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PubMed2001

Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery.

BACKGROUND: Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft. METHODS: Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein. RESULTS: There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p < 0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p < 0.001) and a longer hospital stay (p < 0.001). Mean follow-up was 8.1 +/- 3.9 months. The probability of survival was similar (p = not significant). CONCLUSIONS: The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.

Adult↗

PubMed1992

Effects of dilation with a balloon catheter on the endothelium of the internal thoracic artery.

Controlled dilation of the internal thoracic artery with a balloon catheter has been reported to effectively treat intraoperative arterial spasm. It has been shown in laboratory animals that dilation of the internal thoracic artery at prescribed shear force levels will not cause intimal damage. Using scanning electron and light microscopy, we have examined the effects of calibrated balloon dilation on the endothelium of the human internal thoracic artery. In 10 patients with bilateral internal thoracic artery grafting, the artery was dilated with a Fogarty IMAG balloon catheter (Baxter Healthcare Corporation, Edwards Division, Santa Ana, Calif.) that was withdrawn at tensions of 20 or 30 gm. Arterial segments and nondilated control specimens were prepared for scanning electron microscopy. The intimal surface of each internal thoracic artery was evaluated by assigning a score (from 0 to 3) to 10 examined scanning electron microscopy fields; subsequently the arterial tissue was viewed by light microscopy with paraffin-embedded sections stained for elastic tissue. Arteries were obtained from three additional patients so that the microscopic appearance of the arteries could be observed after rough manipulation or removal of the balloon without shearing. The results of this study are as follows: (1) By scanning electron microscopy, dilated internal thoracic arteries yielded consistently higher scores than the control arteries, reflecting severe, tension-dependent alterations of the endothelium, which included marked desquamation of endothelial cells, with extensive areas of complete denudation and pronounced attachment of platelets to these areas; (2) endothelial injury occurred by inflation alone, without shearing by the inflated balloon; (3) by light microscopy, the internal thoracic arteries showed (a) fenestrations of the internal elastic lamina with occasional transmigration of smooth muscle cells through these gaps and (b) foci of intimal thickening without overt atherosclerotic lesions. We conclude that the endothelium of human internal thoracic arteries is highly vulnerable to balloon dilation, which can severely injure the intimal surface. For this reason we prefer not to include this procedure in our protocol for preparing the internal thoracic artery.

Aged↗

PubMed1992

[Coronary artery bypass grafting by utilizing the artery grafts and bovine internal thoracic artery graft (Bioflow in an elderly patient)].

We performed coronary artery bypass grafting (CABG) in a 80-year-old male with calcified ascending aorta and severe varicose veins utilizing the bilateral internal thoracic arteries and the right gastroepiploic artery under fibrillatory arrest without aortic cross-clamp (aortic no-touch technique). After triple coronary artery bypass grafting was completed, heart failure occurred. Additional Bioflow graft to the circumflex artery restored good cardiac function. The aortic no-touch technique is a useful method for CABG in patients with severe calcified ascending aorta. This experience suggests that the Bioflow graft is a helpful conduit at an urgent situation in CABG.

Aged↗

PubMed1992

[Late results of coronary artery bypass grafting with the internal thoracic artery].

Between November 1981 and December 1991, 755 patients underwent isolated coronary artery bypass grafting. We compared postoperative events, graft patency and survival rates of the patients who received at least one internal thoracic artery graft (n = 517) with those of the patients who had only saphenous vein bypass grafts (n = 238). No significant difference was found between the 2 groups in patient's age at the operation, female ratio and the incidence of emergency operation. The operative mortality was not significantly different in either group. Graft patency was better for internal thoracic artery grafts than for SVG (ITA grafts 97.1%, SVG 85.6% p less than 0.0001). Graft-LAD patency rate was also better for ITA grafts than for SVG (ITA grafts 97.7%, SVG 86.8%, p less than 0.0001). The incidence of late cardiac events (late cardiac death, reoperation, myocardial infarction) is lower in patients with ITA. Furthermore, patients who received ITA grafts had a better survival rate at 8 years (91.1% versus 85.3%, p = 0.048) than those who had vein bypass grafts alone. We conclude that the use of ITA grafts enhances the long-term benefits including long-term survival rate. This is the first observation in Japanese population.

