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PubMed1996

Internal thoracic artery for coronary artery grafting in octogenarians.

BACKGROUND: Use of the left internal thoracic artery as a bypass graft has been shown to result in better long-term patency and improved survival. In elderly patients, the internal thoracic artery has been used less often for coronary artery bypass grafts because of the belief that greater morbidity and mortality are associated with this procedure. This study was undertaken to test this premise in the octogenarian population. METHODS: Over an 8-year period, 474 consecutive patients 80 years of age and greater had coronary artery bypass grafting. The left internal thoracic artery was used in 188 patients (39.7%) (group 1) and saphenous vein grafts only (group 2), in 286 (60.3%). The mean age was 82.6 years (range, 80 to 95 years). There were 312 men (65.8%) and 162 women (34.2%). RESULTS: Use of the internal thoracic artery as a graft has risen steadily each year, as has the number of patients who are octogenarians. The hospital mortality rate was 7.8%. Patients in group 1 had a mortality rate of 9.0% and patients in group 2, a mortality rate of 7.0%. The mortality rate among survivors at 1 year was 6.7%. Long-term survival was significantly greater in group 1. CONCLUSIONS: On the basis of this study, we conclude that the internal thoracic artery is the bypass graft of choice, especially in regard to long-term mortality, and should not be denied to this high-risk group.

Age Distribution↗
PubMed2003

Detrimental effects of papaverine on the human internal thoracic artery.

OBJECTIVE: We sought to determine the effects of papaverine on human and canine internal thoracic artery function and structure. METHODS: Vascular function was assessed with wire myography, and apoptosis was examined with confocal microscopy in arteries stained with ApopTag. RESULTS: Acetylcholine-induced endothelium-dependent relaxation in phenylephrine-precontracted arteries was significantly impaired by papaverine treatment in both human and canine internal thoracic arteries (maximal relaxation: 68.35% +/- 7.13% vs 47.5% +/- 9.32% in human arteries and 74.8% +/- 5.5% vs 34.3% +/- 8.5% in canine arteries) but not by incubation with acidified saline solution (pH 3.9, which is equivalent to the pH of 10(-2) mol/L papaverine solution) in canine internal thoracic arteries. Contraction of human internal thoracic arteries to phenylephrine or to U46619 was not significantly affected by papaverine treatment and neither was the contraction of canine internal thoracic arteries to phenylephrine. Total apoptotic endothelial and smooth muscle cells were significantly greater in papaverine-treated human and canine internal thoracic arteries. CONCLUSIONS: Papaverine impairs endothelial function and triggers apoptosis of endothelial and smooth muscle cells of human and canine internal thoracic arteries. The long-term consequence of this impairment on vascular function is not known. Until this question is answered, it will be prudent to use other vasodilators that are less damaging to the internal thoracic artery for cardiac surgery.

Animals↗
PubMed2005

Incidence of sternal infection in diabetic patients undergoing bilateral internal thoracic artery grafting.

BACKGROUND: Bilateral internal thoracic artery (BITA) bypass grafts have advantages over single internal thoracic artery (SITA) bypass grafts in the medium term, particularly in diabetics. However, the perceived higher sternal complication rates seen in diabetics have led many surgeons to avoid the use of BITA surgery. The aim of our study was to assess the validity of this approach by assessing the incidence of sternal infections over a 10-year period in one institution. METHODS: A retrospective analysis was made of our coronary artery bypass graft (CABG) patients over a 10-year period (7,581 patients). Nine hundred and twenty-two of the patients were diabetics (261 insulin-dependent diabetes mellitus [IDDM]). Of the insulin-dependent diabetics, 166 had SITA, and 95 had BITA grafts. RESULTS: There was no significant difference in this subgroup in terms of gender, preoperative angina, dyspnea class, left ventricular function, and number of distal anastomoses. Comparing the rates of sternal wound complications of SITA and BITA in IDDM are the following: (1) superficial sternal infection, 6.6% in SITA, 1.1% in BITA (p = 0.04); (2) deep sternal infection, 1.2% in SITA, 3.2% in BITA (p = 0.27); (3) sternal dehiscence, 1.2% in SITA, 3.2% in BITA (p = 0.27). CONCLUSIONS: Our data do not support the perception that BITA grafting increases the risk of sternal complications in insulin-dependent diabetic patients.

