Collateralization of an occluded left internal mammary artery coronary bypass graft

The left internal mammary artery (LIMA) is frequently utilized in coronary artery bypass grafting (CABG); adequate visualization of the LIMA bypass graft during diagnostic angiography is critical for determination of myocardial blood supply. We present a novel case of angiography via a left transradial approach demonstrating an occluded LIMA coronary bypass graft with antegrade flow maintained via a collateral branch from the ipsilateral thyrocervical trunk. Given the prevalence of LIMA use in CABG, it is critical to be aware of unusual configurations, including collateralization of a proximally occluded LIMA graft as described in this report.     

Silent Double Aortic Arch Coincidentally Found During Cardiac Catheterization in Elderly Man

We describe a case of an elderly man known for coronary artery disease (previous bypass surgery) hospitalized for ischemia in inferior wall. Since the operation, the patient underwent coronary angiographies. Due to the impossibility of selective engagement of left subclavian artery from femoral access, LIMA was always visualized through a right radial approach. Despite the suspicious of abnormal origin of left subclavian artery, aortic angiography was never performed. During the third angiography, the double aortic arch was coincidentally visualized by using a left Amplatz catheter. The diagnosis was confirmed by 64‐slice computed tomography scan.     

Cannulation of a LIMA graft via the right brachial arterial route using a MANI catheter: an alternative approach

Some different revascularization methods including coronary artery bypass surgery can be performed in the treatment of coronary artery disease. Saphenous vein grafts and/or arterial grafts including left internal mammary artery (LIMA) can be implanted during coronary bypass surgery. It is necessary to perform cannulation of the LIMA, in order to diagnose and treat these patients. In addition to conventional internal mammary artery catheters, several types of catheters can be used for this purpose. In general, LIMA catheterization via the femoral artery has been preferred over other methods. However, the right brachial arterial approach can be mandatory in some rare conditions. In this report, we describe an alternative method to the conventional techniques of the LIMA graft angiography via the right brachial arterial approach using a MANI catheter. According to our knowledge, no data are available using the MANI catheter for this purpose in the current literature.     

Left internal mammary artery bypass dysfunction after revascularization of moderately narrowed coronary lesions. Colour-duplex ultrasound versus angiography study.

BACKGROUND: The left internal mammary artery (LIMA) is the conduit of choice for revascularization of coronary arteries and its popularity further increases in the era of mini-invasive coronary surgery. The aim of this study was first, to assess the accuracy of CDUS in predicting the LIMA graft dysfunction as compared to angiography, and secondly, to correlate the postoperative status of the LIMA graft with preoperative coronary artery stenosis severity of the bridged lesion. METHODS AND RESULTS: We examined 111 patients (pts) by colour-duplex ultrasound after myocardial revascularization by LIMA bypass (3.8 +/- 3.2 years after revascularization). LIMA was detected from the left supraclavicular approach at rest using the 7.5 MHz linear transducer. The ultrasound results were compared to contemporaneous angiography. The LIMA bypass patency was correlated with the preoperative coronary artery stenosis severity. The LIMA was detected by ultrasound in 92.8% (103) pts. At angiography, LIMA was patent and functional in 85 pts (76.6%, group A); in 25 subjects LIMA was stenosed or dysfunctional (22.5%, group B). In one patient the coronary subclavian steal syndrome was detected (0.9%). Haemodynamically moderate stenosis (50-60% by preoperative quantitative coronary angiography) was grafted in 5 pts of group A (6%), but in 10 pts of group B (40%) (P < 0.0001 vs group A). A peak systolic to peak diastolic velocity ratio (SDVR) of <2.0 yielded optimal accuracy to detect the absence of LIMA bypass dysfunction with a negative predictive value of 95%. CONCLUSION: 1. Revascularization of angiographically moderate coronary lesions is associated with a higher risk of postoperative graft dysfunction. 2. Colour-duplex ultrasound is a useful non-invasive tool for the postoperative follow-up of pts with a LIMA graft.     

Internal mammary artery angiography should be a routine component of diagnostic coronary angiography

Left internal mammary artery (LIMA) angiography was performed with diagnostic coronary angiography in 130 cases for which the coronary findings made use of the LIMA as a bypass graft a consideration. In 98% of the cases the approach to LIMA angiography was femoral with a 5F LIMA catheter first directed into the proximal subclavian and then advanced over a guidewire placed into the distal subclavian well beyond the origin of the LIMA. After withdrawing the wire the catheter was brought proximally to selectively can-nulate and visualize the LIMA with nonionic contrast media. The only complication was a single transient occipital visual field loss. LIMA caliber too narrow to permit use as a graft was found twice, LIMA occlusion unrelated to prior surgery was found once, and LIMA occlusion related to prior surgery was found twice. Subclavian and/or vertebral stenosis was present five times. Large proximal branches of the LIMA best identified prior to surgery were present 12 times. Based on this experience, LIMA angiography (1) can be performed safely with a high degree of success, (2) demonstrates significant findings in 15% of cases, and 3) should therefore be performed whenever coronary angiographic findings make it appropriate to consider LIMA to coronary artery bypass grafting.     