Adult↗

PubMed1994

[Quadruple coronary artery bypass grafting with arterial grafts--application of internal thoracic artery and right gastroepiploic artery].

Arterial graft has been widely applied for coronary artery bypass because of its excellent long-term patency. However, when more than four coronary bypass graftings should be carried out using internal thoracic arteries (ITAs) and right gastroepiploic artery (GEA), some surgical techniques must be devised. We performed quadruple coronary artery bypass grafting using three arterial grafts; bilateral ITAs and GEA, and obtained good results. We used free RITA graft for sequential grafting in one case. In another case, GEA was divided into two segments and used as two free grafts. From our experience, we believe it is possible to perform multiple coronary revascularization using only arterial grafts with one median skin incision.

Abdominal Muscles↗

PubMed2005

Hydrodissection technique of harvesting left internal thoracic artery.

Use of internal thoracic arteries in coronary artery bypass surgery has become universal. Skeletonized internal thoracic artery is useful in coronary artery surgery for sequential anastomosis as it also provides a long length of graft. Skeletonizing the conduit is technically more difficult than harvesting it as a pedicle graft. We describe a technique of harvesting the internal thoracic artery in which 10 to 20 mL of normal saline is injected into the fascial plane of the left side of chest wall along the course of artery to develop a plane of dissection.

Coronary Artery Bypass↗

PubMed2000

Interaction between thromboxane A2 and 5-hydroxytryptamine in the radial artery compared to the internal thoracic artery.

The aim of the present study was to investigate if the function of 5-hydroxytryptamine-1B/1D (5-HT1B/1D) receptors in human radial artery (RA) and internal thoracic artery (ITA) can be modified by thromboxane A2 (TXA2) released from the vessel wall in these two arteries that are commonly used in coronary artery bypass grafts. The 5-HT1B/1D agonist sumatriptan contracted the RA with a maximum response of 23.5+/-6.8 mN and a pD2 value of 6.6+/-0.1. The effect of sumatriptan was significantly reduced in the ITA with a maximum of 5.8+/-2.7 mN (P<.05) and a pD2 value of 6.4+/-0.2. The TXA2 receptor antagonist SQ30741 inhibited contractions to sumatriptan in the RA but not in the ITA. It is concluded that the effect mediated by 5-HT1B/1D is augmented by endogenous TXA2 in the RA.

Aged↗

PubMed1993

Clinical evaluation with exercise performance in twenty patients who underwent coronary artery bypass grafting with both the gastroepiploic and internal thoracic arteries.

Postoperative exercise performance was evaluated in 20 patients who underwent complete coronary revascularization with simultaneous right gastroepiploic artery and internal thoracic artery grafts for ischemic heart disease and exhibited patency of all grafts on postoperative angiograms. Three patients received only arterial grafts, and 17 simultaneously received a saphenous vein graft. Forty five right gastroepiploic artery grafts were harvested during this study, but two were not used because of foci of severe calcification. The right gastroepiploic artery was grafted to the distal right coronary artery in 17 patients and to the distal obtuse marginal branches in three patients, accompanied by an internal thoracic artery graft to the left anterior descending artery in seventeen, to the diagonal branch in three, and to the proximal right coronary artery in one patient. A postoperative exercise test with a bicycle ergonometer was administered 6 to 12 weeks after the operation, and the results are reported after conversion into metabolic units. The preoperative exercise test resulted in 3.6 +/- 1.9 metabolic units for 18 patients tested, and the postoperative metabolic units were 7.8 +/- 1.3 for 20 patients. Left ventricular wall motion was analyzed by regional ejection fraction before and after coronary artery bypass grafting in 14 patients who received an right gastroepiploic artery graft for the right coronary system. The mean regional ejection fraction of the posterobasal or diaphragmatic wall was 28.0% or 28.2% before operation and improved to 43.1% or 43.2% after coronary artery bypass graft, respectively. The flow of right gastroepiploic artery seemed to distribute adequately to the revascularized area. Long-term results have not yet been proved; the use of simultaneous right gastroepiploic artery and internal thoracic artery grafts, however, thus produced excellent results, as seen from improvements in both left ventricular wall motion and early postoperative exercise performance.

