Dupla artéria torácica esqueletizada versus convencional na revascularização do miocárdio sem CEC em diabéticos / Double skeletonized internal thoracic artery vs. double conventional internal thoracic artery in diabetic patients submitted to OPCAB

OBJETIVO: Avaliar a influência da técnica utilizada na dissecção das artérias torácicas na evolução de pacientes diabéticos submetidos a revascularização sem CEC. MÉTODOS: Setenta pacientes diabéticos submetidos a revascularização sem CEC com duas artérias torácicas foram avaliados. No grupo A, as artérias torácicas foram dissecadas de modo convencional, enquanto no grupo B foram esqueletizadas. RESULTADOS: A idade média do grupo A foi de 52,14±7,35 anos contra 55,71±8,1 anos no grupo B (p=0,057). No grupo A, seis (17,1%) pacientes eram diabéticos insulinodependentes contra nove (25,7%) no grupo B (p=0,561). O EUROSCORE foi de 3,97±2,49 para o grupo A contra 4,14±3,06 no grupo B (p=0,879). O número médio de anastomoses distais no grupo A foi de 3±0,77 contra 3,03±0,89 para o grupo B (p=0,981). Três (8,57%) dos pacientes do grupo A apresentaram mediastinite contra nenhum do grupo B (p=0,239). A diabetes insulino-dependente foi o único fator estatisticamente significativo (p=0,008) para mediastinite. Neste grupo, a utilização de artéria torácica interna esqueletizada diminuiu significativamente a incidência de mediastinite (p=0,044). CONCLUSÃO: A incidência de mediastinite foi menor no grupo onde ambas as artérias torácicas foram dissecadas de forma esqueletizada, apesar de, devido ao baixo número de casos, não apresentar diferença estatística. Nos portadores de diabetes insulino-dependente, 50 por cento dos pacientes do grupo em que a artéria torácica foi obtida de forma convencional apresentaram mediastinite, sendo que a utilização de artéria torácica esqueletizada diminuiu significativamente a incidência de mediastinite.

OBJECTIVE: To evaluate the influence of the technique used in the dissection of thoracic arteries in the evolution of diabetic patients submitted to OPCAB. METHODS: Seventy diabetic patients submitted to OPCAB using bilateral thoracic arteries were evaluated. In Group A, thoracic arteries were dissected as a pedicle, while in Group B they were skeletonized. RESULTS: The mean age of patients in Group A was 52.14 ± 7.35 years old versus 55.71 ± 8.1 years for Group B (p=0.057). In Group A, six patients (17.1%) were insulin dependent against nine (25.7%) in Group B (p = 0.561). The EUROSCORE was 3.97 ± 2.49 for Group A opposed to 4.14 ± 3.06 for Group B (p = 0.879). The number of distal anastomoses in Group A was 3 ± 0.77 versus 3.03 ± 0.89 in Group B (p = 0.981). Three patients (8.57%) from Group A presented with mediastinitis. Insulin dependence was the only significant risk factor (p=0.008) for mediastinitis. In this group the use of skeletonized internal thoracic arteries significantly decreased the incidence of mediastinitis (p = 0.044). Conclusion: The incidence of mediastinitis was lower in the group for which mammary arteries were dissected using skeletonization. Among insulin-dependent diabetics, 50 percent of the patients from the group in which the pedicled internal thoracic artery was utilized presented with mediastinitis; the utilization of skeletonized internal thoracic arteries significantly decreases the incidence of mediastinitis.

Left upper lobectomy after CABG with the left internal mammary artery graft.

Left upper lobectomy in a patient with a history of Left Internal Mammary Artery (LIMA) graft for Coronary Artery Bypass Graft surgery (CABG) is a challenge for the surgical team. The adhesion formation in the left chest, especially around the left internal mammary artery graft, may cause diffculty for surgery. The injury of LIMA during dissection may lead to serious acute myocardial ischemia and cardiac arrest. The authors reported a case of successful operation after receiving both good surgical and anesthetic plan prior to surgery.

Left internal mammary artery to pulmonary vasculature fistulae closed with particle embolizaton: new form of percutaneous intervention.

The left internal mammary artery is frequently employed as a conduit in coronary bypass surgery. We report a 42-year-old male post-coronary artery bypass grafting patient with, angina on exertion who was found to have multiple atrioventricular fistulae arising from left internal mammary artery to pulmonary vasculature leading to coronary steal and positive stress thallium in left anterior descending territory. These fistulae were selectively embolized with polymer particles leading to improved flow in distal left anterior descending artery. Postintervention, the patient has been asymptomatic for more than 8 months.

Fístula de enxerto coronariano da artéria torácica interna esquerda para artéria pulmonar esquerda após cirurgia de revascularizacão miocárdica: causa rara de isquemia miocárdica / Left internal thoracic artery to left pulmonary artery fistula after coronary artery bypass graft surgery: a rare cause of myocardial ischemia

Descrevemos o caso de um paciente que, seis anos após cirurgia de revascularizacão do miocárdio, desenvolveu dispnéia aos pequenos esforcos. Foi documentada isquemia miocárdica por método de medicina nuclear e a cineangiocoronariografia mostrou todos os enxertos patentes com grande fístula da artéria torácica interna esquerda para artéria pulmonar esquerda. O paciente foi tratado com fechamento cirúrgico da fístula, tendo ótima evolucão pós-operatória.

