Use of the inferior epigastric artery for coronary bypass.

Between December 1988 and April 1991, 74 free inferior epigastric arteries were used in 73 patients for coronary artery bypass grafts. In addition, 72 of the patients received a left internal mammary artery for single or sequential grafting to the left anterior descending system and 62 a right internal mammary artery to the circumflex or the right coronary artery. Twenty-seven patients had no saphenous vein available, and two had no suitable internal mammary artery; in an attempt to make a complete arterial revascularization, we chose the inferior epigastric artery as an alternative conduit in 24 young patients and in 10 reoperations; bilateral internal mammary artery dissection was avoided in four patients with impaired lung function and in six patients with selected two-vessel disease to spare one internal mammary artery. The technique for harvesting the inferior epigastric artery is described. Fifty-three inferior epigastric artery grafts were anastomosed to the distal right coronary artery or to its branches, 18 to the distal obtuse marginals of the circumflex artery (three as sequential grafts and one as a natural Y graft), and three to the left anterior descending system. The mean number of distal anastomoses is 3.60 per patient. Seventy proximal anastomoses of the inferior epigastric artery were made to the aorta and four to one internal mammary artery. There were four early deaths and one nonfatal myocardial infarction. Four abdominal wound hematomas needed surgical drainage. Sixty-one patients underwent angiographic study on postoperative day 10:59 of 61 inferior epigastric artery grafts (63 of 65 inferior epigastric artery distal anatomoses) and 111 of 111 internal mammary artery grafts (155 of 156 internal mammary artery distal anastomoses) were patent. Clinical follow-up of all the survivors (100% follow-up) could be obtained with a mean period of 9 months (1 to 28 months). There was no late cardiac death, no infarction, and all the patients were free of angina. Nineteen patients underwent a 6-month postoperative angiographic study. Seventeen of 19 inferior epigastric artery grafts were patent and 16 of 19 were intact; 34 of 34 internal mammary artery grafts (46 of 47 internal mammary artery distal anastomoses) were patent and intact. In conclusion, free inferior epigastric artery grafts can reach the diaphragmatic ischemic areas of the heart. The early patency rate and the clinical results are encouraging but only long-term evolution and evaluation can determine the true efficacy of the inferior epigastric artery graft as a reliable conduit for coronary artery bypass graft operations.     

Clinical and angiographic assessment of complex mammary artery bypass grafting

The internal mammary artery has become the coronary bypass graft of choice in recent years because of enhanced long-term patency. Along with this trend, sequential, bilateral, and free mammary grafts have been employed more frequently in an effort to maximize the number of distal internal mammary anastomoses. This approach of maximally using the internal mammary artery (complex mammary grafting) seems logical, but at present little information about patency of the newer types of internal mammary artery grafts is available to justify the more complicated procedures. Over a 15 month period, 207 patients underwent bypass graft angiography from 1 to 32 weeks after operation. This is an 85% restudy rate for a consecutive series of coronary bypass procedures. Patency was defined as complete filling of the graft and distal vessel bypassed. A total of 841 distal vessels were grafted, or 4.1 per patient. The overall patency rate was 91% for 503 distal vein graft anastomoses and 99% for 338 internal mammary artery grafts. Individual patency rates of distal anastomoses, expressed as number patent/total (percent patent), were as follows: simple vein grafts, 262/285 (92%); sequential vein grafts, 196/218 (90%); left internal mammary artery to left anterior descending coronary artery, 109/110 (99%); left internal mammary to circumflex marginal artery, 14/14 (100%); right internal mammary to right coronary artery, 19/20 (95%); right internal mammary to left anterior descending coronary artery, 10/10 (100%); right internal mammary to circumflex marginal artery via transverse sinus, 18/20 (90%); sequential left internal mammary artery to left anterior descending system, 133/134 (99%); sequential left internal mammary to circumflex marginal system, 15/15 (100%); free internal mammary artery, 9/9 (100%); free sequential internal mammary artery, 6/6 (100%). Of the 18 patent transverse sinus right internal mammary grafts to the circumflex marginal artery, three exhibited very slow flow and probably were not functional. The hospital mortality associated with internal mammary revascularizations was 0.4% for nonemergency cases and 3.1% for emergency procedures. On the basis of clinical and postoperative graft patency data, expanded use of more complicated types of mammary grafts seems justified. Function of the right internal mammary graft to the circumflex marginal artery was suboptimal, and this method has been discontinued. All other complex mammary techniques had excellent patency rates as compared to vein grafts, and these differences may become even more significant in the late postoperative period.(ABSTRACT TRUNCATED AT 400 WORDS)     

