Does moderate coronary stenosis affect the fate of the left internal thoracic artery graft?

Abstract Introduction: In this study we try to observe the fate of the left internal thoracic artery grafts that were bypassed to left anterior descending artery with moderate stenosis identified with fractional flow reserve (FFR) technique. Doppler ultrasonography was chosen as a noninvasive screening method. Methods: A total of 30 patients who underwent coronary artery bypass grafting depending on results of the fractional flow reserve between January 2007 and January 2012, were subjected to transthoracic color Doppler ultrasonographic evaluation irrespective of the presence of symptoms, and the presence of a systolic-diastolic flow pattern was investigated using the supraclavicular approach. Results: The left internal thoracic artery graft was found to be functional in 63.3% of patients within a mean period of 35.1±19.7 months between coronary bypass and color Doppler ultrasonography. This period was found to be 29.4±19.6 months in the functional graft group, and 44.7±16.6 months in the dysfunctional graft group (P=0.046). Preoperative complaints of angina were reported to fall from 88.9% to 16.7% in the functional graft group, when compared to the postoperative period (P<0.001), but fell from 90.9% to 36.4% in the dysfunctional graft group (P=0.034). Conclusion: Functional left internal thoracic artery graft rates of the study population were found to be lower than the studies reported in the literature.

Lateral costal artery: clinical importance of an accessory thoracic artery

Abstract The lateral costal artery has sometimes been identified as the culprit for the "steal phenomenon" after coronary artery bypass grafting, besides being occasionally used for myocardial revascularization. Its branches make anastomoses with the internal thoracic artery through lateral intercostal arteries. We aim to report, on three cases, the clinical significance of a well-developed lateral costal artery after coronary artery bypass grafting. Two out of three patients who underwent coronary artery bypass graft surgery in our center between June 2010 and August 2017, applied to us with stable angina pectoris, while the third one was diagnosed with acute coronary syndrome after applying to the emergency department. In coronary cineangiography, in all three cases, a well-developed accessory vessel arising from the proximal 2.5 cm segment of the left internal thoracic artery coursed as far as the 6th rib was detected, and it was confirmed to be the lateral costal artery. A stable angina pectoris in two of the patients was thought to be the result of steal phenomenon caused by the well-developed lateral costal artery. In the two cases with stable angina pectoris the lateral costal artery was obliterated via coil embolization. In the other case with the proximal left anterior descending artery stenosis, before percutaneous coronary intervention, the lateral costal artery was obliterated via coil embolization and the occluded subclavian artery was stented. Routine visualization in cineangiography and satisfactory surgical exploration of the left internal thoracic artery could be very helpful to identify any possible accessory branch of the left internal thoracic artery like the lateral costal artery.

Effect of lima harvesting technique on postoperative drainage in off-pump CABG

Abstract Objective: We investigated the effects of pedicled and semiskeletonized left internal mammary artery (LIMA) harvesting techniques on postoperative drainage in patients subjected to off-pump CABG, ignoring other advantages or disadvantages of those techniques. Methods: The present study comprises a total of 160 subjects that underwent coronary artery bypass surgery in our clinic. Data were collected consecutively and retrospectively. An attempt was made to have similar groups in terms of demographic characteristics. Patients that underwent off-pump coronary artery bypass surgery by two surgical teams which differed only in LIMA harvesting technique were dichotomized and compared according to these techniques. The first group (Group 1) consisted of patients in whom LIMA was harvested with surrounding tissues using the pedicled technique. The second group (Group 2) consisted of patients in whom LIMA was harvested using the semiskeletonized technique, with the veins separated from surrounding connective tissues. Results: The mean amount of drainage in the first 24 hours was 706.1±234.2 ml vs. 591±258.8 ml (Group 1 vs. Group 2; P=0.005), the mean amount of drainage in the second 24 hours was 270±133.6 ml vs. 189.4±140.4 ml (Group 1 vs. Group 2; P<0.001), and the mean amount of total drainage was determined to be 976.1±306.9 ml vs. 781.2±335.5 ml (Group 1 vs. Group 2; P<0.001). Conclusion: It was observed that semiskeletonized LIMA presents reduced amount of postoperative drainage in the first and second 24-hour periods and total amount of drainage than pedicled LIMA, independent of pleural integrity.

