多排螺旋CT冠脉成像与冠脉造影对冠心病诊断的对比研究

目的:初步评价MSCT在冠状动脉成像中的临床应用价值。方法:18例疑诊冠状动脉狭窄患者行MSCT扫描,利用影像曲面重建,3D重建,了解冠状动脉病变情况,并与冠状动脉造影对比。结果:18例76支血管同时经MSCT和CAG成像。冠状动脉造影发现狭窄27支,其中左前降支(LAD)病变11支,回旋支(LCA)病变3支,左主干(LMA)2支,右冠(RCA)病变9支,桥支病变2支。MSCT发现狭窄23支,其中左前降支病变11支,回旋支病变3支,左主干病变1支,右冠病变9支,桥支病变2支。MSCT成像的敏感性为81．5％(22／27),特异性100％,阳性推测值91．7％,阴性推测值94．2％。结论:在控制心率的情况下,MSCT可作为冠状动脉狭窄的一种无创筛选检查方法。     

老年冠心病患者经桡动脉途径同时接受冠状动脉、肾动脉和下肢动脉造影的安全性及有效性探讨

目的探讨老年冠心病患者经桡动脉途径冠脉造影同时行下肢动脉及肾动脉造影的方法并分析其安全性及有效性。方法收集可疑冠心病伴外周动脉粥样硬化的老年患者275例(年龄≥60岁)行选择性冠脉造影同时行肾动脉及下肢动脉造影。按介入途径分为左桡动脉组(124例)及右桡动脉组(151例),各组再按年龄段分为三个不同亚组:低龄老年亚组(60~69岁),中龄老年亚组(70~79岁),高龄老年亚组(≥80岁),分别以左、右桡动脉途径运用TIG共用造影管(100cm)及MP A1造影管(125cm)依次行冠脉、双侧下肢动脉和肾动脉造影,比较桡动脉穿刺成功率、造影操作时间、对比剂用量、X线曝光时间及造影完成率等,并分析这些指标与年龄的相关性。结果左、右桡动脉组的穿刺成功率及对比剂用量差异无统计学意义,而左桡动脉组造影操作时间、X线暴露时间均低于右桡动脉组,造影完成率亦明显高于右桡动脉组;左、右桡动脉组造影操作时间均与年龄呈正相关,而X线曝光时间与年龄无相关性。结论老年患者经左桡动脉途径冠脉造影同时行下肢动脉及肾动脉造影完成率高,安全有效,可作为首选路径。     

Simultaneous coronary artery bypass grafting and ascending aorta bifemoral bypass in small aorta syndrome.

A 55-year-old man with severe coronary artery disease and aortoiliac occlusive disease with small aorta syndrome was admitted to our department with angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery with a markedly hypoplastic infrarenal aorta only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in-situ right internal mammary artery graft, an autologous saphenous vein graft, and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and bifemoral arteries were patient. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease, especially in those with small aorta syndrome.     

Mini-sternotomy for off-pump coronary artery bypass grafting

The number of off-pump coronary artery bypass grafting procedures without cardiopulmonary bypass is steadily increasing. We report on a new, minimally invasive surgical approach for off-pump coronary revascularization in multivessel disease. A distal sternotomy is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery, diagonal branches, and right coronary artery for off-pump revascularization.     

Coronary arterial size late after the atrial inversion procedure for transposition of the great arteries: implications for the arterial switch operation