Adult↗

PubMed2004

Mid to long-term results of circumflex coronary artery revascularization with left internal thoracic artery grafts.

The current trend in coronary artery surgery is to revascularize the left coronary artery branches with bilateral internal thoracic arteries (ITA). For this procedure, the right ITA is usually grafted to the left anterior descending coronary artery while the circumflex coronary artery is revascularized by the left ITA. The mid to long-term results of the left ITA on the circumflex system were examined in this study. Forty of 48 patients operated on between 1996 and 1998 who had undergone revascularization of the left coronary artery with both ITAs and who fulfilled the study criteria underwent control coronary arteriography to determine the mid to long-term patency of LITA grafts on the circumflex artery. The median time for follow-up was 53 months (range, 49 to 70 months). Of the 40 angiographically controlled patients, 35 had patent left ITA to circumflex artery anastomosis (87.5%). One graft stenosis and four graft occlusions were observed. In the same group, right ITA to left anterior descending coronary artery anastomoses were patent in 38 patients (95%). Left ITA grafts seem to be the conduit of choice for revascularization of the circumflex coronary artery. In combination with the in situ right ITA to left anterior descending coronary artery anastomosis, in situ left ITA grafting to the circumflex system can be done with acceptably low mortality and excellent long-term patency rates. Its utilization is particularly advised in young patients where the importance of left coronary artery revascularization by bilateral ITA grafts is increased.

Adult↗

PubMed2000

Clinical results of coronary artery bypass grafting with use of the internal thoracic artery under low free flow conditions.

OBJECTIVE: Even when left internal thoracic artery flow is very low, we have used the artery for grafting without any further maneuvers. In this study, we investigated the clinical results of coronary bypass surgery using the left internal thoracic artery with low free flow. METHODS: A total of 163 patients were divided into 2 groups: group L (n = 43) had free flow of 20 mL/min or less and group H (n = 120) had free flow of more than 20 mL/min. We performed a comparative study on the basis of coronary angiography and pulsed Doppler echocardiography. Furthermore, 12 months' postoperative graft angiography was carried out in 11 patients from group L. RESULTS: No patient had low output syndrome or perioperative myocardial infarction. One month after the operation, 3 cases of graft occlusion and 9 cases of the "string sign" were identified in group H. However, group L had no graft occlusion and only 1 case of the "string sign." The 1-month postoperative Doppler echocardiographic study showed no significant differences in the diastolic fraction of velocity time integrals and the diastolic/systolic peak velocity ratio of the grafts. In the 11 patients undergoing angiography after 1 year, graft patency was excellent. Moreover, the graft diameter was significantly larger than it was 1 month after the operation. CONCLUSION: These results suggest that the left internal thoracic artery can be used for coronary artery bypass grafting even when the flow is less than 20 mL/min.

Blood Flow Velocity↗

PubMed2003

Pedicled or skeletonized? A review of the internal thoracic artery graft.

The internal thoracic artery is the gold-standard conduit for coronary artery bypass surgery. Until recently, it was used almost exclusively as a pedicle, with construction of 1 distal anastomosis. Skeletonization of the internal thoracic artery has recently been advocated in order to increase the number of arterial anastomoses and decrease the occurrence of sternal wound infections. When skeletonized, the vessel loses its "milieu" which raises the question of whether this technique sacrifices the superior longevity of the conduit. The current status of research on the effects of skeletonization (depriving the internal thoracic artery of vasa vasorum, innervation, and lymphatic and venous drainage, together with creating an imbalance between vasoconstricting and vasodilating substances) appears to support the superiority of the pedicled graft. Long-term patency studies of the skeletonized ITA, with meticulous follow-up and confirmation by angiography, are not currently available. Theoretically, skeletonization of the ITA might adversely affect its long-term resistance to atherosclerosis. More data are needed before this technique can be universally recommended. If the skeletonized ITA has decreased long-term patency, bypass surgery may be at a disadvantage when compared with the new generation of drug-eluting stents.