Internal mammary artery angiography should be a routine component of diagnostic coronary angiography.

Left internal mammary artery (LIMA) angiography was performed with diagnostic coronary angiography in 130 cases for which the coronary findings made use of the LIMA as a bypass graft a consideration. In 98% of the cases the approach to LIMA angiography was femoral with a 5F LIMA catheter first directed into the proximal subclavian and then advanced over a guidewire placed into the distal subclavian well beyond the origin of the LIMA. After withdrawing the wire the catheter was brought proximally to selectively cannulate and visualize the LIMA with nonionic contrast media. The only complication was a single transient occipital visual field loss. LIMA caliber too narrow to permit use as a graft was found twice, LIMA occlusion unrelated to prior surgery was found once, and LIMA occlusion related to prior surgery was found twice. Subclavian and/or vertebral stenosis was present five times. Large proximal branches of the LIMA best identified prior to surgery were present 12 times. Based on this experience, LIMA angiography 1) can be performed safely with a high degree of success, 2) demonstrates significant findings in 15% of cases, and 3) should therefore be performed whenever coronary angiographic findings make it appropriate to consider LIMA to coronary artery bypass grafting.     

Noninvasive detection of coronary artery bypass graft patency by intravenous electron beam computed tomographic angiography

This study evaluates the usefullness of intravenous electron beam computed tomographic angiography (EBA) for the detection of coronary artery bypass graft patency in 43 patients (33 men and 10 women, mean age, 65 years) who had coronary artery bypass graft surgery. EBA was performed a few days before selective bypass graft angiography (SGA). Forty axial cross-sections of angiographic images of the heart were acquired consecutively by an electrocardiographic trigger signal at 40% of the RR interval, which corresponds to the end-systolic phase. EBA data were reconstructed as a three-dimensional shaded surface display of the heart and bypass grafts. Detectability of the patency of bypass gratis was evaluated, taking selective angiographic images of the bypass grafts as a gold standard. One hundred and nine grafts (96%) out of 114 grafts were subjected to evaluation: 37 grafts were left internal mammary artery grafts (LIMA), 7 were right internal mammary artery grafts (RIMA), 6 were gastroepiploic artery grafts (GEA), 7 were free gastroepiploic artery grafts with venous drainage (free-GEA), 7 were radial artery grafts (RAG), and 45 were saphenous vein gratis (SVG). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBA were 98%, 100%, 100%, 91%, and 98%, respectively. EBA sampled at the end-systolic period was determined to be useful for the detection of coronary artery bypass graft patency and occlusion.     

Left anterior descending artery of anomalous origin; Native lad arises from left internal mammarian artery. A case report and article review

Coronary artery anomalies are encountered in 2.6% of the population. Left anterior descending artery (LAD) stemming from a separate ostium is seen at a rate of 0.48%. In this case, we reported on a left internal mammarian artery (LIMA) giving rise to LAD. Coronary angiography was performed through the right radial artery in 54-year-old female patient. It did not reveal the presence of left main coronary artery in all three aortic sinuses. Pulmonary angiography also did not demonstrate LAD stemming from the pulmonary artery. Then, the LIMA was selectively visualized, and LAD originating from LIMA was observed. The PubMed database contains no reports of LIMA giving rise to LAD. This is the first case report demonstrating LAD originating from LIMA. Accordingly, if LAD cannot be visualized during angiography, an angiographic image of LIMA should be taken before a diagnosis of atresic LAD. For angiographic examination, the right radial route can be used.     

Early postoperative occlusion of a left internal mammary artery bypass graft with subsequent restoration of patency.

Total occlusion of a left internal mammary artery (LIMA) bypass graft is a rare complication, and reversal of a documented occlusion has not been reported. This is a case of an early postoperative occlusion of a LIMA graft that was found to be patent 4 months later. A patient with three vessel disease (including a moderate lesion in the proximal left anterior descending artery and a severe lesion in its mid-portion) underwent coronary artery bypass grafting with a LIMA to the mid-left anterior descending artery (LAD) and saphenous vein grafts to the right coronary and left circumflex arteries. Coronary angiography 3 months after surgery revealed a totally occluded internal mammary artery and saphenous vein grafts. The patient then underwent a successful angioplasty of the more distal lesion in the LAD. She subsequently returned with recurrent angina. Repeat coronary angiography revealed rapid progression of the disease in the proximal LAD with the more distal angioplasty site being widely patent. Selective arteriography of the internal mammary artery at that time revealed a patent vessel. Thus, the internal mammary graft is a physiologically active conduit that is dependent on flow dynamics. Competitive flow through the nonobstructive native LAD in combination with impedance of flow through the internal mammary artery due to a severe lesion in the LAD distal to the anastomosis led to a functionally occluded LIMA. When the obstruction in the proximal LAD progressed and the distal obstruction was successfully angioplastied, the flow dynamics in the internal mammary improved, allowing for its dilatation and restoration of patency.(ABSTRACT TRUNCATED AT 250 WORDS)     

