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PubMed1996

Physical properties of a porcine internal thoracic artery fixed with an epoxy compound.

This study aimed to investigate the physical properties of a porcine internal thoracic artery fixed with an epoxy compound. Fresh and glutaraldehyde-fixed porcine arteries were used as controls. Both the epoxy-fixed and glutaraldehyde-fixed porcine arteries showed significant increases in fixation index and denaturation temperature as compared to the fresh one. Additionally, the resistance of porcine arteries against bacterial collagenase in vitro degradation increased significantly after cross-linking with the epoxy compound of glutaraldehyde. The reduction of the tensile strength of the epoxy-fixed artery after bacterial collagenase degradation was more severe than in its glutaraldehyde-fixed counterpart. Generally, with increasing pH, temperature or fixative concentration, the fixation indices and denaturation temperatures of the epoxy-fixed porcine arteries increased. The results obtained in this study may be used to optimize the fixation process for developing a small-diameter biological vascular graft fixed by an epoxy compound.

Animals↗

PubMed1988

Significance of early angiographic follow-up after internal thoracic artery anastomosis in coronary surgery.

The authors report about the radiological checking of the patency of the internal thoracic artery transplant in 75 patients with coronary artery disease, using intraarterial DSA in the early postoperative phase (between 6th and 8th postoperative day). The left or the right brachial artery was punctated and the contrast medium was injected at a dosage of 50 ml in counter-current. Only one angiogram series per patient was necessary to appraise the anastomosis and the perfusion of the bypass applied. In 5 patients a stenosis and in 4 patients an occlusion of the transplant could to be diagnosed. Early postoperative angiography enables quality control. In case of occlusion reoperation may be indicated.

Adult↗

PubMed1998

The clinical significance of performing preoperative angiography of the internal thoracic artery in coronary artery bypass surgery.

This study was designed to clarify the clinical significance of and indications for performing preoperative internal thoracic artery (ITA) angiography in patients undergoing coronary artery bypass surgery. A total of 300 possible candidates for coronary artery bypass grafting (CABG) underwent ITA angiography during diagnostic catheterization. Semi-selective angiography of bilateral ITAs were performed by injecting contrast medium manually with a 5-F right Judkins coronary catheter. The posteroanterior view of the arteriograms was recorded on a 35-mm cine film or a cut-film. Unusual angiographic findings of the ITAs were observed in nine patients (3%). These findings included: an atrophic ITA in three patients with ipsilateral subclavian artery occlusions; enlarged ITAs giving collaterals to the lower extremities in one patient with extensive aortoiliac occlusive disease; occluded ITAs in one patient with Takayasu's arteritis and two patients with a history of CABG; and a small but nonsclerotic ITA in one patient. Atherosclerotic occlusive ITAs were found in only one patient. Thus, we concluded that routine preoperative angiography of the ITA is not necessary because it is rarely affected by atherosclerosis. However, it should be performed for any of the following reasons: a cervical or supraclavicular bruit; an upper extremity blood pressure difference of greater than 20 mmHg; an extensive aortoiliac occlusion; and certain disorders such as Takayasu's arteritis or Kawasaki disease, or a history of open heart surgery.

Adult↗

PubMed2001

Use of 99Tcm-MIBI scintigraphy in the evaluation of perfusion improvement after myocardial revascularization with the use of the left internal thoracic artery.

In spite of successful revascularization, in a significant group of patients myocardial ischaemia is present after surgery. The final effect of surgery depends on preoperative left ventricular function, initial coronary artery status, completeness of revascularization, the use of arterial or venous grafts, and many other factors. The aim of our 99Tcm-MIBI scintigraphy study was to examine the improvement of perfusion in the left anterior descending artery (LAD) vascular territory after revascularization with the use of the left internal thoracic artery (LITA), with respect to the LAD diameter and use of additional venous graft to diagonal artery. The study group consisted of 45 subjects (42 male, three female) aged 34-68 years (mean age 50.9+/-8.3 years) recruited from patients in whom LITA was grafted into LAD. The operation and postoperative period was uneventful in all patients. Two weeks before, and 3-4 months after surgery, dipyridamole-rest sestamibi SPECT were performed. The revascularization significantly improved both stress (deltaPI = 0.77+/-0.66; P < 0.001) and rest (deltaPI = 0.32+/-0.60; P < 0.001) perfusion of the LAD territory. The improvement was slightly better in patients who received two grafts (deltaPI = 1.42+/-0.91) for the LAD territory in comparison to the group revascularized only with LITA (deltaPI = 0.80+/-0.69; P = patients who received an arterial bypass to the LAD artery the perfusion was abnormal in all eight patients after anterior myocardial infarction and in 39% of patients without a history of infarction. The perfusion improvement was the best when the diameter of LAD was > or = 1.5 mm (deltaPI = 0.88+/-0.95). The independent predictors of perfusion improvement were the number of segments with reversible perfusion defect within the revascularized area (beta = 0.84, P < 0.001), the diameter of revascularized artery (beta = 0.17, P = 0.03) and the presence of pathological Q wave at preoperative ECG (beta = -0.20, P = 0.02). We conclude that the degree of perfusion improvement in the LAD territory after revascularization with the use of LITA depends on the diameter of bypassed coronary artery, completeness of revascularization and the reversibility of preoperative perfusion defect.