Aged↗
PubMed2002

Flow dynamics in internal thoracic artery grafts 10 years after coronary artery bypass grafting.

BACKGROUND: Flow dynamics in internal thoracic artery grafts 10 years after surgery are not known. METHODS: Doppler examination was performed in native internal thoracic arteries as a control (n = 8) and in internal thoracic artery grafts to the left anterior descending coronary artery 6 months postoperatively (group A, n = 25), at 5 years (group B, n = 14), and at 10 years (group C, n = 11). RESULTS: Each graft group showed a diastolic to systolic peak velocity ratio of less than 1.0 at the proximal end, and more than 1.0 at the distal end, but the control group showed a ratio of less than 1.0 throughout the length of the artery. The diastolic peak velocity of the graft groups was significantly faster than that of the control group at the distal end (versus group A, p < 0.01; versus group B, p < 0.005; and versus group C, p < 0.05). The systolic peak velocity of the graft groups was significantly lower than that of the control at the proximal end (versus group A, p < 0.0001; versus group B, p < 0.005; and versus group C, p < 0.0005). There were no significant differences of flow velocities among the graft groups and graft diameter among the four groups. CONCLUSIONS: Although the internal thoracic artery is systolic predominant, when native artery is used as graft, it changes its hemodynamics to diastolic predominance, especially at the distal end. Even after 10 years, graft flow dynamics are unchanged. This hemodynamic character may be one of the factors related to the superior long-term patency.

Angina Pectoris↗
PubMed2005

Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.

BACKGROUND: We sought to compare saphenous vein and internal thoracic artery graft patency by coronary system. METHODS: From 1972 to 1999, 50,278 patients underwent primary coronary surgery; subsequently, 4,333 had angiography of 2,121 internal thoracic artery and 8,733 saphenous vein grafts. Longitudinal analysis was used to model graft occlusion and identify risk factors. Using the model, patency was calculated twice for each graft and compared first as if an internal thoracic artery, and second as if a saphenous vein, were used. RESULTS: Unadjusted 1-, 5-, and 10-year patency was 93%, 88%, and 90% for internal thoracic arteries and 78%, 65%, and 57% for saphenous veins. At 10 years, internal thoracic arteries were more likely than saphenous veins to be patent to left anterior descending in 99.1% of cases, to diagonals in 98.3%, to circumflex in 98.3%, to posterior descending artery in 98.5%, and to right coronary arteries in 82.5%. For right coronary arteries, saphenous vein patency was equivalent to or better than internal thoracic artery patency early after surgery. However, by 10 years, internal thoracic artery patency was better in right coronary arteries with 70% stenosis or greater. At all times after surgery and all levels of clinically important coronary stenosis, internal thoracic artery patency surpassed saphenous vein patency in grafts to the left anterior descending, diagonal, circumflex, and posterior descending arteries. CONCLUSIONS: Internal thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed right coronary arteries. When bypassing right coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.

Coronary Angiography↗
PubMed1989

Sequential, free and Y internal thoracic artery grafts.

The internal thoracic artery (ITA) has excellent durability and its ability to survive for 10 years or more far exceeds the saphenous vein graft (SVG). In an attempt to improve long-term survival from coronary artery bypass grafting (CABG), three or more (up to six) ITA coronary anastomoses have been placed in 718 patients since 1982. Initial flow in the ITA immediately after grafting is critical to the success of the operation. Careful dissection and preparation of the ITA pedicle to prevent injury and spasm, constructing parallel and perpendicular anastomoses so the most proximal portion of the ITA is used for anastomosis and the use of the free right ITA to increase length of graft available are measures employed to increase critical flow. Actuarial survival at 6 years is 92.5% in this group of patients, which includes elderly patients, patients with left ventricular dysfunction and patients undergoing emergency operations.

