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.     

Myocardial revascularization with three native in situ arteries. Gastroepiploic and bilateral internal mammary artery grafting

Three native arteries were used for coronary artery bypass grafting in six patients in whom complete revascularization was not feasible because of varices or previous venous stripping. The right gastroepiploic and both internal mammary arteries were placed as pedicled conduits, and four patients additionally received a total of six vein grafts available from the greater or lesser saphenous system. Surgical complications were minimal and complete relief from angina was obtained in all patients, even in maximal stress testing. All 24 grafts were angiographically checked: 23 (96%) were patent and one gastroepiploic artery was occluded. All patients had at least three patent grafts. These native arteries are excellent conduits when suitable veins are not available. They should also be used on individual indications to replace occluded grafts.     

Mid-term results of radial and mammary arteries as the conduits of choice for complete arterial revascularization in elective and nonelective coronary bypass surgery

OBJECTIVE: The aim of this study is to evaluate the mid-results of the use of the radial artery alongside the internal mammary artery for complete arterial revascularization in elective and nonelective coronary bypass graft surgery. METHODS: All patients undergoing coronary artery surgery alone over a 3-year period with disease of more than one coronary artery were considered for complete arterial revascularization. Preoperatively, all patients had an Allen's test on the dominant arm and a cutoff point of 10 seconds was used. These patients were initially followed in the outpatient clinic after 6 weeks and then further followed up with the help of a mailed questionnaire. The incidence of recurrent angina and reangiogram was obtained and selected patients were further interviewed and examined in the outpatient department. RESULTS: Over a 3-year period, 291 patients underwent total arterial revascularization using the radial and internal mammary arteries alone in Y-graft configuration. The mean age of the study population was 62.4 +/- 8.8 years, with a male to female ratio of 221 to 70. Elective surgery was performed in 230 patients (79.4%), with nonelective procedures comprising a total of 61 patients (20.6%). The mean number of distal anastomoses was 2.9 +/- 0.9. There were four perioperative mortalities (1.37%) and 43 patients (14.7%) developed low cardiac output syndrome, requiring inotropes with or without intra-aortic balloon pump. Forty patients (13.7%) developed postoperative supraventricular arrhythmias. There was no incidence of hand ischemia or wound complications. After a mean follow-up period of 35.4 +/- 6.3 months of 220 patients (75%), there was one further death and 24 patients required readmissions for cardiac-related causes. Ten patients had reangiogram for angina of which one patient had a blocked radial artery graft and two patients underwent angioplasty to their native coronary arteries. The patients' angina score was currently 0.5 +/- 1.0 versus 2.6 +/- 1.4 preoperatively. CONCLUSION: Total arterial revascularization with the internal mammary and radial artery is associated with a low rate of perioperative complications and mortality and can be safely used in both elective and nonelective bypass graft surgery with excellent clinical results.     

Total arterial myocardial revascularization using new composite graft techniques for internal mammary and/or radial arteries conduits

BACKGROUND: Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We present five new surgical configurations for TAMR. METHODS: Between December 1998 and July 1999, 34 patients with triple vessel disease underwent TAMR. All patients were in CCS III or IV. Sketelonized internal mammary arteries (IMAs) were used. The surgical techniques for TAMR consisted of Y or T composite grafts constructed between the in situ RIMA and free LIMA graft or radial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA graft in two configurations. Twenty-six (76%) patients underwent contrast-enhanced TTE color Doppler before and after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography. RESULTS: Overall, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperative day 2. Another patient (2.9%) undergoing the right Y graft technique using IMAs and RA suffered perioperative AMI due to RA conduit vasospasm. Contrast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 +/- 0.2 in the LIMA stem, and in the RIMA stem, a CFR of 2.3 +/- 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs, we found only anomalous flow dynamic parameters of RIMA, suggesting a partial graft closure. The angiographic examination revealed a free LIMA graft closure. At 6 +/- 2.4 months after operation 33 patients were alive and free of angina. The IMAs stem evaluation by TTE color Doppler at follow-up revealed a 2.45 +/- 0.1 mm LIMA diameter and 2.6 +/- 0.2 mm RIMA diameter, which was more than early postoperative data of P < 0.001 and P < 0.007, respectively. CONCLUSION: These data indicate that TAMR in young patients perhaps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the "nontouch" principle and should be taken into consideration in patients with a heavily calcified aorta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasive test, which allows assessment of IMA patency and CFR evaluation. The flow reserve of the IMAs seems to be adequate for multiple coronary anastomoses.     

Internal mammary revascularization in patients with variant angina and normal coronary arteries

Patients with variant angina refractory to medical therapy pose a difficult management problem. In patients with discrete obstructive lesions, coronary revascularization may be helpful. However, it has been widely accepted that coronary revascularization is contraindicated in patients with isolated coronary spasm without evidence of obstructive disease. Here we describe the two patients with life-threatening, medically intractable Prinzmetal's angina and angiographically normal coronary arteries, both of whom underwent coronary-artery-bypass surgery with the internal-mammary-artery (IMA) graft. These operations resulted in rapid, complete remission of coronary spastic attacks in both patients. Postoperative angiography reveals how the IMA graft works during spastic attacks.     