BACKGROUND: Coronary flow reserve in the hypertrophied ventricle is reduced. One contributing factor may be the size of the proximal coronary arteries. In patients who undergo atrial inversion procedures for transposition of the great arteries, the left coronary artery supplies the pulmonary ventricle and may be smaller than the right coronary artery. We hypothesized that the dimensions of the coronary arteries may correlate with symptomatic status after atrial inversion and may be an important factor when these patients are considered for the arterial switch operation. METHODS: The proximal left and right coronary arteries were measured in 9 patients with transposition and failure of the systemic right ventricle after atrial inversion, 10 asymptomatic patients after atrial inversion, and 10 patients with normal hearts. The diameters of the coronary arteries were indexed to body surface area and compared. RESULTS: The absolute and indexed diameters of the right coronary artery were greater in symptomatic patients than in asymptomatic patients (indexed: 3.1 +/- 0.6 vs 2.4 +/- 0.4 mm/m(2), P <.001) or control patients (2.0 +/- 0.3, P <.001), and the absolute diameter of the left coronary artery was smaller (2.9 +/- 0. 7 vs 3.6 +/- 0.5 mm, P =.003 [asymptomatic], 3.6 +/- 0.5 mm, P =.01 [control]). In symptomatic patients, the absolute and indexed diameters of the left coronary artery were smaller than those of the right (indexed: 2.1 +/- 0.6 vs 3.1 +/- 0.6 mm/m(2), P <.001). By contrast, there was no difference in asymptomatic patients (2.2 +/- 0.5 vs 2.4 +/- 0.4 mm/m(2), P =.44), and the left coronary artery was larger in normal control patients (2.2 +/- 0.4 vs 2.0 +/- 0.3 mm/m(2), P <.001). CONCLUSIONS: Differences in the sizes of the proximal coronary arteries may be related to symptomatic status in patients with transposition of the great arteries who have undergone an atrial inversion procedure, as well as to the efficacy of ventricular retraining. When pulmonary artery banding and subsequent arterial switch are considered for patients with a Mustard or Senning procedure and a failing systemic right ventricle, the size of the proximal coronary arteries may be an important factor and should be evaluated with preoperative imaging studies.     

The dimensions of the right ventricular outflow tract and pulmonary arteries in tetralogy of Fallot and pulmonary stenosis.

Studies were undertaken of the cineangiograms in 196 consecutive patients entering two institutions with tetralogy of Fallot and pulmonary stenosis, none of whom had previously undergone a surgical procedure. The median age of the patients at the time of the study was 5.9 months. The diameters of the right ventricular infundibulum, pulmonary trunk, and the entirety of the right and left pulmonary arteries were measured (in millimeters), corrected for magnification, and expressed in standard deviation units (Z-values). The median values of the cineangiographically determined diameters of the right ventricular infundibulum and pulmonary trunk were smaller than those of 95% of normal individuals. The median values throughout the right and left pulmonary arteries were within the range of normal. Those of the distal branches of both the right and left pulmonary arteries were similar to the mean values in normal individuals. However, great variability of the dimensions between individuals, and along the pathway in individuals, characterized patients with tetralogy of Fallot. Diffuse narrowing of the pathways both proximally and distally was uncommon. The relation between the diameters of the pulmonary "anulus" and of the distal pulmonary trunk and origin of the left pulmonary artery explained the difficulty of extending an enlarging patch into a wide area distally in some patients.     

Natural Y-grafting using internal thoracic artery branches for off-pump coronary artery bypass

The excellent long-term patency rates achieved utilizing the internal thoracic arteries (ITAs) have stimulated a variety of approaches to expand the use of these conduits in coronary revascularization. The ITA divides at the level of the fifth or sixth intercostal space into the superior epigastric and musculophrenic branches. If these terminal branches of the ITA are large and long enough for grafting, they can be used to construct a "Y" anastomosis to the coronary arteries. We experienced 2 patients who underwent multivessel off-pump coronary artery bypass (OPCAB) using these ITA branches. In both patients the bilateral ITAs and the right gastroepiploic artery were taken down using the skeletonization technique as in situ grafts. One patient had 5 grafts including the right ITA terminal branches which were used for the left anterior descending branch (LAD) and diagonal branch. Another patient had 6 grafts including the left ITA terminal branches which were used for the posterolateral branch (PL)1 and PL2. Postoperative angiography revealed widely patent grafts in both patients. We believe that one of the advantages of applying the off-pump technique when the ITA branches are used is that it might be easier to arrange the angle of constructing a natural "Y" configuration compared with conventional coronary artery bypass grafting (CABG). In conclusion, the terminal branches of the ITA, if of suitable size, should be considered for "Y" grafts to diseased coronary arteries when performing complete arterial revascularization with only in situ grafts.     

