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.

Does Moderate Coronary Stenosis Affect the Fate of the Left Internal Thoracic Artery Graft?

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.

Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use.

BACKGROUND: The lateral thoracic flap was first studied in the mid-1970s but its use has been limited because of pedicle anatomical variations. However, after the development of lymph node transfer surgery, the axilla/upper lateral thorax presented as a promising donor area. Through a detailed anatomical study, the lateral thoracic flap was evaluated regarding its vascularization and composition. Later, it was used for pedicle and free flap reconstructions. METHODS: A total of 40 flaps were dissected in fresh cadavers and the characteristics of the lateral thoracic pedicle and its relationship to the upper lateral thoracic axillary lymph nodes (LTLN) were analyzed. We performed six pedicle flap reconstructions around the shoulder area and a free lymph node transfer for lower limb lymphedema. RESULTS: In the cadaveric dissections, the lateral thoracic pedicle branched off the axillary vessels and was found to be a primary level I axillary lymph node irrigator before reaching the skin. The cutaneous portion of the artery was present in 87.5% of the dissections. Arterial caliber was an average of 1.3 and venous, 2.6 mm. Five to seven lymph nodes were isolated with each pedicle and a lymph fasciocutaneous flap could be designed. In seven clinical cases, all of the flaps survived. Functioning lymph nodes were visualized on lymphoscintigraphy after their transfer to the ankle. Donor area had an inconspicuous evolution. CONCLUSION: Lateral thoracic flap is a feasible flap with low donor area morbidity in a concealed region that can be harvested with upper LTLN for transplantation.

Elective vs non-elective radial artery grafts: comparing midterm results through 64-Slice computed tomography.

BACKGROUND: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of the coronary artery bypass graft procedure (CABG). This grafting in turn has led to an increased use of other arterial conduits, of which the radial artery (RA) is most popular. Whether RA grafting can be used in the emergency patient is controversial. METHODS: 47 patients with critical stenosis (>70%) in all target vessels underwent CABG with LITA and RA grafts from 1996 to 2003. Patients were divided into elective (23 patients) and non-elective groups (24 patients) with LITA and RA grafts per patient being similar in both groups. Of these 47 patients, 5 died from non-cardiac complications and 12 were unavailable. Thus, 30 patients (71% of survivors) were studied by multidetector computed tomography. A total of 36 LITA and 64 RA grafts were studied. RESULTS: The RA patency rate for elective and non-elective grafts were 82% (31/38) and 85% (22/26), respectively (p=0.75). The RA had a similar patency rate for all target vessels ranging from 73% to 100%. Only one patient had a redo CABG and 29 (97%) are free from angina or re-intervention. LITA-LADA had a 92% (11/12) and 100% (10/10) patency rate for elective and non-elective groups, respectively (p=0.37). The sequential LITA-diagonal-LADA in the elective group had a 50% (03/06) patency rate, which was significantly lower than the 100% (08/08) patency rate of the non-elective group (p=0.02). CONCLUSION: Radial Artery grafts can be used in both elective and non-elective patients with excellent results.

Elective vs non-elective radial artery grafts: comparing midterm results through 64-Slice computed tomography

BACKGROUND: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of the coronary artery bypass graft procedure (CABG). This grafting in turn has led to an increased use of other arterial conduits, of which the radial artery (RA) is most popular. Whether RA grafting can be used in the emergency patient is controversial. METHODS: 47 patients with critical stenosis (>70 percent) in all target vessels underwent CABG with LITA and RA grafts from 1996 to 2003. Patients were divided into elective (23 patients) and non-elective groups (24 patients) with LITA and RA grafts per patient being similar in both groups. Of these 47 patients, 5 died from non-cardiac complications and 12 were unavailable. Thus, 30 patients (71 percent of survivors) were studied by multidetector computed tomography. A total of 36 LITA and 64 RA grafts were studied. RESULTS: The RA patency rate for elective and non-elective grafts were 82 percent (31/38) and 85 percent (22/26), respectively (p=0.75). The RA had a similar patency rate for all target vessels ranging from 73 percent to 100 percent. Only one patient had a redo CABG and 29 (97 percent) are free from angina or re-intervention. LITA-LADA had a 92 percent (11/12) and 100 percent (10/10) patency rate for elective and non-elective groups, respectively (p=0.37). The sequential LITA-diagonal-LADA in the elective group had a 50 percent (03/06) patency rate, which was significantly lower than the 100 percent (08/08) patency rate of the non-elective group (p=0.02). CONCLUSION: Radial Artery grafts can be used in both elective and non-elective patients with excellent results.

