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PubMed2001

Technical aspects and outcome of in situ right internal thoracic artery grafting to the major branches of the circumflex artery via the transverse sinus.

BACKGROUND: Little is known about the anatomic limitations of in situ right internal thoracic artery (RITA) grafting to the circumflex artery. METHODS: To evaluate the technical aspects and outcome of revascularization of the proximal and distal major branches of the circumflex artery (obtuse marginal [OM] branch and posterolateral [PL] branch), a total of 145 patients who possessed a graftable branch of the circumflex artery were enrolled into the prospective project. There were 73 patients who had the PL branch as a primary target and 72 patients with OM branches, which were allocated by a blinded observer who reviewed the preoperative angiography. RESULTS: Changes of primary target vessels were required in 9 patients (6.2%), yielding an overall success rate of RITA grafting of 93.8%. The success rates of RITA grafting to the OM branch and the PL branch were 95.8% (69/72; CI 88.3% to 99.1%) and 91.7% (67/73; CI 83.0% to 96.9%), respectively. The univariate analysis identified grafting under hypothermic ventricular fibrillation as predictors of inability to use in situ RITA grafting for revascularization of the circumflex artery. RITA grafting to the PL branch is not identified as a predictor. Postoperative angiography in 136 patients revealed only one occlusion (0.75%) of the RITA graft anastomosed to the marginal artery. There were no significant differences in patency rates between left and right ITA grafts. CONCLUSIONS: This prospective study showed that in situ RITA was, in most cases, able to reach most branches of the major circumflex artery and demonstrated an excellent patency rate.

Adult↗
PubMed2001

Better ischemic event-free survival after two internal thoracic artery grafts: 13 years of follow-up.

BACKGROUND: We researched our data to determine whether pedicled bilateral internal thoracic artery (BITA) grafting led to better ischemic event-free survival compared to single ITA grafting, at 10 years mean follow-up. METHODS: Retrospectively 249 patients with BITAs with or without additional vein grafts (BITA group) were matched with 233 comparable patients with left ITA and additional vein grafts (LITA group), at a mean follow-up interval of 10 years. RESULTS: At 13 years, 76.2% +/- 5.9% of the BITA and 78.3% +/- 3.8% of the LITA patients were still alive (p = not significant). Death, recurrent angina, new myocardial infarction, or coronary reinterventions occurred more often in LITA (49.4%) than BITA (33.3%) patients (p = 0.0004). The ischemic event-free survival estimates for BITA patients (47.5% +/- 8.4%) was better than for LITA patients (35.4% +/- 5.1%) (p < 0.001). Multivariate analysis showed that BITA was a predictor for ischemic event-free survival (p = 0.0005). CONCLUSIONS: For the decision to use one or two ITAs the positive influence of BITA grafting on ischemic event-free survival is more important than its effect on survival, per se. Compared to the general strategy of BITA grafting, neither total arterial revascularization nor the specific vessels grafted with BITA is relevant for the ischemic event-free survival.

Adult↗
PubMed2000

Increased chymase activity in internal thoracic artery of patients with hypercholesterolemia.

Apart from ACE, various angiotensin II (Ang II)-forming serine proteinases (eg, chymase, kallikrein, and cathepsin G) are known to exist in human tissues, but their clinical significance or the regulatory mechanisms that control their activities are not well established. A recent clinical study has shown that chymase activity was significantly increased in human atherosclerotic or aneurysmal aorta. The association between vascular Ang II-forming activities (AIIFAs) in the human internal thoracic artery (ITA) and various clinical parameters was studied with the use of ITAs obtained from 32 patients who underwent coronary artery bypass graft surgery. Total and ACE- and chymase-dependent AIIFAs in homogenates of ITAs were determined. Total AIIFA was 8.67+/-0.86 (nmol Ang II formed. min(-1). mg protein(-1) [U]), and approximately 95% of the activities were due to chymase. Serum total cholesterol level, but no other risk factors, significantly correlated with chymase- (r=0. 60, P<0.001) and ACE- (r=0.35, P<0.05) dependent AIIFAs, respectively. LDL cholesterol level was also correlated with chymase-dependent AIIFAs (r=0.47, P<0.05). Mast cells identified through the use of toluidine blue or immunohistochemical staining appeared in the adventitia but not in the intima or media of ITAs. Our results suggest that an increased plasma LDL cholesterol level may induce increased arterial chymase and ACE activity.

Aged↗
PubMed1998

Massive spontaneous hemothorax as a presenting sign of aneurysmal rupture of the internal thoracic artery. A case report.