Adult↗

PubMed1994

Left internal thoracic artery graft occlusion following mediastinal radiation therapy.

Premature coronary artery disease is a late consequence of mediastinal radiation therapy. Many of these patients have been successfully treated with coronary bypass surgery. A 51-year-old man underwent bypass surgery for severe multivessel coronary disease 18 years following radiation therapy for a posterior mediastinal tumor. Recurrent angina 1 year later occurred following closure of the left internal thoracic artery graft. We suspect that this occurred as a consequence of injury sustained during mediastinal irradiation. Patients who have undergone prior mediastinal radiation therapy may not be assured the excellent long-term patency of the internal thoracic artery graft which has been reported for the general population. Saphenous vein grafts probably should be considered instead.

Coronary Disease↗

PubMed1994

Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease: an incremental risk?

Although the long-term patency of the internal thoracic artery (ITA) has been well proved, there is still some concern about its preoperative performance. We considered 80 patients with left main disease (mean age 60.2 years) who underwent coronary artery bypass grafting in our institute from March 1988 to September 1992. Patients with left main disease were divided into 2 groups: group I-38 patients receiving only ITA grafts on the left coronary system and group II-42 patients having a single ITA graft together with saphenous vein grafts on the left coronary system. No patients in group I received a saphenous graft on the left coronary system and three patients with right coronary artery involvement received total arterial myocardial revascularization with the use of the inferior epigastric artery. Perioperative complications in group I and group II patients were, respectively: myocardial necrosis in 2 (6.9%) and 3 (8.8%), use of intraaortic balloon pump in 2 (6.9%) and 2 (5.9%). No death occurred in either group. In our experience, the use of bilateral ITA grafts in patients with left main stenosis was not related to an incremental risk. We conclude that left main disease should not be considered as counterindication to the extensive use of arterial conduits.

Aged↗

PubMed1998

Thoracoscopic harvest of the internal thoracic artery: a multicenter experience in 218 cases.

BACKGROUND: Off-pump bypass grafting most commonly involves harvest of the left internal thoracic artery (ITA) through a minithoracotomy under direct vision. Disadvantages to this approach, however, include poor exposure, incomplete dissection resulting in inadequate ITA length, and significant postoperative pain because of rigorous chest retraction. This study determined the safety and efficacy of an alternative to direct ITA harvest using a thoracoscopic approach. METHODS: Two hundred eighteen patients at three institutions underwent thoracoscopic ITA harvest; 118 (54%) for off-pump coronary bypass grafting. RESULTS: The left ITA was harvested in 211 patients (96%); the mean harvest time ranged from 42 to 55 minutes. The ITA was injured in 4 patients (1.8%), and conversion to open ITA harvest occurred in 18 (8%). Complications included intercostal neuropathy (4), reoperation for ITA bleeding (2), phrenic nerve injury (1), and wound infection (1). CONCLUSIONS: This large, multicenter experience demonstrates that thoracoscopic harvest of the ITA can be accomplished safely and within a reasonable time frame in most patients undergoing coronary bypass grafting.

Aged↗

PubMed2003

Off-pump redo coronary artery bypass grafting from descending aorta to the posterolateral area through a left thoracotomy in patients with a patent internal thoracic artery graft.