The use of skeletonized internal mammary artery for coronary artery bypass grafting / 解放军医学杂志

Objective To summarize the early and mid-term results and experience of skeletonized internal mammary artery (IMA) harvesting in coronary artery bypass grafting (CABG). Methods The clinical data of 56 patients (46 males and 10 females, aged 61.8±7.7 years) having undergone conventional CABG with skeletonized IMA harvesting from Jan. 2014 to Oct. 2015, were retrospectively reviewed. The patients' demographic information, major complications, perioperative related parameters and early postoperative results were collected and recorded. All the patients were followed up postoperative, and major adverse events were collected. Results 59 IMAs were harvested from 56 patients, including 55 left internal mammery artery (LIMA) and 4 right internal mammery artery (RIMA). Bilateral IMAs were harvested in 3 patients. The mean harvesting time was 55.5±13.0 minutes. According to the sequence of harvesting, all the patients were divided into group 1 (first 29 patients) and group 2 (later 27 patients). There was no significant difference in success rate of harvesting or graft flow between two groups (30.4±14.4ml/ min vs 30.3±16.0ml/min, P=0.986). The harvesting time was significantly shorter in group 2 than in group 1 (P=0.001). The mean number of anastomosis was 2.96±0.89. There was no hospital death and severe complications such as myocardial infarction, reexploration for bleeding, or deep wound infection, or non-union of the sternum. All patients were followed up for 1-23 months postoperatively. There was no death or any major adverse cardiovascular events during the follow-up period, except one patient died of acute pulmonary embolism 3 months postoperatively. Conclusion Skeletonized IMA harvesting can be safely and reliably applied to CABG with excellent early and mid-term results.

Cirugía coronaria con doble arteria mamaria interna: efecto en sobrevida a largo plazo / Coronary Artery Bypass Graft Surgery with Double Internal Mammary Artery: Effect on Long-Term Survival

Introducción: El uso de la arteria mamaria interna (AMI) izquierda en la cirugía de revascularización miocárdica (CRM) se asocia con mejor sobrevida alejada libre de eventos cardíacos tardíos; asimismo, el empleo de la AMI derecha como complemento de la izquierda ha mostrado resultados favorables. Sin embargo, aún no queda claro si la revascularización con doble AMI es una mejor opción para los pacientes a largo plazo. Objetivo: Analizar la sobrevida a largo plazo de pacientes con CRM con doble arteria mamaria interna (2AMI) en comparación con pacientes con una AMI (1AMI) en la enfermedad de múltiples vasos. Material y métodos: Se revisaron CRM consecutivas realizadas entre 1996 y 2014 de pacientes con 2AMI (n = 2.098) y con 1AMI (n = 1.659). Se comparó la sobrevida a largo plazo entre los grupos en forma global y entre 485 pares de pacientes ajustados por un puntaje de riesgo. Se generaron modelos de riesgos proporcionales de Cox. Resultados: Los pacientes con 2AMI eran más jóvenes (63,7 ± 9,1 años 2AMI vs. 65,0 ± 9,9 años 1AMI; p < 0,0001). La mortalidad hospitalaria global fue menor en el grupo 2AMI (1,2% 2AMI vs. 4,4% 1AMI; p < 0,0001). A los 10 años, la sobrevida no ajustada fue superior en el grupo 2AMI (82,6% ± 1,8% 2AMI vs. 76,1% ± 1,3% 1AMI; p = 0,001). El análisis de regresión logística de Cox en el grupo global demostró mayor sobrevida en los pacientes con 2AMI (HR 0,71, IC 95% 0,58-0,87; p < 0,001). En el análisis ajustado por puntaje de riesgo, la mortalidad hospitalaria fue similar en ambos grupos (1,6% 2AMI vs. 2,9% 1AMI; p = 0,196). La sobrevida alejada a los 10 años fue significativamente superior en el grupo de pacientes con 2AMI que en el grupo con 1AMI (81,0% ± 4,1% vs. 71,8% ± 2,5%, respectivamente; p = 0,039). Conclusión: Los pacientes con CRM y 2AMI presentaron mejor sobrevida alejada que los pacientes con 1AMI más otro tipo de conducto.