Adult↗
PubMed2001

Bilateral internal thoracic artery T grafting for coronary artery revascularization. Angiographic assessment and mid-term outcome.

OBJECTIVES: We studied the early outcome of bilateral internal thoracic artery T grafting. METHODS: Coronary artery bypass grafting was studied retrospectively using bilateral internal thoracic artery T grafting in 51 patients. The T graft was made by anastomosing the free right internal thoracic artery to the in-situ left internal thoracic artery. Average patient age was 63.5 +/- 9.9 years, and the average number of anastomoses per patient was 3.6 +/- 0.9. In 35 patients, the right gastroepiploic artery (21 anastomoses in 20 patients), radial artery (1 anastomosis), free left internal thoracic artery (1 anastomosis) and saphenous vein graft (14 anastomoses in 13 patients) were used as additional bypass conduits. RESULTS: Hospital mortality was 0%. The morbidity of stroke was 1.9% (1 patient) and deep sternal infection 0%. Patency of the in-situ left internal thoracic artery was 49/50 anastomoses (98%) and that of the free right internal thoracic artery 81/84 anastomoses (96.4%). Mid-term coronary angiography in 7 patients demonstrated patent anastomosis of the T graft. Acute myocardial infarction unrelated to graft failure occurred in 2 patients during follow-up. Other patients were evaluated by exercise stress tests every year and none exhibited myocardial ischemia in the areas of T graft coronary revascularization. Three-year actuarial survival rate was 100% and freedom from cardiac events 96%. CONCLUSIONS: The bilateral internal thoracic artery T graft provides satisfactory early and mid-term outcomes in properly selected patients.

Adult↗
PubMed1990

Stimulus-specific patterns of myosin light chain phosphorylation in smooth muscle of rabbit thoracic artery.

When the rabbit thoracic artery was stimulated with submaximal concentrations of agonist [40 mM K+, 30 microM prostaglandin F2 alpha (PGF2 alpha) or 7 microM histamine], about 90% of a maximal contraction occurred. Each agonist induced a rapid development of contraction followed by a sustained response. The maximal rate of force generation stimulated with PGF2 alpha was twice that seen with K+ or histamine. Stimulation with 40 mM K+ increased the extent of monophosphorylated 20 kDa myosin light chain (MLC-P) for up to 1 min to a maximal value of 38.8 +/- 1.0%, there was a subsequent rapid decrease and the MLC-P level remained just above the basal value for 40 min (6.8 +/- 3.0%). In the case of stimulation with 7 microM histamine, MLC-P level increased rapidly and was sustained for up to 40 min (28.0 +/- 4.9%). In contrast to the stimulation with K+ or histamine, PGF2 alpha induced both mono- and diphosphorylated MLC20 (MLC-P and MLC-P2 respectively) at a low concentration (3 microM). The monophosphorylation of MLC20 induced by 30 microM PGF2 alpha reached the maximal value of 32.8 +/- 5.2%, and was sustained for up to 40 min (15.2 +/- 5.4%). The diphosphorylation of MLC20 increased rapidly (7.4 +/- 4.0% at 5 min), then decreased to the basal value within 40 min. These results suggest that different modes of stimulation of smooth muscle contraction produce different profiles of MLC20 phosphorylation. The implications of these observations are that the diphosphorylated form, specifically induced by certain agents, may modify the mode of contraction of the aortic artery.

Animals↗
PubMed2003

Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.