Sequential internal mammary artery grafts. Expanded utilization of an ideal conduit

The internal mammary artery, when used as a conduit for coronary artery bypass, offers a better long-term patency rate and survival rate than the saphenous vein; however, its utility has been limited. Among other factors, the availability of only two internal mammary arteries for anastomosis has been a major limitation. In an attempt to overcome this limitation, we constructed sequential internal mammary artery grafts in 87 patients. In 49 patients (Group I), only one internal mammary artery was used for sequential anastomosis. In another 31 patients (Group II), one internal mammary artery was used for sequential anastomosis and the other was used for single end-to-side anastomosis. Both internal mammary arteries were used in seven patients (Group III) for the construction of sequential anastomoses. Postoperatively, 64 patients were evaluated by exercise stress tests. None of these patients had a positive stress test although seven patients (11%) had electrocardiographic changes that were considered equivocal. Coronary angiography was performed in 35 of the 87 patients, with 92 vein grafts and 90 internal mammary artery anastomotic sites evaluated within 1 year of operation. A total of 83 vein grafts and 84 internal mammary artery anastomotic sites evaluated within 1 year of operation. A total of 83 vein grafts and 84 internal mammary artery anastomoses were found to be patent. Thus the patency rate for vein grafts was 90% and for internal mammary artery grafts, 93%. During the follow-up period (8 to 52 months), three patients died and one was lost to follow-up. Among the remaining patients, 79 had complete relief from symptoms, three had minimal symptoms, and one patient obtained no relief from symptoms. Based on these results, we have concluded that the extended use of internal mammary artery, constructing sequential anastomoses, is technically feasible and provides adequate perfusion to the area of myocardium supplied by such grafts.     

Sequential mammary grafting. Clinical, functional, and angiographic assessment 6 months postoperatively in 231 consecutive patients

Between September 1985 and November 1987, 246 sequential mammary grafts were performed in 231 consecutive patients. Seventy-eight percent had triple vessel disease, and 33% required an urgent procedure. The length of the internal mammary artery pedicle was the only limitation to its use. No account was taken of the free cut-end flow of the internal mammary artery. There were 14 bilateral sequential mammary grafts and 15 free sequential mammary grafts. Of the 531 sequential mammary anastomoses, 482 were built with the left internal mammary artery; 113 (21%) were diamond-shaped anastomoses. The right internal mammary artery was brought through the transverse sinus in 44 cases, 10 times for sequential grafting of circumflex branches. Taking into account the adjunctive venous anastomoses and the single internal mammary artery anastomoses, there were 4.5 distal anastomoses per patient, 2.8 being mammary anastomoses and 2.3 being sequential mammary anastomoses. The hospital mortality rate was 2.6%. The prevalence of perioperative myocardial infarction was 5.2%. Follow-up was complete and averaged 15.4 months. Six patients (2.7%) still had angina pectoris. One hundred fifty-seven (71%) patients were recatheterized 6 months after the operation, and 95% of the sequential mammary anastomoses were still patent. The patency rate of the diamond-shaped mammary anastomoses was 94.5% and that of the anastomoses corresponding to the right internal mammary arteries brought through the transverse sinus was 94.3%. The gratifying functional results (maximal stress test combined with exercise thallium scintigraphy) obtained at an average of 6 months postoperatively illustrated the surprising physiologic adaptability of the internal mammary artery. As the attrition rate of the mammary artery grafts beyond 6 months postoperatively is thought to be minimal, gratifying long-term results with widespread use of sequential mammary grafts can be anticipated.     