Background: Utilization of the left internal mammary artery (IMA) in coronary artery bypass graft surgery (CABG) is associated with long-term survival free from late cardiac events; moreover, use of the right IMA as a complement of the left artery has shown favorable results. However, it is not yet clear whether double IMA revascularization is a better long-term option. Objective: The aim of this work was to analyze long-term survival of patients with multi-vessel disease undergoing double IMA (2IMA) compared with single IMA (1IMA) CABG. Methods: Consecutive 2IMA (n=2,098) and 1IMA (n=1,659) CABG surgeries performed between 1996 and 2014 were reviewed, comparing overall long-term survival between groups and between 485 pairs of patients matched by propensity score. Cox proportional hazard models were generated. Results: Patients with 2IMA CABG were younger (2IMA: 63.7±9.1 years vs. 1IMA: 65.0±9.9 years; p<0.0001). Overall in­hospital mortality was lower in the 2IMA group (2IMA: 1.2% vs. 1IMA: 4.4%; p<0.0001). At 10 years, unadjusted survival was higher in the 2IMA group (2IMA: 82.6%±1.8% vs. 1IMA: 76.1%±1.3%; p=0.001). Overall Cox logistic regression analysis showed higher survival in patients with 2IMA CABG (HR 0.71, 95% CI 0.58-0.87; p<0.001). In the propensity score adjusted analysis, in-hospital mortality was similar in both groups (2IMA: 1.6% vs. 1IMA: 2.9%; p=0.196), but the 2IMA group still had higher long-term survival at 10 years (2IMA: 81.0%±4.1% vs. 1IMA: 71.8%±2.5%; p=0.039). Conclusion: Patients with 2IMA CABG evidenced better long-term survival than patients with 1IMA plus another type of conduit.

Right-sided reverse T composite arterial grafting to complete revascularization of the right coronary artery / Enxerto arterial composto reverso T do lado direito para completar a revascularização da artéria coronária direita

Complete arterial revascularization for the right coronary artery is underused mainly due to technical issues. Herein we report on a new approach for complete arterial revascularization of arterial revascularization for the right coronary artery branches. Complete arterial revascularization for the right coronary artery revascularization was performed in 8 patients using a reverse T composite arterial graft. None of the patients suffered perioperative myocardial infarction. All patients underwent noninvasive coronary imaging, displaying an early patency rate of 100%. Complete arterial arterial revascularization for the right coronary artery revascularization using a reverse T graft offers a new paradigm with enhanced technical flexibility in performing all arterial myocardial complete revascularizations in selected patients.

Revascularização arterial completa para a artéria coronária direita é subutilizada, principalmente devido a problemas técnicos. Nós relatamos uma nova abordagem para a revascularização arterial completa para os ramos da artéria coronária direita. Revascularização arterial completa da artéria coronária direita foi realizada em 8 pacientes usando um enxerto T arterial composto inverso. Nenhum dos pacientes sofreu infarto do miocárdio perioperatório. Todos os pacientes foram submetidos a exame de imagem não invasivo coronária não invasiva, exibindo taxa de patência precoce de 100%. Revascularização arterial completa da artéria coronária direita com enxerto inversa T oferece um novo paradigma com maior flexibilidade técnica na execução todas as revascularizações arteriais completas do miocárdio em pacientes selecionados.