OBJECTIVE: Deep sternal wound infection is a dreaded complication of coronary artery bypass surgery, particularly in patients with diabetes. This study determines whether skeletonization of internal thoracic artery conduits compared with pedicled harvesting reduces the risk of deep sternal wound infection in patients with diabetes undergoing bilateral internal thoracic artery grafting. METHODS: We reviewed prospectively gathered data on all patients who have undergone coronary artery bypass grafting and received bilateral internal thoracic artery grafts at our institution since 1990. We compared patients with diabetes who received skeletonized (n = 79) versus conventional pedicled (n = 36) internal thoracic artery conduits. RESULTS: The proportion of patients taking insulin (19.0% vs 14.0% for skeletonized vs conventional grafts, respectively, P =.6) or oral hypoglycemic agents (68.4% vs 69.4%, P =.9), as well as the prevalence of type I diabetes (2.5% vs 8.3%, P =.18), were similar in both groups. Patients who received skeletonized grafts were more likely to receive a free rather than an in situ right internal thoracic artery graft (93.7% vs 30.6%, P <.001). The prevalence of deep sternal wound infection was significantly lower in patients who received skeletonized grafts compared with patients who received conventional grafts (1.3% vs 11.1%, P =.03). Patients in the skeletonized group were also less likely to develop any (superficial or deep) sternal wound infection postoperatively (5.1% vs 22.2%, P =.03). There was no significant difference in the prevalence of deep sternal wound infection between patients with diabetes who received skeletonized internal thoracic arteries and patients without diabetes who underwent conventional internal thoracic artery grafting (n = 578) (1.2% vs 1.6%, respectively, P =.8). CONCLUSIONS: Skeletonization of internal thoracic artery conduits lowers the risk of deep sternal wound infection in patients with diabetes undergoing bilateral internal thoracic artery grafting. We no longer consider diabetes a contraindication to bilateral internal thoracic artery grafting, provided the internal thoracic arteries are skeletonized.

Adult↗
PubMed2006

Disturbed endothelial function of the internal thoracic artery in patients with coronary artery disease.

OBJECTIVES AND BACKGROUND: The internal thoracic artery is an established arterial graft for myocardial revascularization. It never had been investigated, whether there are functional differences in this vessel between patients with or without coronary artery disease. METHODS: We investigated the left internal thoracic artery of 28 patients (15 with and 13 without coronary artery disease) with a duplex-system at rest and with a handgrip exercise. RESULTS: Concerning the measured flow velocities at rest there was only a significant difference between the diastolic mean and peak velocity between the two groups, the other investigated parameters demonstrate no significant difference. The peak diastolic and the mean diastolic velocity was less in patients with coronary artery disease during the handgrip-test. The flow reserve was decreased in patients with coronary artery disease (12.6+/-24.0% vs. 32.3+/-30.9%, P < 0.05). CONCLUSIONS: We demonstrated, that patients with coronary artery disease have a higher peripheral resistance and a lower diastolic velocity of the internal thoracic artery during stress testing. This corresponds to a disturbed vasomotion and may be an early marker of arteriosclerosis.

Adult↗
PubMed2002

Early clinical and angiographic outcome of the pedicled right internal thoracic artery graft to the left anterior descending artery.

BACKGROUND: The left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery became the gold standard graft in coronary surgery. Subsequently, the right internal thoracic artery (RITA) graft was increasingly used. However, there is still some debate about the optimal way of using this conduit. The aim of the present study was to assess our experience in grafting the pedicled RITA graft to LAD in 212 consecutive patients. METHODS: The records of 212 consecutive patients who underwent isolated coronary artery bypass grafting with the pedicled RITA graft to the LAD artery at Harefield Hospital between January 1998 and May 2001 were retrospectively reviewed. We approached the last 35 consecutive patients to obtain an angiographic control group. All 35 patients (16.5%) consented and, before discharge, underwent angiography to look at the quality of anastomoses and the patency of grafts. RESULTS: Successful catheterization and engagement of the RITA grafts was performed in 32 patients. Angiography showed that 32/32 (100%) of the RITA grafts were widely patent with excellent flow. The distal anastomoses of these RITA grafts were also satisfactory. There were no deaths among the study patients. CONCLUSIONS: Our results show that the use of the pedicled RITA graft to the LAD artery provides a good early clinical and angiographic outcome, and suggests that the pedicled RITA graft to the LAD artery is a good alternative to the pedicled LITA graft to the LAD artery.