The patients were a 73-year-old man (Case 1) and 56-year-old man (Case 2) who developed angina pectoris and heart failure. Case 2 showed chronic renal failure on hemodialysis. These patients showed posterolateral myocardial ischemia with a patent internal thoracic artery graft to the left anterior descending artery. Left ventricle ejection fraction was 29% and 33%, respectively. Catheter intervention was unsuccessful, so we performed revascularization from the descending aorta to coronary arteries with saphenous vein grafts via a left thoracotomy using an off-pump technique. In case 2, proximal anastomosis was constructed with the Symmetric aortic connector. This procedure appeared to be a very safe and useful method as an option for redo coronary artery bypass grafting in the posterolateral area in patients with patent old grafts and poor left ventricular function.

Aged↗

PubMed1996

Right internal thoracic artery through the transverse sinus in myocardial revascularization.

BACKGROUND: This study presents the late patency rate of the right internal thoracic artery (ITA) used in situ through the pericardium transverse sinus to the circumflex artery and its branches. METHODS: From April 1983 to December 1994, 2,642 patients were submitted to myocardial revascularization; 201 of them had bilateral ITAs. The right ITA through the transverse sinus was grafted to obtuse marginal artery in 170 patients (84.5%) and the left ITA was grafted to the anterior descending artery in 188 patients (93.5%). Angiographic studies were performed in 80 patients, 44 patients in the immediate postoperative period and 36 patients in the late follow-up (mean, 51.6 months). RESULTS: The right ITA was patent in 75 patients (93.7%) and the left ITA was patent in 77 (96.2%). At the late postoperative period, the right ITA was patent in 33 patients (91.6%) and the left ITA was patent in 34 (94.4%). CONCLUSIONS: The right ITA placed through the pericardium transverse sinus has a good long-term patency rate, similar to that observed with the left ITA and superior to that of saphenous vein grafts for myocardial revascularization.

Actuarial Analysis↗

PubMed1999

Origin and incidence of xiphoid branch of the internal thoracic artery.

The study presents the incidence of a variant terminal branch of the internal thoracic artery (ITA). The ITA's were cannulated in situ, injected with coloured latex and dissected together with its branches in 62 cadavers. Unlike the usual termination of the ITA bifurcating into the musculophrenic and superior epigastric arteries, this third branch arose from the medial border of the ITA at the level of the 6th costal cartilage. As it descends it inclines medially towards the angle between the xiphoid process and the 7th costal cartilage, giving off 2 or 3 fine branches to the lower sternum. It then passes deep to this angle and can be observed on the anterior surface of the xiphoid process, terminating in fine branches distributed to the inferior aspect of the xiphoid cartilage. It is proposed that this branch at the "trifurcation" of the ITA be termed the xiphoid branch. This branch was noted in 61.3%. An incidence of 30.7% was seen on the right and 21% on the left with bilateral presence in 9.7%. The xiphoid branch contributes to the supply to the lower sternal region and may be of special importance when the collateral supply to the region is compromised in the event of the internal thoracic or superior epigastric artery damage or when used as a conduit in coronary artery by-pass grafts.

Adult↗

PubMedDate not supplied

An internal thoracic artery homograft as a new small caliber vascular substitute.

The authors have examined the possibility of usage of an internal thoracic artery (ITA) homograft as a new small caliber vascular substitute. Left subclavian artery to left atrial appendage shunts with fresh ITA homografts (n = 6) or ITA autografts (n = 5) were made by modified techniques of coronary artery bypass grafting in mongrel dogs (body weight, 11-16.5 kg). All recipient dogs had no anticoagulant therapy or immunosuppression. Inner diameter of the grafts was between 1.4 and 2.0 mm. Blood flow in ITA grafts was measured by electromagnetic flow meter. The graft flow was 6-14 ml/min before harvest and 67-220 ml/min just after implantation, and there was no significant difference between groups. Flow in the ITA homografts decreased significantly compared with ITA autografts 1 month after operation, but five of six ITA homografts were patent. Histopathology of the grafts showed vascular rejection in the homograft group. These results suggest that an ITA homograft with postoperative immunosuppression might be a new small caliber vascular substitute for coronary artery bypass grafting in ischemic heart disease and the systemic-pulmonary shunt operation in congenital heart diseases.

Animals↗

PubMed2004

Endothelial integrity of ultrasonically skeletonized internal thoracic artery: morphological analysis with scanning electron microscopy.