Myocardial revascularization with modified T-graft using bilateral internal thoracic arteries.

OBJECTIVE: By using a T-graft configuration, the myocardium may be completely revascularized with bilateral internal thoracic arteries. This study aimed to evaluate the perioperative morbidity and mortality in a single surgeon's early experience with a modified T-graft using bilateral internal thoracic arteries. METHODS: Between October 1994 to April 1997, 200 consecutive patients mostly selected per protocol, received a T-graft with bilateral internal thoracic arteries for stable angina pectoris (n = 157) or unstable angina pectoris (n = 43). The mean age of patients was 56 years (range of 36 to 78 years). There were 171 males and 29 females. Forty-three patients had diabetes. Concomitant procedures were performed in 8 patients. RESULTS: In 190 patients (95%), total arterial revascularization of the myocardium was achieved solely by the use of bilateral internal thoracic arteries in a T-graft configuration and the number of anastomoses per patient averaged 4.2. Ten patients (5%) received supplemental saphenous veins in addition to T-grafts for low cardiac output (n = 3), intraoperative regional ischaemia (n = 2), postoperative myocardial ischaemia (n = 2) and inadequate conduits (n = 3). The 30-day mortality was 0.5%. Perioperative myocardial infarct occurred in 2 patients (1.0%). Reasons encountered for early re-operation included bleeding (n = 7), sternal dehiscence (n = 5), suppurative sternitis (n = 3) and myocardial ischaemia (n = 2). Twelve patients received inotropes and intraaortic balloon counterpulsation was employed in 3 patients. CONCLUSION: When bilateral internal thoracic arteries were used in a T-graft configuration, total arterial revascularization of the myocardium was achieved with an acceptably low morbidity and mortality.     

Use of gastroepiploic and internal mammary arteries for myocardial revascularization

Triple coronary artery bypass grafting utilizing the right gastroepiploic artery and both internal mammary arteries was performed successfully in a 37-year-old male, achieving primary myocardial revascularization. All grafts were in situ. The right gastroepiploic artery was anastomosed to the posterior descending artery. The right and left internal mammary arteries were anastomosed to the left anterior descending artery and the posterolateral branch, respectively. The postoperative angiogram showed good patency of all grafts. The patient recovered uneventfully with resolution of his angina pectoris.     

Multiple-vessel coronary revascularization with combined in situ and free sequential internal mammary arteries

Bilateral internal mammary arteries were used sequentially (one as an in situ graft to provide inflow and the other as a free graft to provide outflow) in a patient with multiple-vessel coronary artery disease requiring revascularization without an autologous venous conduit available.     

Radial head arthroplasty with an uncemented modular metallic radial head prosthesis: short- and mid-term results

Background  

In comminuted radial head fractures, arthroplasty is an alternative treatment to open reduction and internal fixation or radial head excision. The purpose of this study was to evaluate the short- and mid-term results after the implantation of the EVOLVE™ uncemented modular metallic radial head prosthesis.     

Myocardial revascularization with internal mammary artery graft: analysis of early and late post-operative respiratory morbidity]

To evaluate the respiratory morbidity resulting from myocardial revascularization with internal mammary artery (IMA) graft, we reviewed 153 patients operated on between April and November 1988. There were 124 men with a mean age of 61 years. A bilateral IMA graft was used in 30 patients (20%). During the harvesting of the mammary graft, the homolateral pleura was systematically opened. Acute respiratory failure was more frequent in patients with bilateral IMA (13%) than in patients with unilateral IMA graft (3%) (p less than 0.05). Consequently, the mean duration of mechanical ventilation was longer in patients with bilateral IMA graft: 56 versus 23 hours (p less than 0.05). Lung volume measurements were altered according to a restrictive pattern. On the 9th post-operative day, forced vital capacity was reduced to 59.6% of the pre-operative value in patients with unilateral IMA and to 47.1% in patients with bilateral IMA graft (p less than 0.001). Late results were obtained in 111 patients. After a mean follow-up of 7 months, forced vital capacity was still reduced to 86.8% of the pre-operative value in patients with single IMA and to 78.1% in patients with bilateral IMA graft (p less than 0.001). In conclusion, respiratory morbidity is not negligible. Bilateral IMA grafting should generally be reserved to young patients (less than 65 years) with normal pre-operative pulmonary function tests.     

Pyrocarbon arthroplasty in acute unreconstructable radial head fractures: mid-term to long term results

Background

The aim of this study is to describe the mid-term radiological findings appearing in patients with a pyrocarbon radial head prosthesis, and to correlate them to patient symptoms.