Adult↗
PubMed2000

Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel.

OBJECTIVES: The safety and reliability of a method of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, CVG, Cincinnati, Ohio) were evaluated. METHODS: The mural branches of the internal thoracic artery were cut by means of 3 methods, differentiated by distance from the site of application of the Harmonic Scalpel blade to the internal thoracic artery. A total of 15 branches were cut from the internal thoracic artery at (0 mm) the origin (group I) or at 1 mm (group II) or 2 mm (group III) distal to the origin. Tissue preparations were examined for successful vessel closure and severity of tissue damage. The length of stump (L) and the length of tissue damage from the stump (D) were determined by a computer image analysis system, and pressure testing was performed to evaluate the physical strength of vessel closure. RESULTS: In group I, 8 of the 15 branches exhibited discontinuity of the vascular wall structure, probably because of insufficient sealing of the divided section, and 12 of the 15 branches exhibited tissue denaturation on the internal thoracic artery wall adjacent to areas of origin, which was probably caused by the heat transferred from the branches during the process of coagulation. In groups II and III, continuity of wall structure of stumps suggestive of stable closure of branches was confirmed. The lengths of tissue damage from the stump (D) were 0.96, 0.58, and 0.63 mm in groups I, II, and III, respectively, and the lengths of intact area (L - D) in the corresponding groups were -0.78, 0.61, and 1.51 mm. The negative figure in group I indicates the presence of tissue damage in the internal thoracic artery itself. By contrast, in groups II and III the internal thoracic arteries were intact, with a safety margin of greater than 0.5 mm. On physiologic evaluation of vessel closure, 2 of the 24 (8.3%) branches burst under a pressure lower than 350 mm Hg because of insufficient vessel coagulation, but the remaining 22 branches (91.7%) remained intact under pressures up to 350 mm Hg. CONCLUSION: The internal thoracic artery skeletonization method with an ultrasonic scalpel (Harmonic Scalpel: output level 2) appears to be a safe and reliable method of skeletonized internal thoracic artery harvesting when branches are sectioned at least 1 mm distal to their origin at a sufficiently slow speed.

Animals↗
PubMed2003

Segmentation of the left internal thoracic artery: a new technique for maximal arterial grafting.

The left internal thoracic artery lpa r;LITA) is the preferred graft with the best patency rate in coronary artery bypass grafting (CABG). To maximize its use, we developed a technique of grafting 2 distant coronary arteries with the LITA, using its distal portion segmented to construct a Y graft with either the in situ LITA or right internal thoracic artery (RITA). We applied this technique in 51 patients. The distal segment of the LITA was used to create a Y graft in 4 different configurations according to coronary pathology. Offpump grafting was performed in 11% of cases. The use of a distal segment of the LITA was thus extended not only to the left anterior descending artery and branches but also to the circumflex and right coronary artery territories.

Adult↗
PubMed2001

Continued cigarette smoking after coronary artery bypass surgery reduces endothelium-dependent vasodilation in internal thoracic artery grafts.

BACKGROUND: Cigarette smoking is known to promote endothelial dysfunction, thus it can be responsible for an impaired endothelium-dependent vasomotility in arterial grafts late after coronary surgery. METHODS: Twenty consecutive patients (mean age 64.5 years), previously submitted to coronary bypass surgery with the internal thoracic artery, underwent quantitative angiography of the implanted graft at long-term follow-up (mean time 2.5 years). To assess both endothelium-dependent and independent vasomotility, angiograms were acquired before and after selective infusions of acetylcholine (10(-6) mmol/ml) and nitroglycerine (500 microg). The predictive value of risk factors, including previous and continued smoking, for an impairment in endothelium-dependent vasomotility was assessed. RESULTS: Continued smoking (p = 0.038), but not a previous history of smoking (p = 0.55) was the only predictor of a reduced endothelium-dependent vasodilation. While previous smokers and non-smokers showed a similar response to acetylcholine, current smokers showed a reduced endothelium-dependent vasodilation vs non-smokers (94.8 +/- 2.6 vs 99.6 +/- 2.3% of the maximal vasodilative capacity, p = 0.001). CONCLUSIONS: Although maintained, the vasodilative response to acetylcholine appears reduced in internal thoracic artery grafts of patients who continued smoking long term after coronary bypass surgery. Whether this could affect the long-term outcome of these patients has to be further investigated.