The use of the right gastro-epiploic artery in coronary artery bypass grafting

Thirty consecutive patients with angina pectoris undergoing coronary artery bypass grafting using the proximally attached right gastro-epiploic artery are described. Posterior coronary arteries were grafted using the right gastro-epiploic artery, and grafts to the left coronary artery were done using predominantly internal mammary artery grafts. The right gastro-epiploic artery graft is mobilized along the greater curvature of the stomach, and transected distally. With cardiopulmonary bypass and blood cardioplegic arrest for myocardial preservation during cross-clamping of the aorta, the distal end of the artery is anastomosed end-to-side to the posterior descending artery or a postero-lateral branch, or to both, using a sequential technique. Twenty-five of the patients complained of symptoms suggestive of angina early postoperatively but are currently symptom-free with normal exercise tolerance. Thirteen patients had postoperative exercise tests: eight were normal, two were inconclusive, and three were abnormal. Nine grafted coronary arteries were re-angiogrammed, and seven were judged to be patent. It is concluded that, as an alternative resource, the right gastro-epiploic artery can be used to bypass coronary obstructions expeditiously and with results comparable to those obtained with the saphenous vein or internal mammary artery.     

心脏移植长期存活患者冠状动脉病变一例

目的　探讨 1例心脏移植长期存活患者冠状动脉病变的原因、诊断和处理。方法　对1例心脏移植术后存活 8年的患者进行长期随访。结果　术后患者生活质量好 ,恢复正常工作 ;血液生化正常 ;心电图无心肌缺血改变 ;肱动脉内皮依赖性血管舒张功能正常 ;心内膜心肌活检未见急性排斥反应征象 ;同位素心肌显像提示左室壁心肌放射性分布进行性减低 ;冠状动脉造影显示左冠状动脉弥漫性狭窄、右冠状动脉近段有一局限性严重狭窄 (>90 % )、远端为轻度弥漫性狭窄 ,行右冠状动脉近段成形和支架植入 ,同位素心肌显像示左室壁心肌放射性分布明显改善。结论　慢性排斥反应可能是导致移植心冠状动脉病变的重要原因 ;定期行同位素心肌显像检查有助于了解心肌血液供应 ;严重的局限性冠状动脉病变可应用冠状动脉成形和支架植入予以治疗。     

Coronary ostial stenosis after aortic valvuloplasty (comprehensive aortic root and valve repair)

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.     

Comparative analysis of the patency of the internal thoracic artery in the CABG of left anterior descending artery: 6-month postoperative coronary CT angiography evaluation

Objective

To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively.

Methods

Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory.

Results

The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group.

Conclusion

Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site.     

Gastroepiploic-coronary anastomosis. A viable alternative bypass graft

Although increasing use is being made of arterial grafts (the internal mammary arteries) for direct myocardial revascularization, it is frequently not possible to reach the posterior surface of the heart with the internal mammary as either a pedicle or a free graft. Since June 1984 we have used the right gastroepiploic artery in nine patients as a pedicle graft to the distal right coronary artery (four patients), the posterior descending artery (three patients), and the distal circumflex branches (two patients). Eight patients survived the operation. Celiac axis opacification confirmed patency in six and coronary angiography strongly suggested patency in the remaining two. All survivors are functionally in New York Heart Association Class I or II. The early angiographic and clinical results demonstrate the feasibility of using the right gastroepiploic artery as a bypass graft to coronary vessels on the posterior surface of the heart when traditional conduits are unsuitable. If its long-term patency as a living arterial graft is similar to that of the internal mammary arteries, the gastroepiploic artery may become the coronary bypass graft of choice for the distal right coronary and circumflex systems.     