Massive spontaneous hemothorax is a very uncommon, life-threatening situation. Acute dissection and ruptured aorta can be one of the differential diagnoses, but usually the clinical feature is completely different, and very few patients have survived this event and received medical attention. Among other causes of spontaneous bleeding, some are extremely rare, demanding precise diagnosis and judicial and immediate intervention. We describe a patient who presented with a massive hemothorax. There was no immediately apparent cause. Emergent angiography revealed active bleeding from an extremely unusual source: aneurysmal dilatation of the internal thoracic artery.

Adult↗
PubMed2004

Accelerated graft disease in a composite saphenous vein with internal thoracic artery in a chronic renal dialysis patient.

A 59-year-old man with 18-year history of renal dialysis due to chronic nephritis suffered coronary artery disease, which was complete occlusion of the right coronary artery and diffuse 90% stenosis of the proximal left anterior descending artery. Off-pump coronary artery bypass grafting was performed. Saphenous vein (SV) was anastomosed with left internal thoracic artery (ITA) as a T-graft. Left ITA was anastomosed to the left anterior descending artery. The end of SV was sewn on the posterior descending artery. Coronary and graft angiography performed 2 weeks after the operation showed good patency with good distal run-off of both left ITA and SV. Three months after the operation, he was admitted with unstable angina. Angiography revealed accelerated SV graft stenosis without any change of prior coronary disease. However, angiography 7 months after the operation revealed complete obstruction of the SV graft when he was admitted because of recurrent anginal pain.

Angina Pectoris↗
PubMed2003

Early adaptation of the left internal thoracic artery as a blood source of y-composite radial artery grafts in off-pump coronary artery bypass grafting.

OBJECTIVE: Y-composite grafting with the radial artery (RA) is often used in off-pump coronary artery bypass grafting (OPCAB). However, the early flow reserve of the left internal thoracic artery (LITA) as a blood source of the Y-composite RA graft has not been delineated. METHODS: The size of the LITA was examined angiographically in 42 patients who underwent OPCAB using LITA and Y-composite RA grafting between June 2000 and February 2002. In these patients, the LITA was used as a blood source of the Y-composite RA graft. The mean patient age +/- SD was 67 +/- 8 years. The average number of d i stal anastomoses was 3.2 +/- 0.7. Total coronary revascularization was carried out in 34 patients with only LITA and Y-composite RA grafting. RA grafting was used for revascularization of the circumflex artery alone in 5 patients, for the right coronary artery system (RCS) alone in 6 patients, and for both the circumflex and the RCS in 23 patients. The average number of distal anastomoses using the RA was 1.9 +/- 0.7. Flow measurements of the proximal LITA were achieved intraoperatively with a transit-time flowmeter. The diameters of the LITA before and after the operation were measured angiographically. Intraoperative flow volume was correlated with the ratio of the LITA diameters before and after the operation. RESULTS: The mean flow rate of the LITA was 61 +/- 35 mL/min (range, 9-196 mL/min). The mean diameters of the LITA before and after the operation were 1.97 +/- 0.36 mm and 2.74 +/- 0.60 mm, respectively. The mean ratio of the LITA diameter after the opera t ion to that before the operation was 1.43 +/- 0.27. The intraoperative flow volume was positively correlated with the ratio of LITA diameters (r = 0.414; P =.006). CONCLUSION: These results demonstrate the early adaptation of the LITA as a blood source of the Y-composite RA graft in OPCAB and the rationale for using the LITA as a single blood source for total coronary artery revascularization.

Aged↗
PubMed1991

[A quantitative angiographic study of characteristics of internal thoracic artery grafts in coronary artery bypass surgery].