Acetylcholine↗
PubMed2006

Blood supply of the sternum and its importance in internal thoracic artery harvesting.

BACKGROUND: The internal thoracic artery (ITA) is the conduit of choice in coronary bypass grafting, due to the excellent long-term results achieved using it. However, increased incidence of sternal infections after pedicled ITA harvesting has revived interest in the morphology of sternal blood supply. Our aim was to discuss the topography of the sternal branches with emphasis on internal thoracic artery harvesting. METHODS: This study was conducted on 50 fresh specimens of the anterior thorax wall. Radio-opaque material was injected and angiograms of the ITA were performed. Subsequently, the specimens were preserved and a dry dissection of each ITA and its branches was carried out. RESULTS: In dry dissected specimens, four types of vessels were identified that have the potential to carry blood to the sternum after harvesting the ITA. In the first group, the artery to the sternum also supplies the intercostal space. In the second morphologic variant, the sternal branch gives off the perforating and anterior intercostal arteries. In the third group, we classified the common branch of the sternal and perforating arteries. In the fourth group, the sternal artery originated from the ITA as an independent branch. CONCLUSIONS: For sternal-intercostal, perforating-intercostal, and sternal-perforating branches to function as collaterals after ITA harvesting, the common trunk of origin must remain intact. Based on morphologic data, we recommend ligating the common trunk as close as possible to the ITA; in this way, collateral blood flow to the sternum remains intact.

Adolescent↗
PubMed1998

[Clinical evaluation of right gastroepiploic artery (RGEA) graft--comparison of RGEA with right internal thoracic artery (RITA) graft in the coronary bypass grafting (CABG) operation using only arterial grafts].

From January, 1990 through May, 1997, 100 CABG operations were conducted using only double arterial grafts. RITA/left internal thoracic artery (LITA) (n = 38) and RGEA/LITA (n = 62) groups were compared. The incidence of left main trunk lesion was higher in the RITA/LITA group (29%: 13%), and old myocardial infarction was greater in RGEA/LITA group (77%: 55%). Mean age in the RGEA/LITA group showed high tendency (66.8 +/- 8.5: 63.9 +/- 9.2). Both groups were essentially the same with respect to sex, poor left ventricular function, pre-operative aortic baloon pumping (IABP), diabetes mellitus, hypertension, cerevral vascular disease, hyperlipidemia, smoking, pre-operative ejection fraction (EF). Focal skin infection (32%: 6%) and total operative field infection (focal skin infection + mediastinitis) (39%: 8%) were higher in the RITA/LITA group. Operation time (443 +/- 81: 405 +/- 114) and pleural effusion (29%: 15%) showed high tendency in the RGEA/LITA group. Extracorporeal circulation time, aorta cross-clamping time, reoperation due to bleeding, reoperation due to mediastinitis, post-operative IABP, and post-operative EF were the same for the two groups. The difference of survival rate and cardiac event-free rate between two groups were not recognized. The RGEA/LITA group showed lower complication and similar survival rates than the RITA/LITA group. Based on the present results. RGEA may be considered more usefull than RITA.

Arteries↗
PubMed1995

Multiple aneurysms of the internal thoracic artery.

Nontraumatic aneurysms of the internal thoracic artery are rare. We report a case where multiple aneurysms of the right internal thoracic artery presented as an asymptomatic density on the chest radiograph. Operative findings and pathology are reviewed.

Aneurysm↗