Twelve-year experience with internal mammary artery for coronary artery bypass

From Feb. 1, 1972, to Jan. 30, 1984, 1,000 patients had isolated coronary bypass with at least one internal mammary artery, and 103 of them had bilateral internal mammary artery grafts. There were 1,395 associated vein grafts and 1,158 internal mammary artery anastomoses, for a total of 2,556 grafts (2.5 per patient). Patients were followed up for 1 to 12 years (mean 6.3 years) and 77 patients were lost to follow-up at a mean of 4.0 years. Operative mortality was 1.4%, with 11 of 14 deaths in the first 240 patients (4.6%) and eight of 14 in the 103 patients with bilateral internal mammary artery grafts. There were 93 late deaths, with an actuarial survival rate of 93% at 5 years and 84% at 10 years. Angina occurred at a mean rate of 6.2% +/- 1.2% per year. Perioperative infarction was detected in 37 patients (3.7%). Late infarction occurred in 75 patients, for a mean rate of 1.5% +/- 0.3% per year. Reoperation (or percutaneous transluminal coronary angioplasty) was necessary in 35 patients, for a mean rate of 0.85% +/- 0.28% per year. Graft patency was assessed by 1,029 follow-up catheterizations in 519 patients. The patency rate of the left internal mammary artery was 96.4% at 1 year, 88.1% at 5 years, and 88.1% at 10 years. That of the right internal mammary artery was 92.8% (p = NS) at 1 year, 84.6% (p = NS) at 5 years, and at 10 years the numbers were too small to be meaningful. Comparison of patency rates for all internal mammary artery grafts with vein grafts gave 1 year graft patency rates of 95.7% versus 93.4% (p less than 0.025), 5 year rates of 87.9% versus 74.0% (p less than 0.001), and 10 year rates of 83.0% versus 41.0% (p less than 0.001). Included in these patency data are 20 free internal mammary artery grafts; 16 were studied (mean 2.3 years) and 12 of these 16 (75%) were patent. Of the 58 sequential internal mammary artery grafts, 18 were studied by catheterization (mean interval 2.0 years); 35 of 36 anastomoses were patent and one end-to-side anastomosis was closed. Morbidity and mortality for patients having internal mammary artery grafting are comparable to those of patients having saphenous vein bypass only. The demonstrated superior patency for internal mammary artery grafts supports the routine use of bilateral internal mammary artery grafting.     

Myocardial revascularization with combined arterial grafts utilizing the internal mammary and the gastroepiploic arteries

Coronary artery bypass grafting with a combined arterial graft using both the internal mammary artery and the right gastroepiploic artery was performed in 22 patients during a 21-month period. There were 17 men and 5 women ranging in age from 34 to 73 years (mean age, 53.4 years). Three patients were having a reoperation, and 2 patients had no segment of long saphenous vein available. Twelve patients were less than 55 years old. The mean number of distal anastomoses including vein grafts was 3.2 and the mean number of arterial grafts was 2.5 per patient. The mean aortic cross-clamp time was 63.8 minutes and the mean cardiopulmonary bypass time was 116.7 minutes. There was 1 early and 1 late death. The other 20 patients are alive without angina. Studied within 3 postoperative months, graft patency was 95% (19/20) in internal mammary artery and 93% (14/15) in gastroepiploic artery grafts. It is concluded that the combined arterial graft can be used safely and effectively, and its application facilitates complete revascularization with more arterial and fewer vein grafts.     

Sequential internal mammary-coronary artery bypass

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.     

Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery

Thermal coronary angiography was evaluated in 50 patients undergoing 137 saphenous vein and 48 internal mammary artery bypass grafts. A total of 177 thermal coronary angiograms were performed after completion of the distal anastomoses by injection of cold cardioplegia into the vein or by reperfusion with warmer blood in the internal mammary artery grafts. These angiograms provided details of graft and anastomosis patency, flow directions, and presence of native coronary stenoses. Temperature differences between the injectant and the epimyocardium of greater than 4 degrees C resulted in high-contrast images. Thermal coronary angiograms were obtained in 173 of the 177 studied bypass grafts; 172 grafts were patent, and 1 internal mammary artery graft was occluded. Unsuspected stenoses were detected at the site of four distal anastomoses. Subsequently, two anastomoses were successfully revised and three additional grafts performed. Ninety-six native coronary stenoses were located in the recipient coronary arteries. In ten instances, the thermal coronary angiograms were obscured by excess fat or myocardium, thereby impeding correct image analysis. We conclude that thermal coronary angiography can be clinically relevant and helps improve decision making during coronary artery bypass operations.     

非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

Predictive factors for the intermediate-term patency of arterial grafts in aorta no-touch off-pump coronary revascularization.

OBJECTIVE: Graft flow is one of the important determinants of the arterial graft patency. To establish the optimal graft design, we examined detailed characteristics of the arterial composite and sequential grafts, and sought to delineate the risk factors of graft occlusion due to insufficient bypass flow. METHODS: Angiograms of 2547 bypass grafts in 677 consecutive patients who underwent total arterial off-pump CABG without aortic manipulation followed by early postoperative angiography since December 2000 were reviewed. The angiographic flow was graded as A (antegrade), B (competitive), C (reversal), and O (occlusion). RESULTS: The overall early graft patency rate was 98.2% (2502/2547). The rate of grade A was 91.3% (2325/2547), while the rates of grades B and C were 2.9% (73/2547) and 4.1% (104/2547), respectively. For the main trunk of the anterior descending branch (LAD), the graft patency rate was 99.3% (674/679). The grade A rate of the internal thoracic artery (ITA) grafts to LAD in an individual fashion was 99.5% (203/204), being comparable with that in the sequential or composite grafting which had two distal anastomoses (98.1%, 159/162; p=0.33). The actuarial patency rates at 3 years were 84.7% for the bypass grafts with grade A flow and 33.9% for those with grade B/C flow, respectively (p<0.0001). The multivariate Cox-regression analysis demonstrated that grade B/C (p<0.0001, HR=4.19) and 51-75% stenosis of the native coronary artery (p=0.02, HR=2.86) were significant predictors of graft occlusion. CONCLUSIONS: For the LAD, the results of graft flow in sequential ITA grafting or composite grafting with two distal anastomoses were comparable with that in individual ITA grafting. Prediction and prevention of competitive and reverse flow are mandatory for achieving the advantages of the arterial materials.     

Gastroepiploic artery free graft for coronary bypass

The internal mammary artery (IMA) is the graft of choice for CABG but has a limited number and length. For multivessel coronary disease, saphenous vein grafts have to be added but they show poorer long-term patency. Investigation to provide adjunctive reliable grafts has recently focussed on the right gastroepiploic artery (GEA) and encouraging results have been reported employing this vessel as a pedicled graft to bypass distal coronary vessels. From December 1988 to February 1989, to achieve complete myocardial revascularization with only arterial grafts we used a GEA free graft in combination with the two IMAs in 20 consecutive patients under 70 years of age undergoing elective surgery. Before starting, histological studies were carried out and a significant similarity between IMA and GEA was found. In the 20 patients, 76 coronary anastomoses were performed (3.8 bypasses/patient), the GEA graft revascularized the right coronary artery in 9 patients, the circumflex in 8 patients and the anterior descending and/or diagonal in 3 patients; in 7 patients the GEA graft was used for sequential anastomoses. No perioperative deaths, no myocardial infarctions and no gastroenterological complications occurred. Coronary angiographic postoperative control showed 20/20 patent GEA grafts. After follow-up ranging from 7 to 9 months, all patients are free from angina. The GEA free graft is not difficult to harvest, is easier than the pedicled GEA graft to handle in the pericardium and is suitable for sequential anastomoses. The use of GEA graft however increases the complexity of bypass operations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sequential vein bypass grafting: tactics and long-term results