Prospective evaluation of coronary arteries: influence on operative risk in coronary artery surgery.

OBJECTIVE: Coronary angiography data included in the analysis of operative mortality after coronary artery surgery are generally limited to left main coronary artery stenosis and classification into one-, two- or three-vessel disease, but the role of stenoses and quality of distal runoff on each main coronary artery have never been analysed. The aim of this study was to assess the influence of coronary artery status (stenoses and distal runoff) on operative mortality in patients undergoing coronary artery surgery. METHODS: Stenoses of the five main coronary arteries and their distal runoff were prospectively evaluated in a series of 2461 patients undergoing isolated coronary artery surgery. These angiographic variables were included in analysis of operative mortality in combination with conventional preoperative data. RESULTS: Univariate analysis founded 21 preoperative variables being significant: age >70, body surface area <1.8 m2, arterial disease of lower limbs, history of peptic ulcer, CCS class IV angina, unstable angina, post-infarction unstable angina, congestive heart failure, left ventricular ejection fraction <50%, urgency, preoperative intra-aortic balloon pump, previous myocardial infarction, previous cardiac surgery, previous coronary bypass graft, presence of significant stenosis on the left main coronary artery or the circumflex marginal branch or the distal circumflex artery or the right coronary artery, absence of significant stenosis on the left anterior descending artery, impaired distal runoff on the left anterior descending artery or the circumflex marginal branch (for all, P < 0.05). Multivariate analysis identified poor quality distal runoff in the left anterior descending artery and circumflex marginal branch as independent risk factor (P = 0.0005 and P = 0.04, respectively), while left main coronary artery stenosis was not. This lesion appears to be a significant risk factor only in a small subgroup of patients with CCS class IV angina. Other independent risk factors were CCS class IV angina, previous cardiac surgery, body surface area <1.8 m2, diabetes mellitus, age <70, history of peptic ulcer, left ventricular ejection fraction <50%. Impaired distal runoff or the presence of stenoses on the diagonal branch, right coronary artery, or distal circumflex artery does not significantly influence the operative mortality rate. CONCLUSIONS: The quality of distal runoff of the most frequently grafted vessels is a significant risk factor for operative mortality in coronary artery surgery. Left main coronary artery stenosis was not identified as a risk factor when these angiographic variables were included in the analysis. Functional status remains the most powerful predictive factor.     

Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions

Myocardial areas distal to complete coronary artery occlusions are poorly protected by antegrade cardioplegia. We assessed the effects of coronary sinus cardioplegia in 30 patients undergoing bypass operations and at high risk of cardioplegic maldistribution because of the following anatomical patterns of coronary artery disease: critical (greater than or equal to 50%) stenosis of the left main trunk with total occlusion of the right coronary artery (16 patients) or critical (greater than or equal to 70%) stenosis of the right coronary artery with total occlusion of the left anterior descending (11 patients) or circumflex artery (3 patients). After induction of arrest through the aorta, coronary sinus cardioplegia was given intermittently during the cross-clamp period at a flow rate of 100 mL/min. Intraoperatively, occluded arteries were consistently found to be filled with the retrogradely infused solution. One patient died early postoperatively of low cardiac output and a second patient died later during his hospital stay, presumably of an arrhythmia. At autopsy, none of them had pathological evidence of inadequate myocardial protection. One patient sustained a myocardial infarction and 3 others required inotropes for more than 24 hours postoperatively. Postoperative values for right and left stroke volume indices were not significantly different from prebypass levels. Overall, these results are consistent with the occurrence of limited intraoperative ischemic damage and, by inference, suggest the efficacy of the coronary sinus route in preserving myocardial areas supplied by completely occluded coronary arteries and, hence, in jeopardy of inadequate cardioplegia delivery.     

