In LITAs without stenosis (n = 14, group A), the APV, MPV, and VTI values at the diastole were significantly greater than those for distal stenosis (minimal lumen diameter >75%, n = 10, group B). The values of the 3 indexes at the systole in each segment did not differ significantly between the 2 groups. Both groups showed gradual increases in the diastolic/systolic ratios of the 3 indexes from the proximal to distal portions, the ratios in group A being significantly larger than that in group B (APV, P <. 001; MPV, P <.01; TVI, P <.01, respectively). For these indexes, sensitivity and specificity for predicting stenosis of LITA was higher in the proximal and mid portion than in the distal. CONCLUSIONS: Anastomotic stenosis decreases the diastolic flow component but not the systolic one. By using diastolic/systolic ratios of the 3 indexes, it is possible to predict distal stenosis of LITA from the resting phasic flow velocity pattern.

Aged↗

PubMed1994

[Quantitative hemodynamic assessment of internal thoracic artery grafts using transthoracic duplex imaging].

The hemodynamics of blood flow in internal thoracic artery (ITA) grafts were studied using transthoracic duplex imaging prior to and following coronary artery bypass grafting (CABG) in 37 patients. Transthoracic images of the ITA were obtained through the first intercostal space using a 7.5 MHz probe, and their diameter and area were measured by B-mode imaging. Systolic, diastolic, mean and end-diastolic blood flow velocity (Vs, Vd, Vm, and Ved) were determined based on Doppler signals and systolic, diastolic, and total blood flow (Fs, Fd, and Ftotal) were calculated by the following formula: Flow = Vm x area x 60/10(3). The diameter of the ITA increased following CABG. Prior to CABG, Vs, and Fs, were dominant, while following CABG, the hemodynamic pattern was diastolic dominant, although individual variation existed. The ITA blood flow was measured in 4 groups, in patients who had had a previous anterior myocardial infarction and no redistribution on myocardial scintigraphy (group I), in patients with 99-100% coronary artery stenosis who had not had an anterior myocardial infarction or who had an anterior myocardial infarction and had redistribution (group IIa), in patients with the same criteria as group IIa but who had 90% coronary stenosis (group IIb), and in patients with 75% coronary stenosis who had not had anterior myocardial infarction (group IIc). Blood flow was 57, 73, 44mL and 34 mL/min, and the percentage of diastolic flow was 72, 69, 61, 59% respectively. These results show that ITA blood flow competes with native coronary artery flow in patients with moderate coronary stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2000

Neointimal formation at the sites of anastomosis of the internal thoracic artery grafts after coronary artery bypass grafting in human subjects: an immunohistochemical analysis.

OBJECTIVES: The aim of this study was to evaluate the cellular composition and cell proliferative activity of neointimal tissue in human internal thoracic artery grafts and to characterize the differentiation state of neointimal smooth muscle cells at early stages after coronary artery bypass grafting. METHODS: The anastomotic sites and body segments of 7 patent grafts were obtained at autopsy from 7 patients who died within 92 days after operation. Serial sections were examined by immunohistochemical techniques to identify macrophages, endothelial cells, smooth muscle cell phenotype, and proliferating cells. For the identification of the cell types that show cell proliferative activity, immunodouble staining was also performed. RESULTS: In all body segments the luminal surface was completely covered by endothelial cells, and no areas showed thrombus formation or neointimal proliferation after grafting. In contrast, in the anastomotic segments endothelial denudation and focal disruption of the internal elastic lamina with adherence of fibrin-platelet thrombus and infiltration of macrophages were observed in the earliest stage after grafting. At these sites of injury, early neointimal tissue response had occurred, and cell proliferative activity was detected in macrophages and dedifferentiated smooth muscle cells. During the evolution of neointimal thickening, redifferentiation of neointimal smooth muscle cells occurred associated with the decline in proliferative activity. CONCLUSIONS: These observations strongly support the concept that excessive neointimal proliferation, which may occur at the site of anastomosis because of extensive damage to the arterial wall, could be one of the possible causes of failure of the internal thoracic artery graft in human beings.

Aged↗

PubMed2001

Should the supplemental vein graft be anastomosed upstream or downstream of the internal thoracic artery (ITA) for ITA hypoperfusion?