INTRODUÇÃO: A anastomose da artéria torácica interna esquerda com a artéria descendente anterior (ATIE-DA) se tornou parte fundamental da cirurgia de revascularização do miocárdio (RM). Esta técnica levou ao aumento de utilização de outros enxertos arteriais, entre os quais, a artéria radial (AR) é muito usasa. Na literatura há controvérsia se a AR pode ser usada em pacientes em RM de emergência. MÉTODOS: 47 pacientes com lesões críticas (>70 por cento) em todas as artérias alvo foram submetidos à RM com ATIE e a AR entre 1996 e 2003. Os pacientes foram agrupados em eletivos (23 pacientes) e não eletivos (24 pacientes) sendo similares para número de enxertos de ATIE e AR por paciente. Dos 47 pacientes, 5 morreram de complicações não cardíacas e 12 não estavam disponíveis. Portanto, 30 pacientes (71 por cento dos sobreviventes) foram estudados com tomografia computadorizada. Um total de 36 ATIE e 64 AR foram analisadas. RESULTADOS: a perviabilidade da AR nos grupos eletivo e não eletivo foram respectivamente 82 por cento (31/38) e 85 por cento (22/26) (p=0,75). A AR teve perviabilidade semelhante para todas as artérias alvo variando de 73 por cento a 100 por cento. Apenas um paciente foi submetido à nova RM e 29 (97 por cento) estão livres de angina ou nova re-intervenção. ATIE-DA teve perviabilidade de 92 por cento (11/12) e 100 por cento (10/10) respectivamente nos grupos eletivo e não-eletivo (p=0,37). ATIE-Diagonal-DA seqüencial obteve perviabilidade de 50 por cento (03/06) no grupo eletivo que foi significativamente menor que a perviabilidade de 100 por cento (08/08) do não-eletivo (p=0,02). CONCLUSÃO: A AR pode ser utilizada nos pacientes eletivos e não eletivos com excelentes resultados.

Coronary revascularization with the left internal thoracic artery and radial artery: comparison of short-term clinical evolution between elective and emergency surgery.

BACKGROUND: Left internal thoracic artery-to left anterior descending artery grafting has become a fundamental part of coronary artery bypass grafting. This grafting has led to increased use of other arterial conduits, of which the radial artery is most popular. Whether radial grafting can be used in the emergency patient is not known. This study compares the short-term clinical evolution between elective vs emergency coronary artery bypass grafting surgery with left internal thoracic artery and radial artery. METHODS: A retrospective study of 47 patients who underwent elective or emergency coronary artery bypass grafting from 1996 to 2003. All patients had coronary stenosis>70% in all target vessels. Only the left internal thoracic artery and radial artery were used as grafts. Patients were divided into elective group (23 patients) and emergency group (24 patients). Emergency criteria were unstable angina and/or critical coronary stenosis with high risk for acute myocardial infarction. Groups were similar for age and number of diseased vessels. RESULTS: The mean number of left internal thoracic artery grafts per patient in the elective and emergency groups were respectively 1.17 and 1.38 (P=.17). The mean number of radial artery grafts per patient in the elective and emergency groups was respectively 2.26 and 2.08 (P=.48). The 30-day mortality was 0. There was no postoperative cardiogenic shock. The elective group had 1 acute myocardial infarction (4.4%) postoperatively, and emergency group had 5 (20.8%). A nonsignificant trend towards acute myocardial infarction was noted in the emergency group (P=.18). Intensive care unit and postoperative stay were similar in both groups. CONCLUSION: Coronary artery bypass grafting using left internal thoracic artery and radial artery accomplishing complete revascularization can be performed in emergency patients with results similar to those for elective patients.

Coronary revascularization with the left internal thoracic artery and radial artery: comparison of short-term clinical evolution between elective and emergency surgery

O uso de artéria torácica interna esquerda para descendente anterior se tornou fundamental na revascularização do miocárdio. Este enxerto levou ao aumento da utilização de enxertos arteriais, dos quais a artéria radial é muito popular. O uso de artéria radial em pacientes de emergência foi pouco estudado. Este estudo compara a evolução clínica imediata entre revascularização do miocárdio eletiva vs. emergência com artéria torácica interna esquerda e artéria radial. MATERIAL E MÉTODOS: Estudo retrospectivo de 47 pacientes que se submeteram a revascularização do miocárdio eletiva ou de emergência entre 1996 e 2003. Apresentavam estenose crítica (>70%) em todas as artérias alvo. Apenas a artéria torácica interna esquerda e a artéria radial foram utilizadas. Os pacientes constituíram dois grupos: eletivo (23 casos) e emergência (24 casos). Critérios de emergência foram angina instável e/ou estenose coronariana crítica com alto risco de infarto agudo do miocárdio. Os grupos eram homogêneos para idade e artérias acometidas. RESULTADOS: A média de enxertos de artéria torácica interna esquerda por paciente eletivo e de emergência foi respectivamente 1,17 e 1,38 (P=.17). A média de enxertos de artéria radial por paciente eletivo e de emergência foi respectivamente 2,26 e 2,08 (P=.48). A mortalidade até 30 dias foi zero. No pós-operatòrio não ocorreram casos de choque cardiogênico. Um paciente eletivo (4,4%) e 5pacientes de emergência (20,8%) apresentaram infarto agudo do miocárdio no pós-operatório; tendência não significativa para ocorrência de infarto agudo do miocárdio no grupo de emergência (P=.18). Tempo de internação na unidade de terapia intensiva e hospitalar foi semelhante nos dois grupos. CONCLUSAO: A revascularização do miocárdio com utilização de artéria torácica interna esquerda e artéria radial pode ser realizada em pacientes de emergência com resultados equivalentes aos pacientes eletivos.