Segmentation of the left internal thoracic artery: a new technique for maximal arterial grafting

The left internal thoracic artery lpa r;LITA) is the preferred graft with the best patency rate in coronary artery bypass grafting (CABG). To maximize its use, we developed a technique of grafting 2 distant coronary arteries with the LITA, using its distal portion segmented to construct a Y graft with either the in situ LITA or right internal thoracic artery (RITA). We applied this technique in 51 patients. The distal segment of the LITA was used to create a Y graft in 4 different configurations according to coronary pathology. Offpump grafting was performed in 11% of cases. The use of a distal segment of the LITA was thus extended not only to the left anterior descending artery and branches but also to the circumflex and right coronary artery territories.     

In situ retrocaval skeletonized right internal thoracic artery anastomosed to the circumflex system via transverse sinus: technical aspects and postoperative outcome

BACKGROUND: The aim of this study was to investigate whether, by using the in situ right internal thoracic artery via the transverse sinus (eventually retrocaval), both the proximal and distal major branches of the circumflex system could be grafted and to evaluate the early and late outcome in these patients. METHODS: Between January 1997 and March 2002, 452 consecutive patients underwent grafting of the circumflex system with the in situ skeletonized right internal thoracic artery routed via the transverse sinus. The mean age was 62.4 +/- 10.3 years. A mean of 2.2 +/- 0.3 arterial grafts per patient were used, and 271 (60%) patients underwent total arterial myocardial revascularization. At 3 months after surgery, 86 patients (right Y or T graft) underwent echo color Doppler imaging before and after an adenosine provocative test. The mean follow-up was 27 +/- 8 months. RESULTS: The success rate of skeletonized right internal thoracic artery grafting to the circumflex system branch was 100%. There were 15 (3.4%) hospital deaths. In 116 patients who underwent postoperative angiography, the total patency rates of the right and left internal thoracic arteries were 94% and 96.6%, respectively. Strong predictors for nonfunctional internal thoracic artery grafts were a small internal thoracic artery caliber (P <.001), recipient coronary artery diameter less than 1.5 mm (P =.012), stenotic lesions of less than 60% (P =.016), and diffuse stenotic lesions (P =.015) of the recipient coronary artery. In 86 patients who underwent postoperative echo color Doppler imaging, the flow reserves at the main stem of the left and right internal thoracic arteries were 2.24 +/- 0.5 and 2.48 +/- 0.6, respectively. Cumulative actuarial survival at 3 years was 96.3%, and event-free cumulative survival was 93%. The Cox model revealed a left ventricular ejection fraction of less than 35% (P =.016), age greater than 70 years (P =.025), New York Heart Association grade greater than III (P =.0019), nontotal arterial myocardial revascularization (P =.002), and the preoperative presence of more than 1 ischemic area (P <.001) as strong predictors for poor overall cumulative event-free survival. CONCLUSIONS: The skeletonized right internal thoracic artery, placed via the transverse sinus and eventually retrocaval, can reach most branches of the circumflex system and is associated with an excellent patency rate. The predictors for poor overall event-free survival seem to be similar to those of the general population undergoing conventional coronary artery bypass grafting. Use of bilateral internal thoracic arteries and in situ right internal thoracic artery grafting via the transverse sinus offers the possibility of various configuration constructions, making possible total arterial myocardial revascularization with a minimum number of arterial conduits.     

冠状动脉造影检出心肌桥91例分析

目的探讨心肌桥（MB）的冠状动脉造影及临床特征。方法回顾分析5209例冠状动脉造影中检出的91例MB病例的冠状动脉造影及临床特点，分析MB与冠状动脉粥样硬化及缺血性心脏事件的关系。结果MB检出率1．75％，其中左冠状动脉前降支MB86例，对角支4例，回旋支1例，孤立性MB患者75例。91例中，31例无典型临床症状，44例表现为心绞痛等临床症状，8例MB近段有粥样硬化病变，7例MB合并其他冠脉血管的粥样硬化，1例MB合并肥厚型心肌病。结论MB有促进其近段血管发生粥样硬化病变的可能；MB的狭窄程度越严重，引起心肌缺血越严重。     

Flow capacity of the human retrograde internal mammary artery: surgical considerations