Resultados preliminares de una nueva técnica de revascularización miocárdica mínimamente invasiva / Preliminaries results about new technique of minimally invasive direct coronary artery bypass grafting

Antecedentes: La cirugía coronaria mínimamente invasiva (CRMMI) intenta disminuir la invasividad de la cirugía convencional (CRM). Objetivo: Presentar los resultados iniciales de una técnica de CRMMI y compararla con los de la CRM. Diseño: Estudio observacional prospectivo (grupo experimental), observacional histórico (grupo control). Población: 20 pacientes operados con CRMMI (experimental) y 36 con CRM (control), todos con lesión única de descendente anterior (DA). Método: Descripción de técnica quirúrgica y análisis de morbimortalidad comparativo entre CRMMI y CRM. Resultados: En el grupo con CRMMI el 60 por ciento (12/20) presentaba algún factor de riesgo importante. No surgieron durante las operaciones situaciones que no pudieron ser resueltas por el mismo abordaje, excepto 2 casos de conversión (10 por ciento). El dolor torácico en el posoperatorio alejado fue importante en el 15,8 por ciento (3/19). Los resultados comparativos CRMMI vs CRM fueron: antecedentes CRM previa 20 por ciento (4/20) vs 2,7 por ciento (1/36) p < .04, infarto posoperatorio 5 por ciento (1/20) vs 2,7 por ciento (1/36) p = NS, mortalidad operatoria 0 por ciento (0/20) vs 2,7 por ciento (1/36) p = NS y mortalidad a 6 meses 5 por ciento (1/20) vs 5,7 por ciento (2/35) p = NS. Conclusión: La CRMMI se presenta como una alternativa válida para tratar las estenosis proximales únicas de DA

Tratamento da estenose da artéria subclávia com utilizaçäo de stents em pacientes previamente submetidos à anastomose da artéria mamária interna com a artéria descendente anterior / Treatment of subclavian artery stenosis with stents in patients underwent internal mammary left anterior descending artery bypass surgery

Descrevemos dois casos de pacientes que haviam sido submetidos a revascularizaçäo do miocárdio com a utilizaçäo da artéria mamária interna esquerda e que desenvolveram na evoluçäo, quadro de insuficiência coronária por estenose da artéria subclávia esquerda. A cinecoronariografia evidenciou fluxo retrógrado da artéria descendente anterior para artéria mamária com enchimento da artéria subclávia distal à estenose que se localizava na sua origem. Após dilataçäo inicial com catater baläo de angioplastia coronária, foram implantados stents de Palmaz-Schantz, obtendo-se excelente aspecto angiográfico, sem complicaçöes e regressäo dos sintomas. Nossos resultados demonstram que a implantaçäo de stents nestes pacientes pode ser realizada com eficácia e segurança, mostrando ser um tratamento alternativo a outras formas de revascularizaçäo cirúrgica ou percutânea para esta doença.

We reported two cases of patients that underwent leftinternal mammary (LIMA) - coronary bypass graft and developed recurrent myocardial ischemia in the follow-up period caused by stenosis in the subclavian artery. The angiography showed retrograde flow from the left anterior descending artery to subclavian artery. After initial dilatation with a conventional angioplasty balloon catheter, we implanted Palmaz-Schatz Stents, achieving an excellent final result. Our finding suggest that Stent implantation is a safe and effective procedure, and provides an alternative to other forms of revascularization for the treatment of this disorder

Implante de stent Palmaz-Schatz em tronco de coronária esquerda protegido. Reestenose e redilatação utilizando o ultra-som intracoronário como fator de otimização / Palmaz-Schatz Coronary Stent Implantation in the Protected Left Main Coronary Artery. Restenosis and Repeat Angioplasty Using the Intravascular Ultrasound as Optimal Deployment's Factor

White woman 46 years old was admitted with oppressive rest angina. Two months prior, she had been submitted to a coronary artery bypass surgery: saphenous vein graft to the left anterior descending coronary; left internal mammary artery to the 1st diagonal branch and a radial artery as a free artery graft, to the biggest branch of the left circumflex artery. On coronary angiography, both the saphenous vein and the radial artery were occluded, with patency of the left internal mammary artery. The patient underwent coronary angioplasty with a Palmaz-Schatz stent 3.0/15 mm implantation in the left main coronary artery and was submitted to a high-pressure balloon inflation. She was discharged free of angina from the hospital and one month later retrosternal chest pain recurred. On coronary angiography a restenosis in the left main coronary was seen. Repeat coronary angioplasty with high-pressure balloon inflation technique and with intravascular ultrasound guidance was done. Larger balloons and progressive higher-pressure balloon inflations were used until reaching a stent internal lumen greater than the reference distal diameter. The patient was asymptomatic at four months of follow-up.

Sternal wound infection after myocardial revascularization with internal mammary artery.

The use of the bilateral mammary artery in myocardial revascularisation in diabetic patients has been thought to increase the risk of sternal wound infection. We studied unilateral IMA grafting retrospectively in 701 consecutive patients to determine the incidence of sternal wound infection. One hundred and six patients were diabetic; 595 were non-diabetic. Both groups of patients were comparable for age, number of bypasses, and cardiopulmonary bypass time. No patient in the diabetic group developed mediastinitis; two patients of 595 in the non-diabetic group (0.3%) developed mediastinitis. Incidence of subcutaneous wound infection was slightly higher in the diabetic group than in the non-diabetic group (2% vs 0.3%) but was not statistically significant. We conclude that unilateral internal mammary artery grafting in diabetics is not associated with increased risk of sternal wound infection and should remain the conduit of choice for myocardial revascularization.