The sequential bypass grafting technique has many advantages over coronary artery bypass grafting with single grafts. The aim of this study was to evaluate the consequences of sequential bypass graft failure. Between 1 January 1984 and 31 December 1996, 3846 patients underwent primary coronary artery bypass vein grafting. A total of 3490 patients received sequential vein bypass grafts and 356 patients received single vein bypass grafts (9%). There were 6177 sequential bypass grafts (3490 postero-lateral grafts (56%) and 2687 in the antero-lateral position (44%)) and 1468 single grafts (972 vein grafts and 496 internal thoracic artery grafts). Overall, there were 80 hospital deaths (2.1%). Mortality in relation to type of grafts used was: 13 deaths in 356 patients with only single graft (3.7%) and 67 deaths in 3490 patients who received sequential vein grafts (1.9%). Of 3766 hospital survivors, 3731 were followed for an average of 76 months. During follow-up, 85 patients died (2.3%), 15 patients (0.4%) underwent cardiac transplantation and 52 (1.4%) had re-do coronary artery bypass vein grafting. Graft-percutaneous transluminal coronary angioplasty was performed in 56 patients (1.5%), 37/1390 single bypass grafts (2.7%) and 19/6023 sequential bypass grafts (0.3%). There were 272/6023 symptomatic sequential graft occlusions (4.5%) (182 were in postero-lateral position and 90 in the antero-lateral position). There were 66/667 single vein graft occlusions (9.9%) and 15 symptomatic internal thoracic artery graft occlusions (2.1%) during follow-up. In 97% of patients, presenting symptoms of postero-lateral sequential bypass graft occlusion took the form of a renewed angina with a myocardial infarction rate of 3% and a mortality rate of 7%. Corresponding figures for antero-lateral sequential bypass grafts were 22, 78 and 68%, and anterior single vein bypass grafts were 70, 30 and 15%, respectively. The overall 10-year survival rate in patients with sequential bypass grafts was 81.2% and the cumulative patency rate (1464 angio-controls of 2576 sequential vein grafts) was 72.2%. A symptomatic occlusion of a postero-lateral sequential vein bypass results in a low incidence of myocardial infarction with low mortality, when the terminal anastomosis is connected to a high flow vessel. An antero-lateral sequential vein bypass graft has better long-term patency than single vein bypass, but should occlusion occur, it would usually be associated with a higher myocardial infarction and mortality rates than a single vein graft. The highest risk for failure of a sequential graft in the antero-lateral position occurs when the left anterior descending artery (LAD) is small or severely diseased. In this situation the single graft technique with internal thoracic artery appears to be safer.     

Angiographic assessment of sequential and individual coronary artery bypass grafting

OBJECTIVE: In trying to answer the question about the controversial use of sequential grafts, we determined the mid-term angiographic outcome of patients in whom coronary artery bypass was performed with different types of vein grafts. METHODS: A total of 1034 coronary anastomoses on 724 saphenous vein grafts (SVGs) (apart from 497 left internal mammarian artery (LIMA) anastomoses) were assessed in 509 patients in an average of 55.4 +/- 17.6 months after coronary artery bypass grafting. RESULTS: The patency rates of sequential conduits were markedly higher than those of individual ones (86.6% vs 69.6%, p = 0.0001). Also, the anastomoses on the sequential conduits had better patency rates (80.6% vs 69.6%, p = 0.0001). This difference was even more pronounced in coronary arteries of poor quality/small (< 1.5 mm) diameter (68.9% vs 51.6%) for the sequential and individual grafts, respectively (p = 0.03). Also, the patency of the entire sequential conduit was lower when most distally located anastomosis was of poor runoff (45.2%). CONCLUSIONS: The patency of a sequential vein conduit is generally superior than that of an individual one, especially for poor runoff coronary vessels, provided that the most distally located anastomosis is performed on a good coronary artery in terms of quality and diameter. Using a minimal length of SVG is another advantage. However, failure of a single sequential conduit jeopardizes all of the anastomoses along that graft segment. Besides, being technically more demanding, technical expertise in performing a sequential anastomosis is probably among the important predictors of patency.     