BACKGROUND: This study was designed to compare internal thoracic artery (ITA) flow in different settings of supplemental vein grafting for ITA hypoperfusion. METHODS: Fourteen dogs each received two coronary bypass grafts to the circumflex artery (CFX), using left ITA and vein grafts, and then the proximal CFX was ligated. The animals were divided into two groups. G-I dogs receiving the vein graft proximally to the ITA graft and G-II receiving the vein distally. ITA flow was evaluated regarding 1) effects of competition from the vein graft, and 2) pharmacological or physiological effects on the ITA's contribution to distal perfusion. Flow is expressed as a mean (ml/min). RESULTS: ITA flow was 44.2+/-5.9 in G-I, and 45.7+/-6.5 in G-II (p=ns), when the vein graft was occluded. With a vein graft open, ITA flow decreased to 7.5+/-1.6 in G-I, and 6.8+/-1.8 in G-II (p=ns), and ITA's contribution to total perfusion requirements was 18% in G-I and 16% in G-II. Adenosine (0.2 mg/min/kg) increased the ITA flow in both groups, 18.4+/-3.2, and 16.3+/-3.8, respectively (p=ns), and ITA's contribution to distal perfusion was increased to 32% in G-I and 27% in G-II. In contrast, phenylephrine (0.003 mg/min/kg) decreased ITA flow and ITA's contribution to distal flow in both groups (6.1+/-1.1, 11% vs 6.2+/-1.4, 11%, p=ns), but increased vein flow significantly. Cardiac pacing (150 bpm) increased the ITA flow and ITA's contribution to distal perfusion equally in both groups (8.4+/-1.5, 16% vs 7.6+/-2.6, 15%, p=ns). CONCLUSIONS: Supplemental vein grafting, whether it is placed distally or proximally, limits ITA flow and ITA's contribution to distal perfusion both in the resting heart and during the increased myocardial oxygen demand.

Anastomosis, Surgical↗

PubMed2003

Internal thoracic artery flow competition: studies in a canine H-graft model.

OBJECTIVE: Internal thoracic artery (ITA) flow competition is a diversion of graft flow through intact ITA branches with a net decrease in perfusion to the grafted coronary. Although a widely acknowledged phenomenon, the conditions under which flow competition occurs have not been established. This is examined in a canine H-graft model. METHODS: Eight dogs had a right ITA segment interposed (H-graft) between their in situ left ITA (LITA) and the snared left anterior descending (LAD) coronary artery. Proximal LITA and H-graft flows were measured at baseline and during pacing-induced tachycardia, phenylephrine-induced hypertension, and nitroprusside-induced hypotension. Flows were measured with the distal LITA open and occluded. Two additional animals were subjected to eight separate 2-min periods of LAD ischemia, after which post-ischemic H-graft flow measurements were obtained with and without distal LIMA occlusion. RESULTS: During baseline conditions, proximal LITA flow was greater when the distal LITA was open rather than occluded (46+/-15 versus 35+/-12 ml/min, respectively; P=0.002), but H-graft flow did not change significantly (32+/-18 versus 35+/-18 ml/min, respectively; P=0.21). Similarly, occlusion of the distal LITA had no impact on H-graft flow during tachycardia, hypertension, or hypotension. Only in animals subjected to transient LAD ischemia did H-graft flow increase with distal LITA occlusion, albeit marginally (65+/-7-70+/-9 ml/min, occluded versus open, respectively; P=0.04). CONCLUSIONS: Mild diversion of flow from the LAD was demonstrated during immediate post-ischemic coronary reperfusion only, and could not be elicited under any other physiologic condition. These data suggest that flow competition is unlikely to constitute a clinically significant limitation to the use of H-grafts or other modalities that leave ITA branches patent.

Animals↗

PubMed2000

Bilateral internal thoracic artery operations in the elderly.