Análise da medida de fluxo por tempo de trânsito da artéria torácica interna direita anastomosada para a artéria interventricular anterior comparada com a artéria torácica interna esquerda / Analysis of transit time flow of the right internal thoracic artery anastomosed to the left anterior descending artery compared to the left internal thoracic artery

Introdução: Avaliamos por meio da medida de fluxo por tempo de trânsito o desempenho das artérias torácicas direita e esquerda quando utilizadas como enxerto para revascularização da artéria interventricular anterior. Métodos: Cinquenta pacientes submetidos à operação para revascularização do miocárdio sem circulação extracorpórea foram divididos em dois grupos. No grupo A, os pacientes receberam enxerto de artéria torácica interna direita para o ramo interventricular anterior. No grupo B, os pacientes receberam enxerto de artéria torácica interna esquerda para o mesmo ramo. Ao término da operação, o fluxo foi avaliado por meio da medida de fluxo por tempo de trânsito. Resultados: No grupo A, idade média foi de 60,6±9,49 anos. A média de peso e altura do grupo foi de 80,4±10,32 Kg e 169,2±6,86 cm. A média de pontes por paciente neste grupo foi de 3,28±1,49. O fluxo médio e a resistência distal obtidos na artéria torácica interna direita foi de 42,1±23,4 ml/min e 2,8±0,9 respectivamente. No grupo B, a idade média foi de 59,8±9,7 anos. A média de peso e altura deste grupo foi de 77,7±14,2215,7 Kg e 166,0±8,2 cm. A média de pontes por paciente neste grupo foi de 3,08±0,82. O fluxo médio e a resistência distal observados neste grupo foi de 34,2±19,1ml⁄min e 2,0±0,7. Não houve óbitos nesta série. Conclusão: A artéria torácica interna direita apresentou um comportamento similar ao da artéria torácica interna esquerda quando anastomosada ao ramo interventricular anterior da coronária esquerda. Não houve diferença estatística entre a medida de fluxo obtida entre ambas as artérias. .

INTRODUCTION: We evaluated with transit time flow the performance of the right and left thoracic arteries when used as a graft for the left anterior descending artery. Methods: Fifty patients undergoing surgery for myocardial revascularization without cardiopulmonary bypass were divided into two groups. In group A patients received graft of right internal mammary artery to the anterior interventricular branch. In group B patients received graft of left internal mammary artery to the same branch. At the end of the operation the flow was assessed by measuring transit time. Results: In group A, mean age was 60.6±9.49 years. The average height and weight of the group was 80.4±10.32 kg and 169.2±6.86 cm. The average number of grafts per patient in this group was 3.28±1.49. The mean flow and distal resistance obtained in right internal thoracic artery was 42.1±23.4 ml/min and 2.8±0.9 respectively. In group B, the mean age was 59.8±9.7 years. The average height and weight of this group was 77.7±14.22 kg and 166.0±8.2 cm. The average number of grafts per patient in this group was 3.08 ±0.82. The mean flow and distal resistance observed in this group was 34.2±19.1 ml/min and 2.0±0.7. There were no deaths in this series. Conclusion: Right internal mammary artery presented a similar behavior to left internal mammary artery when anastomosed to the anterior interventricular branch of the left coronary artery. There was no statistical difference between the measured flow obtained between both arteries. .

Intercostal artery: study to assess its suitability as a coronary bypass grafting vessel / 中华胸心血管外科杂志

Objective To assess potential suitability of the intercostal artery as a conduit in coronary bypass graft.Methods Collected 36 cases of chinese adult thoracic aorta CTA original cross-sectional images,the images were retrospectively reconstructed under volume rendering technology (VR),multi-planar reconstruction (MPR),curved planar reformation (CPR) and maximum intensity projection(MIP).Observed and measured the data of the 8th,9th and 10th bilateral intercostal arteries and internal thoracic arteries.Results Toshiba 320-slice volume scanning CT can clearly display the intercostal arteries.The average length and diameter at corresponding point of the left and right 8-10th intercostal artery is similar,all the length is longer than 180 mm,and the diameter at axillary line is all bigger than 2.1 mm,the mean length of right intercostal arteries is slightly longer than the left intercostal arteries,the diameter at each corresponding point of left and right intercostal artery is similar,and equivalent to approximately 85％-90％ of internal thoracic artery.Conclusion Intercostal artery can be used as an ideal alternative vessel in coronary artery bypass grafting.