Implante intra-miocárdico de artéria torácica interna: cirurgia de Vineberg / Internal mammary artery myocardial implantation: Vineberg's procedure

OJBETIVOS: Demonstrar nossa experiência com o implante da artéria torácica interna, para revascularização do miocárdio, procedimento proposto por Vineberg, em 1946. CASUISTICA E MÉTODO: De agosto de 1994 a setembro de 1998, foram operados 10 pacientes nos quais foi implantada a artéria torácica interna esquerda na parede ântero-lateral do ventrículo esquerdo. Em todos esses pacientes também foi feito enxerto de safena aorto-coronária. A idade dos pacientes variou de 42 a 73 anos, tendo sexo masculino prevalecido (60 por cento). Todos os pacientes apresentavam doença coronária arterosclerótica difusa, mas com miocárdio viável. A indicação para o implante de artéria torácica interna foi feita durante a operação, devido a impossibilidade de fazer enxerto ou endarterectomia. RESULTADOS: Todos os pacientes estavam muito bem no pós-operatório imediato. O reestudo angiográfico foi feito em 9 pacientes entre 45 dias e 23 meses de pós-operatório, mostrando patência da artéria implantada e uma vasta rede que se comunicava com a coronária nativa. CONCLUSAO: O implante de artéria torácica interna em miocárdio viável pode ter lugar no arsenal terapêutico da revascularização miocárdica, em casos especiais. Agora, baseados nos erros do passado, podemos selecionar os pacientes e obter melhores resultados. É uma técnica pouco estudada, que deveria ser mais usada, assim possibilitando uma avaliação mais precisa de sua eficácia

Video-endoscopic dissection of multiple pedicled arterial grafts for use in minimally invasive coronary artery bypass surgery.

BACKGROUND: We evaluated the possibility of video-endoscopic dissection of both internal thoracic arteries (rTAs) through the left thoracic approach and right gastroepiploic artery (GEA) via a small laparoscopic access, for use in minimally invasive coronary artery bypass surgery. METHODS: The procedure was performed on twenty-two mongrel dogs. Three 10 mm ports were inserted in the left hemithorax to enable the introduction of a rigid 0-degree videoscope and forceps which allowed access to the left and right ITAs. For dissection of the GEA, one 10 mm and two 5 mm ports were inserted in the para-umbilical region. RESULTS: The left and right ITAs and the GEA were easily visualized and dissection and complete mobilization was achieved without injury, which was checked by the presence of good blood flow. The ITAs and GEA were divided distally, exteriorized through a small left anterior thoracotomy and the length of these three grafts were able to reach all of the left coronary artery branches. CONCLUSIONS: We have demonstrated, in dogs, the feasibility of video-assisted dissection of both the left and right ITAs through the left thoracic approach, without sternotomy, avoiding the risks of sternal complications and expanding its use for all patients. Furthermore, a third arterial conduit (the RGA) can be used without requiring laparotomy.

Artéria gastroepiplóica direita na cirurgia de revascularização do miocárdio / Gastroepiploic artery in coronary artery bypass grafting

CASUÍSTICA E MÉTODOS: Entre janeiro de 1996 e julho de 1999, a artéria gastroepiplóica direita (AGED) foi usada como enxerto na revascularização do miocárdio (RM) de 26 pacientes, sendo 25 do sexo masculino, com média de idade de 55,2 anos. Indicamos a operação em pacientes que apresentavam obstruções críticas e/ou totais nas artérias coronárias direita, interventricular anterior e ramos da artéria coronária circunflexa. Angina estável foi diagnosticada em 15 (57,8 porcento) pacientes e angina instável em 10 (38,4 porcento); 1 paciente apresentou isquemia silenciosa. Cinco (19,2 porcento) pacientes foram submetidos à reoperação, sendo em 2 a segunda reoperação. A circulação extracorpórea (CEC) foi usada em 24 pacientes, normotérmica em 18 (75 porcento) e hipotérmica em 6 (25 porcento). Dois, 5 e 19 pacientes apresentavam obstruções em um, dois e três vasos coronários, respectivamente. A AGED foi usada na forma pediculada em 24 pacientes, servindo de enxerto para o ramo interventricular anterior (3), artéria coronária direita (8) e seus ramos descendente (11) e ventricular posteriores (1) e ramo descendente posterior da artéria circunflexa (1). Como enxerto livre, a AGED revascularizou o ramo diagonal em 2 pacientes. Utilizamos, concomitantemente as artérias torácicas internas esquerda e direita, radial esquerda e a veia safena magna para a total RM. RESULTADOS: Angiografia seletiva de controle pós-operatório foi realizada em 12 (46,7 porcento) pacientes. Em 10 (83,4 porcento) visibilizou-se que a AGED estava pérvia, em 1 não foi possível cateterizar o tronco celíaco e no outro o enxerto estava ocluído. Não houve óbito hospitalar/30 dias e todos os pacientes tiveram alta hospitalar assintomáticos. CONCLUSÃO: Concluímos que a AGED, neste estudo, mostrou ser um enxerto seguro para ser utilizado na operação de RM