BACKGROUND: Elderly surgical patients have higher operative morbidity and mortality than younger cohorts, particularly when the procedure is lengthy and complex. While use of bilateral internal thoracic arteries (BITA) is often associated with increased surgical risk, we nevertheless hypothesized that the use of BITA in elderly coronary artery bypass patients would not significantly increase their operative risk beyond that encountered using single internal thoracic arterial (SITA) or saphenous vein grafts (SVG). We maintained that arterial grafts remain essentially unaffected by arteriosclerosis, and that extension of a high-quality life is a desirable outcome regardless of age at operation. METHODS EXPERIMENTAL DESIGN: We studied myocardial revascularization in 673 patients over 65 years of age at the time of operation. All operations were conducted or supervised by a single surgeon during a ten-year period from January 1986 to January 1996. Preoperative and operative dates were recorded prospectively. SETTING: All patients underwent coronary artery bypass grafting. INTERVENTIONS: The study compared outcomes in patients having all veins, SITA or BITA operations. For the first analysis, 673 patients were divided into three groups: 163 patients (Group 1) had saphenous vein used for all bypasses; 338 patients had a SITA with supplemental vein grafts (Group 2); and 172 patients (Group 3) had BITAs with additional vein grafts as needed. In the second analysis, Group 3 was subdivided and grouped by the coronary arteries which received the ITA grafts, and the analysis was repeated. One hundred and sixteen patients (Group 3A) underwent traditional placement of ITA bypasses (left ITA to the LAD, right ITA to the RCA); in Group 3B, 56 patients received revascularization of branches of the left coronary artery (left ITA to the circumflex system, right ITA to the LAD). MEASURES: We communicated directly with 90.5% of the patients, their families, or their physicians. The survival status of the remainder was determined through the National Social Security Death Index Network. This allowed us to obtain follow-up longevity data for 100% of the study sample at a mean observation period of 5.03+/-3.1 years with variation between 10.8 years to 2.4 years. RESULTS: A multivariate analysis showed that placement of both ITA grafts to left-sided arteries in older patients independently improved long-term survival (p=0.031). CONCLUSIONS: The BITA procedure does not have greater operative morbidity or mortality in the elderly despite the length or complexity of the surgery. To realize improved long-term survival rates, however, both ITAs must be grafted to the left coronary artery branches.

Aged↗

PubMed2000

Simple exposure of the internal thoracic artery for minimally invasive coronary artery bypass.

A simple method is described for harvesting a pedicle of internal thoracic artery for minimally invasive coronary artery bypass grafting with the use of a small scapular retractor. The technique has been used successfully in 39 patients. All patients were followed up early postoperatively by angiography, and the patency rate was 96%. Follow-up angiography (mean [and standard error] 9.6 [4.8] months) was carried out in 63% of the patients, demonstrating a cumulative patency rate of 95.4% with no evidence of steal. None of the patients died and there were no cases of myocardial infarction perioperatively. Recurrent angina developed in 2 patients. This technique is safe, effective and inexpensive.

Coronary Angiography↗

PubMed1998

Internal thoracic artery atherosclerosis after coarctation repair in an adult.

We report a rare case of a patient with an unsuitable grossly atherosclerotic and extensively calcified right internal thoracic artery found during a coronary bypass grafting operation. He had undergone an aortic coarctation repair 35 years before, with long-term systemic hypertension previous to the operation and sustained after it. It is advisable to be alert to the possibility of atherosclerotic degeneration of the internal thoracic artery in these patients.

Aortic Coarctation↗

PubMed2001

Early results of coronary grafting using ultrasonically skeletonized internal thoracic arteries.

BACKGROUND: We have developed an ultrasonic complete skeletonization technique for obtaining internal thoracic artery (ITA) grafts and have used this method clinically since January 1998. In this report, we discuss the early results of bilateral ITA grafts obtained with our method. METHODS: We studied 200 consecutive patients who underwent coronary artery bypass grafting using ITAs obtained by this technique. Angiography of the grafts was performed in 188 patients (94%) within 1 month after coronary artery bypass grafting. RESULTS: The ITA grafts were about 4 cm longer than pedicled ITA grafts. The free flow through the grafts was at least 30% higher than through pedicled ITAs. The early patency rate determined by postoperative angiography of the grafts was 99.7% for left ITAs and 100% for right ITAs. No patient required postoperative intervention or repeated surgery. CONCLUSIONS: Ultrasonic complete skeletonization increases the effective length of ITA bypasses, improves free flow through the bypasses, and it is less invasive than conventional pedicled harvesting. These excellent early results indicate that this technique is a straightforward, safe, less invasive, and optimal method for obtaining ITA bypass grafts.