OBJECTIVE: The skeletonized internal thoracic artery (ITA) has several advantages over a pedicled one in coronary artery bypass grafting (CABG). An ultrasonic scalpel makes ITA skeletonization easy and speedy, however, the ultrasonic energy that is transmitted to the artery itself can occasionally injure the endothelium. Therefore, the endothelial integrity of the ultrasonically skeletonized ITA is a major concern related to this technique. The purpose of this study is to assess the endothelial integrity of the ultrasonically skeletonized ITA. METHODS: We skeletonized the left ITA with an ultrasonic scalpel in nine patients who underwent CABG, and thereafter the terminal portion of this artery was subjected to a morphological study. The endothelial integrity of this artery was morphologically assessed using scanning electron microscopy, and the results were compared to that of the left ITA skeletonized with fine scissors. RESULTS: All ITA specimens showed a completely confluent endothelium, and no endothelial injury was observed by the scanning electron microscopic study. CONCLUSIONS: The skeletonization of the ITA with an ultrasonic scalpel had no deleterious effect on the endothelium. This morphological study confirmed the safety and the reliability of this technique, and we therefore recommend its clinical use in the skeletonization of the ITA for CABG.

Endothelium, Vascular↗

PubMed2006

Effects of milrinone on blood flow of the Y-graft composed with the radial and the internal thoracic artery in patients with coronary artery disease.

OBJECTIVE: Milrinone has been known to dilate the internal thoracic artery (ITA) and the radial artery (RA). The effect of milrinone, however, on each graft is unclear when the left ITA (LITA) and the RA form a Y-graft. This study evaluated the changes in blood flow of a composite Y-graft in response to milrinone. METHODS: Thirty-two patients undergoing an isolated coronary artery bypass graft surgery were included in this study. A Y-graft was created with an in situ LITA and free RA graft attached to the proximal side of the LITA. Graft flow was measured by opening the graft end for 30s, and is expressed in 'ml/min'. Graft flow and hemodynamic data were recorded before and 10 min after intravenous milrinone (50 microg/kg) administration. RESULTS: Milrinone significantly increased the RA graft flow, measured while the LITA graft end was clamped, and total Y-graft flow. Respective graft flows were not increased by milrinone when both clamps were released simultaneously, in spite of a significant decrease in the resistance of both grafts. The ratio of flows through the RA and the LITA grafts was not changed by milrinone. CONCLUSION: Milrinone significantly reduced RA and LITA resistances and increased the total Y-graft flow. Milrinone might dilate each individual arterial graft to a different degree. Milrinone did not, however, change the flow ratio through the RA to LITA grafts when they were measured simultaneously. Therefore, it would not significantly divert graft flow to one side in a composite Y-graft.

Aged↗

PubMed2002

Feasibility and suitability of the routine use of bilateral internal thoracic arteries.

BACKGROUND: It has been demonstrated that bilateral use of internal thoracic arteries (ITAs) confers better long-term results in patients than does unilateral use. However, routine use of bilateral ITAs has usually been avoided. METHODS: Since 1997, we have used bilateral ITAs extensively for patients who required multivessel bypasses. Recently, 243 consecutive patients, including 127 diabetic patients, were reviewed. RESULTS: Every patient received at least one ITA graft, and 200 patients (82%) received bilateral ITAs. The majority (93%) of ITA grafts were used as in situ grafts. The hospital mortality rate was 0.41%, and deep sternal infections were observed in 5 patients (2.0%). There was no difference in the incidence of chest wound infection between the group treated with bilateral ITA grafting and that treated by unilateral ITA grafting. CONCLUSIONS: These observations suggest that ITAs can be used bilaterally for treatment in the majority of patients who require multivessel bypass, with low mortality and morbidity.

Adult↗

PubMed1997

Effect of different methods of internal thoracic artery harvest on pulmonary function.

