[Double coronary revascularization using the internal mammary arteries. Mid-term results of 74 cases]. / Doubles revascularisations coronariennes par les artères mammaires internes. Résultats à moyen terme de 74 cas.

This study reports our experience of 74 multiple coronary artery bypass, using either the two internal mammary arteries (IMA) (43 cases), or the left internal mammary artery (LIMA), alone for sequential bypass (31 cases). Comparison with a series of 200 patients operated upon in a previous period (1981-83), when the LIMA was used alone for single bypass, showed that post-operative mortality, post-operative infarction and mediastinitis were significantly more frequent with double bypass using the two IMA; similarly, the mid-term results seemed to be less satisfactory with the double IMA bypass technique. This difference was due to the fact that using the right and left IMA means longer dissection time, greater problems of haemostasis, stronger surgical trauma and prolonged exposure of the sternum, which is a source of infection. In addition, the right internal mammary artery (RIMA) being further away from the sites of coronary grafting lends itself less readily than the LIMA to this type of bypass, and it is often used for the right and marginal coronary artery which is less suitable for surgery. Using the LIMA alone for sequential bypass does not seem to produce more complications than using that vessel for single bypass. On the basis of the results obtained, we consider that the double IMA bypass should only be used when the internal saphenous vein bypass is contraindicated (past history of stripping, varices, fragile aorta forewarning of difficult grafting).(ABSTRACT TRUNCATED AT 250 WORDS)

[Left internal mammary artery. Choice graft for coronary bypass]. / L'artère mammaire interne gauche. Greffon de choix pour les pontages coronaires.

The left internal mammary artery is a vessel with relatively constant anatomical features and which in almost all subjects is congruent with their own anterior interventricular artery. In addition, atheromatous lesions of this artery are exceptional; when grafted onto the anterior interventricular artery, it adjusts itself to the diastolic coronary flow. Finally, and this is remarkable, once grafted onto the anterior interventricular artery it virtually never undergoes long-term alterations in contrast with the internal saphenous vein. For these reasons, the left internal mammary artery should be used as often as possible to revascularize the anterior intraventricular artery. Preoperative angiography of the left internal mammary artery to evaluate its quality does not seem to be necessary; what is important in the choice of a graft is the quality of the spurt after the vessel is dissected and its distal end is severed. However, the left internal maxillary artery is smaller and more friable in women, in hypotrophic subjects and in elderly people, especially when hypertensive. In these cases, it should be used with caution or not at all, particularly for bypass with a fairly wide, atheromatous and calcified anterior intraventricular artery. Accounting for these restrictions and with some experience at least 90% of anterior interventricular arteries can be revascularized by the left internal mammary artery.

[Follow-up angiography of 100 revascularizations of the anterior interventricular artery by the left internal mammary artery]. / Contrôle angiographique de 100 revascularisations de l'interventriculaire antérieure par l'artère mammaire interne gauche.

One hundred and fifty patients who underwent revascularisation of the left anterior descending artery (LAD) by the left internal mammary artery (LIMA) between 1981 and 1983 were recalled for control coronary angiography one year after surgery. One hundred patients gave consent. The patency rate in these 100 patients was 90 per cent. The presumed causes of the 10 thromboses observed were: for LAD (5 cases), technical problems (3 cases), competitive flow (2 cases). Ten per cent of the patent LIMA grafts were abnormal: moderate stenosis of the anastomosis (5 cases), small LIMA (3 cases), stenosis of the middle segment of the LIMA (1 case). In addition, we observed 7 cases of competitive flows: 3 cases with a LAD which was not sufficiently stenotic, 4 cases with a large saphenous diagonal bypass graft. If a diagonal artery bypass is necessary, it is better to revascularize by either a latero-lateral anastomosis with the LIMA or by using the right IMA. Ninety per cent of the patent grafts were quite satisfactory ar 1 year: regular, supple, and perfectly congruent with the bypassed artery which was injected massively. As a number of North American teams have shown, this good patency rate seems to be maintained at long term, which is not the case with saphenous vein bypass grafts.

[Medium-term results of 200 consecutive systematic operations for revascularization of the anterior interventricular artery by the internal mammary artery]. / Résultats à moyen terme de 200 interventions de revascularisation consécutives et systématiques de l'IVA par l'artére mammaire interne.