In adult patients with atherosclerotic coronary artery disease and in pediatric patients with Kawasaki heart disease, characteristics of internal thoracic artery grafts (ITA grafts) used for coronary artery bypass grafting (CABG) were quantitatively assessed by postoperative angiography. In 142 adult patients with a ITA graft for the left anterior descending artery (LAD), the diameter ratio between ITA graft and recipient LAD at the point close to the anastomotic site (ITA/LAD diameter ratio) was determined by postoperative angiography. This ratio for the adult patients as a whole was 1.04 +/- 0.34. The multivariate analysis (Quantification I) was performed to assess the effects of the following 12 factors on the ITA/LAD diameter ratio: (1) age at the time of operation, (2) sex, (3) time-duration from the operation to angiography, (4) laterality of the ITA used, (5) presence of an undivided major side branch of the ITA graft, (6) presence of blood flow competition between the ITA graft and other grafts, (7) presence of distal stenosis of the recipient LAD, (8) severity of LAD stenosis after the operation, and (9-12) presence of hyperlipidemia, diabetes mellitus, hypertension, or smoking history. The standardized category scores of 25% LAD stenosis, 50% LAD stenosis, and blood flow competition between the ITA and other grafts were -0.815, -0.359, and -0.306, respectively. Insignificant stenosis of the recipient coronary artery was associated with reduction of the ITA/LAD diameter ratio, and this ratio strongly correlated with the severity of LAD stenosis (partial correlation coefficient: 0.627). However, no other factors significantly influenced on the ITA/LAD diameter ratio. In 15 pediatric patients, the length and diameter of 19 ITA grafts and 5 saphenous vein grafts (SVGs) which remained patent in the early (about one month) and late (14 +/- 4 months) postoperative period were determined. Only in the ITA graft, increases in graft length and diameter associated with patient growth were recognized. In the present study, the physiological characteristics of the ITA graft were demonstrated as a viable conduit with flow adaptability and growth potential.

Adult↗
PubMed1978

[Anatomical and surgical justification for selective catheterization of the thoracic lymphatic duct and thoracic arteries for infusion immunochemotherapy of breast cancer].

An anatomo-topographic and operative study aimed at the elaboration of approaches and methods of the catheterization of the thoracic lympheduct and of the selective catheterization of the internal thoracic, external thoracic and acromiothoracic arteries for the regional infusion of activated proper lymphocytes and chemopreparations in breast cancer was carried out on 25 cadavers. An experimental injection of stained solutions proved that the selective catheterization of the thoracic arteries allows to create a significant concentration of injected drugs in the breast and regional lymphatic nodes without their propagation into adjacent regions, which is different from other methods of the regional chemotherapy in breast cancer.

Adult↗
PubMed2006

Benefit of partial right-bilateral internal thoracic artery harvesting in patients at risk of sternal wound complications.

BACKGROUND: Excellent long-term patency of the internal thoracic artery (ITA) graft promotes use of bilateral ITA bypass grafting; sternal devascularization, however, increases the risk of wound complications. We hypothesized that restricting right ITA (RITA) harvesting to a short proximal skeletonized segment (3 to 5 cm) would result in adequate residual blood supply to reduce that risk. METHODS: Seventy-eight patients with numerous risk factors for wound complications underwent composite double ITA grafting, utilizing the RITA segment anastomosed to the left skeletonized ITA and to the obtuse marginal branch in Y fashion. Blood flow in the distal RITA was assessed by parasternal transthoracic Doppler ultrasonography. Comparisons were made with prospectively collected data of patients undergoing pedicled single (n = 160) or skeletonized bilateral ITA grafting (n = 143) during the same period. RESULTS: Incidence of obesity, chronic obstructive pulmonary disease, diabetes, and peripheral vascular disease was higher in study patients. Postoperative Doppler ultrasonography detected reversed systolic dominant flow pattern. Wound complications occurred in 2 of 78 (2.6%) patients, compared with 14 of 143 (9.8%) after bilateral ITA (p = 0.04) and 8 of 160 (5%) after single ITA grafting (p = ns). Technique of bilateral ITA harvesting (partial right versus full length; odds ratio, 0.2; confidence interval: 0.04 to 0.9) and diabetes mellitus (odds ratio, 2.7; 95% confidence interval: 1.1 to 6.3) were independent predictors of wound complications in the entire series. CONCLUSIONS: Substantial residual blood supply is detectable after partial RITA harvesting and may prevent wound complications in high-risk patients.

Aged↗
PubMed2003

Does skeletonization compromise the integrity of internal thoracic artery grafts?

BACKGROUND: There are few reports that demonstrate the chronologic changes in the functional integrity of the internal thoracic artery (ITA) wall after skeletonization. We investigated the impact of skeletonization on ITA wall integrity by immunohistochemical analyses in acute and chronic phases. METHODS: Nine mongrel dogs underwent bilateral ITA dissection with one skeletonized vessel and the other pedicled. The following studies were performed 1 week (acute phase, n = 3) and 12 weeks (chronic phase, n = 6) after ITA harvesting. All specimens of the ITAs were stained by antibodies against von Willebrand Factor (VWF), endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and proliferating cell nuclear antigen (PCNA). After observation with confocal laser scanning microscopy, quantitative analyses of the staining signal for VWF and eNOS expressed on endothelial cells were performed. RESULTS: There were significantly more microvessels positive for VWF in the adventitia of skeletonized ITAs than in the adventitia of pedicled ITAs but the expression of PCNA in both groups was minimal, as in normal vessels. iNOS was not detected in any specimen. The intensity of VWF and eNOS expressed by endothelial cells had no significant differences between groups at either phase. CONCLUSIONS: The functional integrity of skeletonized ITA was similar to that of pedicled ITA in both acute and chronic phases. Although skeletonization induced neovascularization in the adventitia it did not induce proliferation of smooth muscle cells in the media, which is supposed to be a feature of vascular remodeling.