Assessment of the left thoracic artery graft late postoperative patency by ultrasound contrast with angiography / 中华超声影像学杂志

Objective To access the left internal thoracic artery (LITA) graft late postoperative patency after coronary artery bypass grafting (CABG) by peripheral blood vessel ultrasound combined with color Doppler coronary flow imaging (CDCFI).In contrast with angiography,try to find available flow parameter to access graft patency.MethodsForty-six patients with CABG more than 1 year postoperatively followed-by angiography were detected by ultrasound.The LITA graft and left anterior descending artery were examined.Systolic and diastolic peak velocity(Smax,Dmax),velocity time integral(VTIs,VTId)of each segment were measured separately.The ratio of diastolic and systolic peak velocity (D/S),and diastolic velocity time integral fraction(DVTIF) were calculated.All patients were divided into groups according to angiography results.ResultsThirty -one LITA grafts were patent,11 were dysfunctional,4 were occlusive.According to the angiography results,the flow parameters of the proximal segment of LITA graft were significant.The D/S and DVTIF of patent group was higher than that of dysfunctional group.The diastolic peak velocity of distal segment of LAD of patent group was higher than that of dysfunctional group.ConclusionsPeripheral blood vessel ultrasound combined with CDCFI could provide the evidence to access the patency of the graft.It was an effective method for the clinical follow-up.

Iatrogenic Left Internal Mammary Artery to Great Cardiac Vein Anastomosis Treated With Coil Embolization

Inadvertent left internal mammary artery (LIMA)-great cardiac vein (GCV) anastomosis is a rare complication of coronary artery bypass graft surgery. Patients with iatrogenic aortocoronary fistula (ACF) were usually treated surgical repair, percutaneous embolic occlusion with coil or balloon. We report a case of iatrogenic LIMA to GCV anastomosis successfully treated with coil embolization and protected left main coronary intervention through the percutaneous transfemoral approach.

Iatrogenic Left Internal Mammary Artery to Great Cardiac Vein Anastomosis Treated With Coil Embolization

Inadvertent left internal mammary artery (LIMA)-great cardiac vein (GCV) anastomosis is a rare complication of coronary artery bypass graft surgery. Patients with iatrogenic aortocoronary fistula (ACF) were usually treated surgical repair, percutaneous embolic occlusion with coil or balloon. We report a case of iatrogenic LIMA to GCV anastomosis successfully treated with coil embolization and protected left main coronary intervention through the percutaneous transfemoral approach.

Cirugía de revascularización miocárdica de la arteria descendente anterior con arteria mamaria interna izquierda sin circulación extracorpórea: Experiencia en el largo plazo / Beating heart anterior descending coronary artery grafting with left internal mammary artery: A long term follow up experience

Background: In recent years the use of left internal mammary artery (LIMA) as a gran to anterior descending artery (DA) with the offpump technique has been associated with similar good long term results as with the on pump technique. Aún: To repon the results of LIMA to DA bypass grafting without extracorporeal circulation (EC) for isolated DA lesions. Patients and methods: Descriptive study of 80 patients subjected to coronary surgery between 1999 and 2007. Results: Mean age ofpatients was 63 + 10 years and 60 were male. There was no operative mortality or stroke. One patient with a myocardial infarction required a reoperation. Actuarial survival was 98% at 97 months. Conclusions: In this group ofpatients the use ofLIMA as a coronary bypass gran to DA with the off pump technique is a safe surgical procedure, providing a prolonged cardiac event free survival (mortality, angina, myocardial infarction, and need for a new coronary procedure).