Coronary Artery Bypass↗

PubMed1996

Coronary arteries bypass grafting with use of both internal thoracic arteries.

The internal thoracic artery is a preferred conduit for bypass grafting. While the single ITA grafting has been universally accepted -- the use of both ITA's remains controversial. The risk factors analysis based upon assessment of operative results and mid-term functional follow-up was performed. The clinical applicability of transthoracic B-mode ultrasonic imaging and Doppler spectrum analysis in the postoperative evaluation of use of two ITA's was investigated. From January 1989 to January 1993, 97 patients received bilateral ITA and additional vein or RGEA grafts at Groby Road Hospital, Leicester, UK. There were 77 men (79.4%) and 20 women (20.6%) with mean age of 52.1+/-10.1 years. 19 cases were urgent. 14.4% of patients suffered from diabetes mellitus, 8.3% -- COAD and 46.6% did not work because of angina. The average number of anastomoses per patient was 3. The operative mortality was 4.1%. Complications included: reoperation for bleeding=3.2%, sternal infection=6.5%, IABP=2.1%. There were no evidence of perioperative myocardial infarction. 80 patients were followed-up for 26,5+/-13 months. 49 patients were in angina NYHA class I while preoperatively: 7. 1 patient was in NYHA class III while preoperatively there were 40 patients. Nearly twice more patients worked, and more than three times fewer patients did not worked because of angina, comparing to preoperative period. With the use of colour Doppler technique the blood flow was measured in 78.3% of left and 74% of right ITA's. The average flow in left ITA was: 46.4+/-17 ml/min and 41.7+/-17 ml/min in right ITA. The multivariate analysis for risk factors of bilateral ITA's grafting was performed. There were no risk factors for postoperative complications of bilateral internal thoracic arteries grafting in presented material. The risk of perioperative death is higher for patients with triple vessels disease than for patients with double vessels disease. Bilateral ITA grafting procedure has positive influence on patients working abilities. Percutaneous ultrasonic assessment of flow in ITA's used for bypass appears to be useful non-invasive investigation of their function.

Coronary Disease↗

PubMed1993

[The assessment of multiple coronary artery bypass with bilateral internal thoracic artery grafts].

From 1982 to March 1991, 68 patients underwent coronary artery bypass grafting (CABG) using bilateral internal thoracic arteries (ITA). There were 62 males (91.2%) and 6 females (8.8%) ranging from 33 to 74 years old (mean 58.5 +/- 9.2). Thirty four patients had old myocardial infarction (OMI) and left main trunk disease was seen in 8.5% of the patients. The number of grafts was 2 to 6 per patient with an average of 3.2 +/- 1.0. In bilateral ITA grafting the combinations of RITA to LAD and LITA to LCX were most frequently used. There were no operative deaths except for one death which occurred while at the hospital. The patency rates for the RITA and LITA were 98.3% and 96.7%, respectively. Postoperative complications included reexploration for bleeding and heart tamponade in 9 patients, and low output syndrome in 7 patients. The frequency of blood transfusion decreased with the use of cell saver. Routine bilateral ITA grafting for multiple CABG is considered safe, with the early patency being relatively better than with saphenous vein grafting.

Adult↗

PubMed1996

Exclusive use of arterial grafts in coronary artery bypass operations for three-vessel disease: use of both thoracic arteries and the gastroepiploic artery in 256 consecutive patients.