[The use of left and right internal thoracic artery grafts for revascularization of the left coronary artery]. / Uso das artérias torácicas internas esquerda e direita na revascularização da artéria coronária esquerda.

PURPOSE: To analyze the late results of patients who underwent left coronary myocardial revascularization with both internal thoracic arteries, with the right internal thoracic through the transverse sinus. METHODS: From July/83 to September/96, 233 patients underwent myocardial revascularization, with ages ranging from 35 to 76 (average of 52.8) years. One hundred and eighty five were male and 48 female. Internal thoracic arteries (466), saphenous veins (192) and epigastric arteries (11) were employed. RESULTS: The hospital mortality was 3% and the late mortality was 6.1%. The immediate postoperative bleeding was 0.8%, mediastinitis 1.7% and myocardial infarction 2.1%. The immediate and late coronariography showed the rates of patency, respectively: left internal thoracic artery 98% and 96%, right internal thoracic artery 96% and 92, and saphenous vein grafts 80% and 67.5%. CONCLUSION: The main advantage in using both internal thoracic arteries in the revascularization of the left coronary branches was the better quality of life, the low rates of cardiac events and the absence of reoperation due to occlusion of the grafts.

Uso das artérias torácicas internas esquerda e direita na revascularização da artéria coronária esquerda / The Left and Right Internal Thoracic Arteries Grafts for Revascularization of the Left Coronary Artery

PURPOSE: To analyze the late results of patients who underwent left coronary myocardial revascularization with both internal thoracic arteries, with the right internal thoracic through the transverse sinus. METHODS: From July/83 to September/96, 233 patients underwent myocardial revascularization, with ages ranging from 35 to 76 (average of 52.8) years. One hundred and eighty five were male and 48 female. Internal thoracic arteries (466), saphenous veins (192) and epigastric arteries (11) were employed. RESULTS: The hospital mortality was 3and the late mortality was 6.1. The immediate postoperative bleeding was 0.8, mediastinitis 1.7and myocardial infarction 2.1. The immediate and late coronariography showed the rates of patency, respectively: left internal thoracic artery 98and 96, right internal thoracic artery 96and 92, and saphenous vein grafts 80and 67.5. CONCLUSION: The main advantage in using both internal thoracic arteries in the revascularization of the left coronary branches was the better quality of life, the low rates of cardiac events and the absence of reoperation due to occlusion of the grafts.

Right internal thoracic artery through the transverse sinus in myocardial revascularization.

BACKGROUND: This study presents the late patency rate of the right internal thoracic artery (ITA) used in situ through the pericardium transverse sinus to the circumflex artery and its branches. METHODS: From April 1983 to December 1994, 2,642 patients were submitted to myocardial revascularization; 201 of them had bilateral ITAs. The right ITA through the transverse sinus was grafted to obtuse marginal artery in 170 patients (84.5%) and the left ITA was grafted to the anterior descending artery in 188 patients (93.5%). Angiographic studies were performed in 80 patients, 44 patients in the immediate postoperative period and 36 patients in the late follow-up (mean, 51.6 months). RESULTS: The right ITA was patent in 75 patients (93.7%) and the left ITA was patent in 77 (96.2%). At the late postoperative period, the right ITA was patent in 33 patients (91.6%) and the left ITA was patent in 34 (94.4%). CONCLUSIONS: The right ITA placed through the pericardium transverse sinus has a good long-term patency rate, similar to that observed with the left ITA and superior to that of saphenous vein grafts for myocardial revascularization.

Acotovelamento de enxerto de artéria torácica interna na revascularizaçäo do miocárdio: relato de caso / Thoracic intern artery graft kinking in myocardial revascularization: a case report

Os autores apresentam caso de revascularizaçao do miocárdio, complicado por acotovelamento da artéria torácica interna esquerda, tratando com sucesso.