Adult↗

PubMed1991

[Clinical results of free (aorta-coronary) internal thoracic artery grafting].

In the two year period from 1989 to 1990, 22 patients (18 men, 4 women; age range from 40 to 59 years) underwent coronary artery bypass grafting (CABG) using in situ and free internal thoracic arteries (ITAs). 23 of total 38 ITA grafts were free grafts in the aorta-coronary position, mainly to provide sufficient graft length. All of 34 ITA grafts were patent in 20 patients with coronary arteriography about one month after operation. There were no early and late death, and all patients were free from angina after a 9.4 month mean follow-up. Perioperative complications included reoperation for the bleeding in one case and the elevation of left diaphragm in one case, but there was no other major complication such as perioperative myocardial infarction, cerebral infarction or mediastinitis. These results indicated that the free ITA could be applied as well as the in situ ITA in multiple CABG of the Japanese with good patency rate and low operative risk.

Adult↗

PubMed1996

Intermediate clinical results of combined gastroepiploic and internal thoracic artery bypass.

BACKGROUND: To improve the postoperative results of coronary artery bypass grafting (CABG), the internal thoracic artery (ITA) has become the conduit of choice, with a low operative risk. The gastroepiploic artery as a third arterial conduit for grafting was first reported in 1987, and the early results were reported to be as good as those for the ITA graft. In this report, we present the intermediate-term results of combining ITA and gastroepiploic artery grafts up to 7 years after the operation. METHODS: Between April 1988 and April 1992, 214 patients received CABG with at least one ITA graft and were followed up for more than 3 years. They were divided into two groups: Group I consisted of 155 patients who had CABG using one ITA with or without saphenous vein grafts, and group II consisted of 59 patients who had CABG using an ITA and a gastroepiploic artery with or without saphenous vein grafts. The duration of follow-up for hospital survivors ranged from 36 to 89 months. RESULTS: There were six late cardiac deaths in group I and one in group II. Fifteen patients complained of recurrent symptoms of angina: 13 in group I and 2 in group II. The actuarial survival rate excluding noncardiac deaths was 95.9% in group I and 96.8% in group II at 7 years (p = not significant). The cardiac event-free rate was 75.4% in group I and 92.2% in group II, which was a significant difference (p < 0.05). CONCLUSIONS: When using both the ITA and gastroepiploic artery, CABG can be performed with minimal operative risk and seems to offer an improved quality of life at least 7 years postoperatively.

Adolescent↗

PubMed2006

Use of bilateral internal thoracic arteries in CABG through lateral thoracotomy with robotic assistance in 150 patients.

BACKGROUND: Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system. METHODS: Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management. RESULTS: Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 +/- 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 +/- 2.9 days. CONCLUSIONS: The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.

Anastomosis, Surgical↗

PubMed1992

[Advantage of internal thoracic artery for coronary arterial bypass surgery in patients over 70 years of age].

Between April 1988 and September 1991, 16 among 23 patients over 70 years of age underwent coronary bypass grafting (CABG) with at least one arterial graft. The age ranged from 70 to 77 years (mean, 72.1 years) and involved coronary lesions were two vessels in two patients and three vessels in 14 patients. Seven patients with unstable angina received emergency CABG. The number of distal anastomosis with arterial graft was mean of 1.3 per patient and left internal thoracic artery (ITA) was used as a pedicled graft in all patients. Sequential grafting with left ITA arterial graft was performed in two and right gastroepiploic artery was concomitantly used in three patients. No atherosclerosis was seen in left ITA, however, poor quality saphenous vein graft (SVG) was in five and atherosclerosis of ascending aorta was in five patients. After operation deep vein thrombosis of leg after harvesting SVG occurred in one patient. The angiogram performed within one month of operation in nine patients showed that the patency rate of arterial graft was 100% and that of SVG was 94.4%. The longest follow-up period was 42 months and New York Heart Association Functional Class improved to Class I or II in all patients. The use of pedicled ITA in elderly patient showed advantage for diseased ascending aorta and it seemed to prevent the postoperative complication due to the use of SVG.

Aged↗