METHODS: From September 1989 to September 1994 we operated on a consecutive group of 256 patients with three-vessel disease in whom we used the right gastroepiploic artery together with both internal thoracic arteries. Vein grafts were not used in these patients. This population consisted of 233 men and 23 women whose ages ranged from 31 to 77 years (mean age 57.8 years). RESULTS: Hospital morbidity and mortality were not directly related to the use of the gastroepiploic artery. Patency of the anastomoses in a subgroup of 56 patients (22%) a mean of 16 months after the operation was 98% for the left internal thoracic artery, 96% for the right internal thoracic artery, and 88% for the gastroepiploic artery. Five-year actuarial survival (including in-hospital deaths) was 95.9% and was related only to age. From discharge until the end of follow-up, two patients had a myocardial infarction, six patients underwent a reintervention procedure, and 18 patients had a return of angina pectoris. CONCLUSION: We conclude that the concomitant use of the gastroepiploic artery with the both internal thoracic arteries has low morbidity and mortality in patients with three-vessel disease operated on by experienced surgeons. At this moment, we have no reason to believe graft patency will deteriorate in the future. On the basis of these results, the knowledge that arteries are to be preferred over veins for coronary bypass grafting, and the absence of a leg incision, we believe this operative technique is superior to the use of venous grafts.

Adult↗

PubMed2003

Mid-to-long-term patency comparison of the right internal thoracic artery grafts on the left anterior descending and on the right coronary arteries.

BACKGROUND: The excellent results obtained from internal thoracic artery for myocardial revascularization have led surgeons to simultaneous use of other arterial conduits, particularly the right internal thoracic artery. However, some controversy still exists regarding the optimal target coronary artery for this graft; different strategies have been proposed for bilateral internal thoracic artery grafting. PATIENTS AND METHODS: 59 patients with right internal thoracic artery grafts were monitored using coronary arteriography in order to compare the patency of this graft on the left anterior descending and the right coronary arteries. The right internal thoracic artery was grafted to left anterior descending artery in 39 patients (group 1) and to right coronary artery in 20 patients (group 2). RESULTS: The mean period of follow-up was 64.07 months (range: 37 to 185 months). Overall, 8 of the 59 grafts (13.6%) were occluded at the arteriography. In group 1, 1 of 39 (2.6%) grafts and in group 2, 7 of 20 (35%) grafts are found to be occluded. These results are considered statistically significant (p < 0.001). COMMENT: The results show that the patency of the right internal thoracic artery is significantly better on the left anterior descending artery than on the right coronary artery in the mid-to-long term, and patency does not differ from the left internal thoracic artery on the left anterior descending artery.

Adult↗

PubMed1995

[CABG using Y arterial graft which consists of internal thoracic artery Y branched with inferior epigastric artery].

From December 1994 to April 1995, nine patients were submitted to myocardial revascularization using Y arterial graft, which consists of internal thoracic artery (ITA) Y branched with inferior epigastric artery (IEA). The age ranged 50 to 76 (mean age, 67.2 years); seven patients were male. Five patients had three vessel CABG and four patients had four vessel CABG. There was no operative mortality and no mechanical supports with IABP. Aortic clamping and operative time was not longer in this series. Early postoperative angiographic evaluation of Y arterial grafts showed that nine ITA grafts were patent (100%) and seven IEA grafts were patent (77.8%). Because of the low patency rate of IEA graft, Y graft using IEA appears to be an interesting alternative only in patients who have no other available conduits.

Aged↗

PubMed1992

The internal thoracic artery and its branches after coronary artery anastomoses in pediatric patients.

The internal thoracic artery has been favored because of its superior early and late patency for coronary artery bypass grafting (CABG) in pediatric patients. We have studied the angiographic changes of the internal thoracic artery and its side branches before and after CABG with internal thoracic artery to the left anterior descending artery. The internal thoracic artery with remaining thymic or pericardial branches was patent but showed enlargement of the branches in the early period after the operation, and a postoperative exercise test suggested a remaining ischemic lesion in the bypass. Angiogram taken 1 year after CABG demonstrated the grown internal thoracic artery with disappearance of most of the side branches, which had been enlarged 1 month after the operation. Our findings suggest the importance of ligation of the whole proximal internal thoracic artery branches to maintain good early and late patency.

Child↗

PubMed1996

Cystic medical necrosis of the internal thoracic artery.

In an internal thoracic artery intended as a graft in coronary angioplasty, multiple intramural haematomas impeded blood flow and consequently precluded use of the artery as a free graft. The cause was found to be cystic medical necrosis of the internal thoracic artery. A good result was obtained with three single aorto-coronary venous bypass grafts.

Coronary Artery Bypass↗