Coronary revascularization with arterial graft alone]

In the period from December 1989 until July 1991, coronary revascularization were performed on 56 patients using arterial grafts and no venous grafts. The ages of the patients ranged from 43 to 85 years (average; 66.8 years), and there were 33 males and 23 females. Twenty-four patients had angina pectoris, 23 had old myocardial infarction and 9 had acute infarction. There were 3 patients with single-vessel coronary disease, 19 with double-vessel, 31 with triple-vessel and 9 with left main coronary disease. The bypass grafts used were 58 left internal thoracic artery (LITA) grafts, 29 right internal thoracic artery (RITA) grafts, and 56 right gastroepiploic artery (RGEA) grafts. Thus, 143 grafts were used and an average of 2.6 bypasses were created per patient. There were two operative deaths. One of these patients had acute myocardial infarct. Investigation of postoperative graft patency was performed in the 122 grafts that could be examined angiographically after surgery. Only 7 were obstructed, yielding a patency rate of 94.3%. By using both the ITA and RGEA, in situ anastomoses with all the coronary arteries could be performed. Also in emergency surgery arterial grafting was possible. This operative form is considered to be a useful technique and may be expected to produce favorable long-term results.     

Mid-term angiographic results of radial artery (RA) graft in CABG: Does the proximal site of anastomosis affect graft patency?

Background Use of arterial conduits in coronary artery bypass grafting (CABG) is based on the documented excellent patency rates of left internal thoracic (mammary) artery (LITA). Alternative arterial conduits such as radial artery and gastroepiploic artery also showed superior long-term patency rates compared to vein grafts. Free arterial grafts are being used increasingly to replace the long saphenous vein as a conduit. This study was undertaken to compare two methods of radial artery grafting as a free graft and a composite graft. Methods Between January 1997 and October 2003 a total of 441 patients were operated for coronary artery bypass grafting using radial artery (RA) as one of the conduits. Among these patients, 125 patients received radial artery as a composite graft; In 68 patients RA was used with left internal thoracic artery as a composite y graft (n=68), and in 57 patients it was used with right internal thoracic artery (RITA) as an in situ composite pedicle graft (n=57). In the remaining 316 patients the radial artery was used as a free graft. Angiographic evaluation of radial artery graft was carried out in 63 patients who consented. Angiograms were carried out after an interval of 6–72 months (mean of 28.15±21.17 months). Of these 63 patients who underwent reangiography, the different surgical strategies used were RITA+RA composite in situ graft (n=34), LITA+RA composite y graft (n=17) and aorto coronary (free) RA graft (n=12). Results There were 3 hospital deaths in the series 441 patients. Among the 63 patients who underwent check angiography 60 patients were in NYHA C1 I and 3 patients were in C1 II. None of the patients had perioperative myocardial infarction. Angiographically overall radial artery graft patency rate was 94.1% (59 patients). In patients with RITA and RA in situ grafts patency rate was 94.1%, LITA+RA composite y graft patency was 94.1% and aorto coronary (free) radial artery grafts patency was 91.6%. Conclusion In 63 selected asymptomatic patients studied, we found that radial artery graft when used as an aortocoronary (free) graft or as a composite y graft with left internal thoracic artery or in situ pedicle graft with right internal thoracic artery the patency rates were comparable in all three groups.     

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.     