The diastolic flow of the retrograde internal mammary artery (IMA) was calculated in 30 patients and compared with the expected coronary flow of the left ventricle and that of specific branches. Arterial pressure and free flow were measured in the proximal and distal IMA as well as in the superior epigastric and musculophrenic arteries. Systolic and mean arterial pressure were significantly higher in the proximal IMA than in any other site, but diastolic pressure was comparable. Overall and diastolic antegrade IMA flows (77 +/- 6 and 44 +/- 3 mL/min) were significantly greater than the retrograde flows through the distal IMA (18.5 +/- 2 and 11.5 +/- 1 mL/min), musculophrenic artery (13.3 +/- 1 and 7.9 +/- 1 mL/min), and superior epigastric artery (5.3 +/- 0.4 and 3.1 +/- 0.2 mL/min). Only patient-size-related variables correlated significantly with retrograde IMA flow. Diastolic retrograde IMA flow represented 8.5% +/- 0.6% of the expected left ventricle coronary flow and in 12 patients (40%) was greater than the expected flow of at least one posteroinferior coronary artery. Based on these data, the retrograde IMA may adequately perfuse the posterior descending or other posterolateral coronary branches in select patients. Previous measuring of the retrograde flow is mandatory.     

Arterial myocardial revascularization with in situ crossover right internal thoracic artery to left anterior descending artery

BACKGROUND: The extra length obtained by skeletonizing the internal thoracic arteries (ITAs) enables versatile use of in situ bilateral ITAs for coronary artery bypass grafting, as the longer skeletonized right ITA more easily reaches the anastomotic site on the left anterior descending coronary artery. METHODS: Between April 1996 and November 1999, 365 consecutive patients underwent revascularization with bilateral in situ ITAs (29% of 1,250 grafting procedures performed with both ITAs in our department during this period). The right ITA was routed anterior to the aorta to graft the left anterior descending coronary artery, and the in situ left ITA was used to graft circumflex branches. Right coronary artery branches were grafted with right gastroepiploic artery or saphenous vein graft. The right ITA crossed the midline above the aorta at the most cranial point to avoid damage in case of a repeat sternotomy in the future. RESULTS: The operative mortality rate was 2.2% (8 patients). Postoperative morbidity included seven strokes (1.9%), eight sternal wound infections (2.2%), and four perioperative myocardial infarctions (1.1%). Follow-up (6 to 49 months) of 97% of hospital survivors showed a return of angina in 3%. Postoperative coronary angiography (22 patients) revealed a 95% patency rate of both ITAs. One-year and 4-year survival rates (Kaplan-Meier) were 95% and 92.4%, respectively. Important predictors of an early unfavorable event were chronic obstructive pulmonary disease, old age (> or = 70 years), emergency operation, and diabetes. Chronic obstructive pulmonary disease was the only independent predictor of sternal wound infection (odds ratio, 15; 95% confidence interval, 2.8 to 80). It also predicted decreased late survival (hazard ratio, 8.3; 95% confidence interval, 3 to 21.5). CONCLUSIONS: With skeletonized dissection of ITAs, the right ITA easily reaches the left anterior descending coronary artery for left-sided arterial revascularization with in situ bilateral ITAs. This procedure is safe, but we recommend avoiding its use in patients with chronic obstructive pulmonary disease.     

Coronary artery bypass grafting using a bifurcating radial artery

A 61-year-old man with angina pectoris was admitted for elective coronary artery bypass grafting. The left anterior descending artery, and the two posterolateral branches (PLA1 and PLA2) of the circumflex artery required bypass grafting. At operation, the distal portion of the left radial artery was found to bifurcate, both branches having an equal size. We decided to use the bifurcating radial artery as a conduit for bypass grafting to the branches of the left circumflex artery. One distal end of the radial artery was subsequently anastomosed to the PLA1 branch and the other distal end was anastomosed to PLA2. Postoperative coronary angiography showed both branches of the radial artery to have good patency.