BACKGROUND: In several clinical studies, internal thoracic artery (ITA) grafting for myocardial revascularization has been identified as increasing the risk of postoperative pulmonary complications. This study was designed to determine whether the technique used to harvest the ITA has an effect on postoperative pulmonary function. METHODS: Seventy-nine consecutive patients undergoing coronary artery bypass grafting using the left ITA were compared with patients undergoing coronary artery bypass grafting using saphenous vein grafts only. Two methods of ITA harvesting were used: (1) incision of the endothoracic fascia dissected off the ITA as a skeletonized vessel (group 1, n = 33) and (2) mobilization of the ITA as a wide musculofascial pedicle (group 2, n = 46). Thirty-two patients underwent coronary artery bypass grafting using saphenous vein grafts only (group 3). Pulmonary function tests were performed between postoperative days 20 and 30. RESULTS: The postoperative values of forced vital capacity were reduced in patients in all groups (p < 0.0001). The ratios of postoperative to preoperative forced vital capacity were 84% in group 1, 77% in group 2, and 84% in group 3. The reduction in group 2 was significant compared with group 1 (p < 0.05) and group 3 (p < 0.05). CONCLUSIONS: Postoperative pulmonary dysfunction was significantly greater in patients who underwent wide musculofascial pedicle dissection of the ITA compared with skeletonization of the artery. Thus, of the two techniques, the latter may be the method of choice with regard to lowering the incidence of postoperative pulmonary dysfunction.

Case-Control Studies↗

PubMed2006

Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial.

OBJECTIVE: Conventional harvesting of the saphenous vein in coronary artery bypass surgery produces vessel damage that contributes to graft failure. A novel "no touch" technique provides high short- and long-term patency rates. METHOD: This randomized longitudinal trial compares graft patency of two patient groups undergoing coronary artery bypass surgery. Conventional: 52 patients had their veins stripped, distended, and stored in saline solution. No-touch: 52 patients had veins removed with surrounding tissue, not distended, and stored in heparinized blood. Angiographic assessment was performed at mean time 18 months after the operation in 46 patients in the conventional group and 45 patients in the no-touch group and repeated at mean time 8.5 years in 37 patients from both groups. RESULTS: The distribution of the grafts to the recipient coronary arteries regarding their size and quality was similar in both groups. The angiographic assessment at 18 months postoperatively showed 89% conventional versus 95% no-touch grafts were patent. Repeated angiography at 8.5 years showed a patency rate for the conventional group of 76% and 90% for the no-touch group (P = .01). The multivariate analysis showed that the most important surgical factors for graft patency were the technique of harvesting (odds ratio= 3.7, P = .007) for the no-touch versus the conventional technique and the vein quality before implantation (odds ratio = 3.2, P = .007) for veins that were of good quality. By comparison the patency of the thoracic artery grafts was 90%. CONCLUSION: Harvesting the saphenous vein with surrounding tissue provides high short- and long-term patency rates comparable to the left internal thoracic artery.

Coronary Angiography↗

PubMed2006

Chylothorax after internal thoracic artery harvest.

Chylothorax is a rare complication following coronary artery bypass graft surgery. We report a case of chylothorax that complicated a left internal thoracic artery harvest and review the literature regarding this subject.

Chylothorax↗

PubMed1998

Assessment of internal thoracic artery graft with intraoperative color Doppler ultrasonography.

BACKGROUND: Intraoperative ultrasonography has the potential to provide anatomic and functional information about internal thoracic artery (ITA) graft, but this potential has been hindered by the relatively large standard probe. In this study, we used a color Doppler microprobe to evaluate ITA grafts. METHODS: The subjects were 15 consecutive patients who underwent elective coronary artery bypass grafting either with cardiopulmonary bypass (n = 14) or without (n = 1). All patients underwent anastomosis of the left ITA to the left anterior descending artery. The ITA graft was assessed before the chest was closed, with the microprobe placed directly on the graft. RESULTS: A good-quality color Doppler image of the ITA graft was easily obtained in all 15 patients within a few minutes. The ITA graft function was assessed by analyzing the shape of the pulsed Doppler wave. All ITA grafts were patent, and the mean graft diameter was 1.8 +/- 0.04 mm. The peak systolic velocity, peak diastolic velocity, and mean velocity were 52.0 +/- 14.9 cm/s, 58.3 +/- 22.4 cm/s, and 36.5 +/- 10.9 cm/s, respectively. The ratio of peak diastolic velocity to peak systolic velocity was 1.24 +/- 0.66. The ITA graft seemed to function well when the biphasic diastolic predominant flow appeared. The mean blood flow was 55.1 +/- 22.0 mL/min. CONCLUSIONS: Intraoperative ultrasonography using the microprobe provides adequate anatomic and hemodynamic information regarding ITA grafts. As the Doppler flow evaluation has high sensitivity and specificity, we suggest that intraoperative ultrasonography is useful for the assessment of these grafts.

Anastomosis, Surgical↗