Materials and methods

We review 18 patients who underwent radial head implantation of the MoPyC prosthesis between 2004 and 2015, due to unreconstructible radial head fractures. The clinical outcomes were assessed with Mayo Elbow Performance Score (MEPS). Range of motion, pain, and elbow radiological assessments were recorded. A non-parametric, statistical analysis was carried out to assess the radiological findings with the clinical outcomes.

Results

We have found that after a mean follow-up of 6.5 years (2–11 years), patients have recovered a median flexion arch of 113°, therefore 77% are classed as satisfactory outcomes and the average MEPS score is 89.5. The presence of periprosthetic changes on X-ray is highly frequent—we found radiolucent lines in 38% of cases, radial neck re-absorption in 83%, and arthrosic changes in 78%. However, the differences found when correlating these changes with the clinical results have not been statistically significant (p?>?0.05).

Conclusions

Satisfactory outcomes can be expected midterm when using pyrocarbon prostheses in around 75% of the cases. We consider radial neck re-absorption to be a sign of good stem osteointegration, whereas progressive radiolucencies and loss of the ballooning of the stem legs are signs of bad prognosis in our series.

Level of Evidence

IV retrospective case series.

     

Myocardial revascularization. Early and late results after reoperation.

In a series of 4,522 consecutive patients who underwent aorta-coronary bypass (ACB) with the saphenous vein at the Texas Heart Institute, 32 had a second revascularization procedure. All patients were reoperated upon because of recurrence of incapacitating angina. Reappearance of angina was related to obstruction of the grafts alone in 6 patients, to the disease of other arteries alone in 16, and to both sources in the remaining 10 patients. In 9 patients progression of the native coronary disease was found, in 16 significant coronary obstructions had been left unbypassed at the time of initial operation, and in the remaining 7 patients inadequate indication and/or performance of revascularization was considered responsible for the failure. Of the 31 survivors, 61 per cent experienced complete relief of angina or were improved, whereas 39 per cent were unimproved. Reoperation was more successful in relieving angina when performed in patients with new lesions or with previously unbypassed lisions than when done in patients with graft occlusion. Incidence of myocardial infarction after the first and second procedure was similar (3 per cent). Reoperation was performed with a mortality rate of 3 per cent, comparable to that of the original procedure, but relief of angina was not achieved so consistently.     

Comparison of systemic vasodilators: effects on flow in internal mammary and radial arteries

BACKGROUND: Spasm is a major concern with the use of arterial conduits in coronary artery bypass surgery (CABG). We evaluated the effect of systemic vasodilators on in vivo radial artery flow compared with internal mammary artery (IMA) flow. METHODS: Fifty patients undergoing primary CABG with a mean age of 69 +/- 5 years enrolled in this study and were randomized to 1 of 5 groups based on the vasodilating agent administered (nitroglycerin, nitroprusside, dobutamine, milrinone, and normal saline as control group). Radial artery and IMA flows, blood pressure, central venous pressure, and heart rate were measured before and 10 minutes after drug administration. RESULTS: Mean arterial pressure decreased significantly after drug administration in both the nitroglycerin (p = 0.007) and nitroprusside (p < 0.001) groups and increased in the dobutamine group (p < 0.001). There were no significant differences between IMA flow or radial flow among the groups before drug administration. A multivariate general linear model was created and revealed drug (specifically nitroglycerin) as the only predictor to increase flow in the IMA (p < 0.001) or the radial artery (p = 0.009). CONCLUSIONS: We conclude that intravenous nitroglycerin causes in vivo vasodilatation of both the IMA and radial artery and is a good systemic vasodilator to be given when harvesting these two conduits.     

Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery

Background. Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft.

Methods. Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein.

Results. There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p < 0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p < 0.001) and a longer hospital stay (p < 0.001). Mean follow-up was 8.1 ± 3.9 months. The probability of survival was similar (p = not significant).

Conclusions. The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.     

Myocardial revascularization using bilateral internal mammary arteries for total occlusion of LMCA in an adult case: sequelae of Kawasaki's disease in childhood

A 43-year-old female patient suffering from effort angina underwent coronary artery bypass grafting. Coronary arteriogram demonstrated complete occlusion of the left main, proximal circumflex (Cx), and proximal left anterior descending coronary arteries (LAD) and a nonocclusive fusiform calcified aneurysm of the proximal right coronary artery (RCA). The left coronary artery system opacified via collateral vessels from the RCA. No other abnormalities were found in the entire aorta and its major branches. Myocardial revascularization was performed using the right IMA to bypass to the Cx and the left IMA to bypass to the LAD successfully. Prior to the operation, she had neither coronary risk factors nor inflammatory signs, though she had experienced fever of unknown origin lasting about a week when she was 11 years old. Accordingly we supposed that such coronary arterial lesions might have arisen from Kawasaki's disease in her childhood.