Animals↗
PubMed1999

Characterisation of constrictor endothelin receptors in the human internal thoracic artery and saphenous vein.

We studied the endothelin receptors mediating contraction in the human saphenous vein (SV) and internal thoracic artery (ITA). In the SV, the ET(A)-receptor antagonist BQ123 (1 microM) did not significantly shift the ET-1 concentration-response curve but did cause a parallel shift in the ITA. In the SV, the ET(A)-receptor agonist sarafotoxin 6b (S6b) produced a monophasic concentration-response curve that was antagonised biphasically by BQ123 (0.1-1 microM). In the ITA, S6b was an ineffective agonist with contractions seen only at 3 x 10(-9) M upward. The ET(B)-receptor agonist sarafotoxin 6c (S6c) caused constrictions in only 74% of SV rings and 42% of ITA rings. In the tissues that did respond, S6c caused a monophasic concentration-response curve with a lower maximal response than ET-1. The ET(B) antagonist BQ788 did not antagonise the responses to ET-1 in either the SV or the ITA but did antagonise the responses to S6c in the SV. The results from this study suggest that mainly ET(A) receptors mediate the contractile responses in the human SV and ITA. There is also evidence for an ET(B)-mediated response, although the contractions were much smaller than those elicited by ET-1. We also conclude that the ET(A) receptors mediating responses in these human vessels are atypical because of the different effects of BQ123 on the two vessels.

Adult↗
PubMed2003

Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting.

OBJECTIVE: To evaluate the risk of deep sternal infection in a large patient cohort following bilateral internal thoracic artery (BITA) grafting using skeletonized BITA dissection. SUMMARY BACKGROUND DATA: Complete myocardial revascularization using BITAs improves long-term survival and lowers the rate of repeat operations. Harvesting of ITAs as skeletonized vessels preserves sternal collateral blood supply, thus enabling rapid sternal healing with less risk of deep sternal infection. METHODS: One thousand consecutive patients (763 men, 340 patients >70 years old, 304 diabetics) underwent skeletonized BITA grafting from April 1996 to July 1999. RESULTS: The 30-day mortality rate was 3.4%. There were 10 perioperative infarcts, 16 strokes, and 22 deep sternal infections. There was an increased risk of deep sternal infection in repeat coronary artery bypass grafting (CABG) operations (15%), chronic obstructive pulmonary disease (COPD) (6.2%), congestive heart failure (4.7%), left ventricular dysfunction (ejection fraction < 35%, 4.5%), and longer aortic cross-clamping time. After adjustment for other demographic, clinical, and surgical predictors, the only independent predictors of deep sternal infection were repeat operations, COPD, and duration of aortic cross-clamping. No patients in the reoperation subgroup died, but three of six COPD patients with deep sternal infection died, and COPD was an independent predictor of overall (early + late) mortality. CONCLUSIONS: Skeletonized BITA grafting carries an acceptable risk of deep sternal infection but is not recommended for repeat CABG or for patients with COPD.

Aged↗
PubMed1999

Blunt trauma-induced internal thoracic artery injury: case report.

We report the case of a 54-year-old male motorcyclist with an apparent grade IV liver injury and life-threatening hemomediastinum and right hemothorax following blunt deceleration trauma. Massive hemothorax and an unstable hemodynamic status even under copious blood volume replacement made emergent surgical intervention mandatory. A midline laparotomy was performed at first to rule out abdominal bleeding accompanied by a diaphragmatic tear, but the procedure was soon converted to a thoracotomy after finding an intact diaphragm and persistent bleeding from the chest tube. An isolated internal thoracic artery (ITA) transection was identified. It was actively bleeding and causing a huge anterior mediastinal hematoma and had ruptured into the right pleural cavity. The bleeder was controlled with suture ligation and the hemodynamic status was soon stabilized. The patient recovered without significant sequelae. The rarity of this kind of presentation is discussed, including both the ITA injury mechanism and the problems posed in making an early and correct diagnosis.