This study presents the preliminary results of systematic revascularisation of the left anterior descending (LAD) by the internal mammary (IM) artery. Between 1981 and 1983, 200 IM bypass procedures were performed (88.5% of bypassed LAD arteries during the same period). With experience, the contraindications of IM bypass surgery progressively decreased (none in the latter 100 cases). The IM bypass grafting was an isolated procedure in 35% of cases and associated with one or more saphenous vein (SV) bypass grafts in 64.5% of cases with an average of 1.9 grafts per patient. The surgical results were better than those of SV bypass grafting alone in the period 1978-1980 with a mortality of 2.5% and a perioperative infarction rate of 2.5% compared to 4.3% and 7% respectively. The medium term results (average follow up 2.5 years) show that more patients undergoing IM bypass surgery were asymptomatic (75%) than those undergoing SV bypass (46%). However, the patients operated more recently by IM bypass benefitted from the latest technical advances in bypass surgery. An unselected sample of 55 volunteers (out of 90 recalled patients) underwent angiography at 1 year. The patency rate was 93% with a very satisfactory angiographic appearance of the graft in nearly all patients suggesting the likelihood of a good long term result. It was possible to demonstrate graft patency by Doppler ultrasound and digitised intravenous angiography in some cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indications and results of coronary surgery in patients aged 70 or more]. / Indications et résultats de la chirurgie coronaire à 70 ans et plus.

Among 400 consecutive patients who underwent coronary bypass performed by the same surgical team, 20 (5%) were aged 70 or more (mean: 71.52 years). This group represented one-third of coronary arteriographies carried out at that age. Most patients had stage III or IV coronary disease. All were seriously invalidated but in good general condition without systemic disease or dangerous arterial lesions. Coronary arteriography showed highly surgical lesions in all 20 cases, with 3-vessel lesions in 45% and tight stenosis of the main vessel in 25%. Ventricular function was generally normal. The average number of bypasses per patient (1.65) was distinctly lower than in younger subjects. The results obtained were most encouraging, with no death and no myocardial infarction either postoperatively or during a mean follow-up period of 2.5 years. Only 2 patients had residual angina. Compared with operated patients under 70, this group was characterized by a longer duration of the disease prior to surgery and by a higher percentage of severe clinical stages and life-threatening and highly surgical lesions. Post-operative and medium-term results were also distinctly better, probably because of stricter selection for surgery. All this has been confirmed in several North American publications which also report excellent results in patients over 70 years of age. To conclude, there are excellent reasons for performing coronary bypass in these elderly patients and age should not preclude pre-surgical arteriography, especially when the patient is seriously invalidated and when his general condition is sufficiently good to tolerate cardiopulmonary bypass.

[Role of preventive surgery in patients with multiple arterial disease. 700 patients successively treated by revascularization operations]. / Place des interventions préventives chez le polyartériel. Septcents malades traités de façon consécutive par une intervention de revascularisation.

In a series of 700 patients who underwent successive recanalizations, 1.8% of patients who had coronary bypass and 8.1% of those operated upon for arteritis presented with associated lesions of the carotid arteries; 10% of patients with arteritis and 25.7% of patients with carotid artery lesions had a history of coronary artery disease. Although associated arterial lesions were relatively frequent, no coronary bypass was carried out preventively. Seven patients had preventive endarteriectomy of the carotid artery (6 before surgery for arteritis and 1 concomitantly with coronary bypass) without complications ascribable to angiography or surgery. Post-operative or medium-term complications of coronary artery and carotid artery lesions were exceptional. Except for one questionable case, the patients' general condition was so poor that they could not have benefited from preventive surgery. No post-operative complications due to associated lesions of the renal or gastrointestinal arteries occurred in this series. Only one patient had bilateral recanalization of the renal arteries during surgical treatment of the aortic bifurcation. In view of these findings, systematic exploration by invasive methods of asymptomatic or clinically stable associated arterial lesions seems to be unnecessary. This view is shared by most authors. The best way of preventing complications from associated arterial lesions resides in the quality and improvement of modern intensive care techniques.