Long-term blood flow potentials in sequential internal mammary artery grafts. Exercise thallium scan for myocardial perfusion study.

In two groups of patients, coronary artery bypass surgery for angina pectoris included internal mammary artery (IMA) sequential grafts (group I) or single grafts (group II). At postoperative angiography all grafts were patent. In addition, the patients received on average 1.8 vein grafts into other coronary arteries. The mean interval to postoperative follow-up was 9.5 years in group I and 9.7 years in group II. The preoperative incidence of acute myocardial infarction was 44% and 45% in groups I and II. Exercise thallium scan at follow-up showed IMA graft-related ischemia in 33% of the patients with sequential graft and in 64% of those with single graft (ns). Our results indicated that sequential IMA grafts functioned at least as well as single grafts and maintained adequate myocardial supply even 10 years postoperatively. Internal mammary arteries are superior graft material and can be recommended both as single and as sequential graft in coronary artery bypass surgery.     

Utility and limitation of sequential saphenous vein graft for complete revascularization in coronary artery surgery

Multiple bypass grafting in complete myocardial revascularization requires frequently the use of sequential saphenous vein grafts as well as arterial grafts. To expect the favorable good clinical results of revascularization, therefore, refined surgical technique for saphenous vein grafting and proper selection of suitable coronary arteries for bypass are important. Between January 1989 and April 1990, 91 patients underwent CABG utilizing internal thoracic arteries (ITA) in 79% and SVG in 99% of the patients with an average of 3.3 anastomoses per patients. Postoperative angiography was performed 4 or 8 weeks after surgery. Early patency rates were 92% (204/221) in overall anastomotic sites, 96% (52/54) in ITA and 91% (152/167) in SVG respectively. There was no difference in patency rates between individual (90%) and sequential (92%) grafts. In sequential grafting, however, patency rate of side-to-side anastomosis was higher than that of end-to-side anastomosis. Patency rates of the grafts were also evaluated in terms of the sizes of coronary arteries and intraoperative graft flows. These studies lead to the following conclusions: In individual grafting, the acceptable patency rate can be expected when the graft flow exceeds 30 ml/min even if the internal diameter of coronary artery is less than 1.5 mm. In sequential grafting, on the other hand, a diameter more than 1.5 mm is desirable for the coronary artery at the site of end-to-side anastomosis.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

Sequential use of internal thoracic artery in myocardial revascularization: mid- and long-term results of 430 patients(1)

BACKGROUND: There is still controversy about early and late results of sequenital use of internal thoracic artery (ITA) in coronary artery bypass (CAB) operations.METHODS: In this study, we report on a series of 430 consecutive patients who underwent CAB operations between 1986 and 1998, with the use of at least one sequential ITA graft. The patients, 379 men and 51 women had a mean age of 56.4 years (range 29-80 years). Both ITA grafts were used in 227 (52.8%) patients. A total of 1744 (mean 4.05 per patient) distal coronary anastomoses were performed: 1172 of which (mean 2.72) were arterial and 980 (mean 2.28) were sequential ITA anastomoses.RESULTS: Thirty-day mortality was 1.8% (n=8 patients). Perioperative myocardial infarction occurred in 12 patients (2.8%) and five of them (1.2%) were confined to the sequential ITA grafted area. Follow-up ranged from 1 month to 13 years (mean 63+/-37.7 months) for 372 patients (86.5%). Nine patients died during follow-up period. According to Kaplan-Meier method, 5 and 10 year survival rates were 95.6 and 93.4%, respectively. Coronary angiography was performed in 64 patients (17.2%) after a mean of 33 months. In 31 of these patients angiography was performed due to return of symptoms. Overall patency rate of sequential ITA anastomoses was 91.7% (111/121). Two patients underwent repeat CAB operations.CONCLUSION: Sequential use of ITA grafts was not associated with the increased perioperative mortality and morbidity and has the potential to improve the long-term results of CAB surgery because of excellent patency rates of sequential ITA anastomoses.