Humans↗
PubMed2005

Left internal thoracic artery graft assessed by means of intraoperative transesophageal echocardiography.

BACKGROUND: We report a method of intraoperative assessment of left internal thoracic artery (LITA) graft with transesophageal echocardiography regarding patency, stenosis, and presence of remnant branch artery. METHODS: In 52 consecutive coronary artery bypass grafting surgery patients, blood flow velocity was measured at the origin of the LITA after coronary artery bypass grafting by means of transesophageal echocardiography. The flow pattern and velocity change at temporary clamping of the graft was examined and was compared with the postoperative angiographic findings. RESULTS: The LITA was visualized in 47 of 52 cases (90.4%). The LITA flow was diastolic dominant, systolic dominant, or equivalent in 41, 3, and 3 cases, respectively. The anastomosis was stenotic in 2 of 6 cases of the latter two groups, but in none of the 41 cases with diastolic dominant flow (p = 0.0139). The branch artery was present in 4 of 6 cases of the latter two groups, but in only 2 of 41 cases with diastolic dominant flow (p = 0.0012). Remnant branch artery was found in all three cases with systolic dominant flow. The LITA flow was instantaneously reduced at clamping and recovered at declamping in every case with graft occlusion but one. The ratio of velocity change at clamping was less than 0.50 in all 41 cases without remnant branch, whereas it was more than 0.50 in 5 of 6 cases with a branch (p < 0.0001). CONCLUSIONS: The transesophageal echocardiographic assessment with the clamp test is feasible intraoperatively in the majority of patients, enabling us to assess LITA graft patency, stenosis, or presence of a remnant branch.

Adult↗
PubMed2004

Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting.

The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.

Coronary Artery Bypass, Off-Pump↗
PubMed2001

Bilateral internal thoracic artery use for dialysis patients: does it increase operative risk?

BACKGROUND: The efficacy and risk of using the bilateral internal thoracic artery (BITA) for coronary artery bypass grafting in dialysis patients is virtually unknown. METHODS: Twenty-five patients on dialysis who underwent coronary artery bypass grafting using the BITA were retrospectively studied (BITA group). For comparison purposes, 52 patients on dialysis who underwent coronary artery bypass grafting using the left ITA were selected (LITA group). RESULTS: No wound healing problems occurred in the BITA group. Mean postoperative bleeding volume was 1,427 +/- 808 mL and 800 +/- 508 mL in the BITA and LITA groups, respectively (p = 0.00009). Blood transfusions for the BITA and LITA groups required an average of 6.8 and 6.2 units of packed red blood cells, respectively, with no significant difference. Five patients in the BITA group (20%) showed severe atherosclerotic deterioration of the ascending aorta, precluding clamping. Hospital mortality was 4% (1 of 25 patients) in the BITA group and 7.7% (4 of 52 patients) in the LITA group, with no significant difference (p = 0.49). CONCLUSIONS: In patients on dialysis, especially those with severe atherosclerotic or calcified deterioration of the ascending aorta, coronary artery bypass grafting using BITA grafting (arterial in situ conduits) may offer the easiest and most suitable solution without increased operative risk.

Adult↗
PubMed1999

[Assessment of internal thoracic artery grafts using duplex scanning].

In an effort to develop a noninvasive method to evaluate flow characteristics of the internal thoracic artery grafts (ITAG) after coronary artery bypass grafting, we performed duplex scanning of ITAGs of 51 patients who underwent bypass grafting. The ITAG was visualized with a duplex scanner of 7.5 MHz through the first or second left intercostal space. The visualization of the ITAG was adequate to make reliable measurements in 47 patients (92.2%). The diameter of the vessel, systolic peak velocity, and diastolic peak velocity were recorded, and systolic flow volume, diastolic flow volume, velocity ratio, flow volume ratio, and diastolic flow volume fraction were calculated. The velocity ratio, flow volume ratio, and diastolic flow volume fraction were markedly higher in the unstenotic subjects than in the stenotic subjects. In the group in which severe LAD stenosis were recognized preoperatively, both systolic and diastolic flow volumes were increased compared with moderately stenotic group. No differences in flow characteristics could be demonstrated between the subjects with old anterior myocardial infarction and without it. In 10 patients in whom flow pattern was abnormal or not identified, angiography revealed graft stenosis or predominant native coronary arterial flow. Duplex scanning is thought to be a reliable, sensitive, and noninvasive technique for the assessment of the ITAG.

Adult↗