Association of atretic left internal mammary graft with internal mammary to pulmonary vasculature fistula: a case series

Left internal mammary artery (LIMA) graft to pulmonary vasculature (PV) fistula is a rare complication of coronary artery bypass surgery (CABG), with only a handful of cases being reported. The fistula in these cases connects to a distal branch of the pulmonary artery. The etiology of these fistulae is uncertain, but is thought to be related to post surgical injury and inflammation leading to adhesions and neorevascularization. The association of an atretic LIMA with these fistulae has not been previously reported. We report six cases of LIMA to PV fistulae that were identified on coronary angiography. All six cases were associated with an atretic LIMA graft. All fistulae were small and did not appear to have significant hemodynamic or clinical consequences. This report describes a previously undescribed association of atretic LIMA graft with small LIMA to PV fistula and discusses possible mechanisms for this association.     

Early postoperative occlusion of a left internal mammary artery bypass graft with subsequent restoration of patency

Total occlusion of a left internal mammary artery (LIMA) bypass graft is a rare complication, and reversal of a documented occlusion has not been reported. This is a case of an early postoperative occlusion of a LIMA graft that was found to be patent 4 months later. A patient with three vessel disease (including a moderate lesion in the proximal left anterior descending artery and a severe lesion in its mid-portion) underwent coronary artery bypass grafting with a LIMA to the mid-left anterior descending artery (LAD) and saphenous vein grafts to the right coronary and left circumflex arteries. Coronary angiography 3 months after surgery revealed a totally occluded internal mammary artery and saphenous vein grafts. The patient then underwent a successful angioplasty of the more distal lesion in the LAD. She subsequently returned with recurrent angina. Repeat coronary angiography revealed rapid progression of the disease in the proximal LAD with the more distal angioplasty site being widely patent. Selective arteriography of the internal mammary artery at that time revealed a patent vessel. Thus, the internal mammary graft is a physiologically active conduit that is dependent on flow dynamics. Competitive flow through the nonobstructive native LAD in combination with impedance of flow through the internal mammary artery due to a severe lesion in the LAD distal to the anastomosis led to a functionally occluded LIMA. When the obstruction in the proximal LAD progressed and the distal obstruction was successfully angioplastied, the flow dynamics in the internal mammary improved, allowing for its dilatation and restoration of patency. Therefore, an angiographically occluded internal mammary graft may be only functionally occluded and reversible even when the occlusion is demonstrated several days apart.     

Prevalence and treatment of proximal left subclavian artery stenosis in patients referred for coronary artery bypass surgery

The left internal mammary artery (LIMA) is currently used in most coronary artery bypass graft (CABG) surgeries due to excellent long-term patency. Left subclavian artery stenosis (SAS) proximal to the LIMA origin can cause a steal syndrome leading to myocardial ischemia or LIMA failure. We retrospectively evaluated the records of 608 consecutive patients referred for CABG at our institution between October 1, 2004 and October 1, 2006 and identified 226 patients (37%) who underwent left subclavian angiography immediately after diagnostic coronary angiography. Significant left SAS was found in 6 of those 226 patients (2.7%). Subclavian angiography did not result in any complications. All left SAS lesions were successfully stented, followed by CABG surgery (using the LIMA artery) after 22+/-7 days. Left subclavian angiography in patients referred for coronary artery bypass surgery has low risk and may identify a small proportion of patients with significant proximal left SAS. Stenting of proximal left SAS can be accomplished before CABG with low risk and excellent short-term outcomes.     

Novel use of a GuideLiner catheter to visualize distal LAD after LIMA anastomosis in selective coronary angiography

We report a case of GuideLiner catheter use during transradial intervention for selective coronary angiography of the distal left anterior descending artery (LAD), beyond the left internal mammary artery (LIMA) anastomosis. The lesion within the LAD was located distal to the anastomosis of a very tortuous LIMA, otherwise unable to be visualized due to competitive flow from the LIMA. Stenting by way of the LIMA could not be performed due to this severe tortuosity as well. Alternatively, performance of the intervention without GuideLiner assistance would have required dual access, with injections both through the LIMA graft and the native LAD for angiography and intervention. Use of the GuideLiner served the purpose of selective LAD angiography to visualize the lesion, as well as delivery of the stent through a proximally calcified LAD. Using this single transradial route allowed the intervention to be completed, while reducing complications due to multiple access sites.     

Can left internal mammary artery side branches affect blood flow rate?

Summary

The left internal mammary artery (LIMA) is the most commonly used arterial graft for coronary artery bypass graft (CABG) surgery, and occluding the LIMA side branches during surgery is important to avoid myocardial ischaemia afterwards. In this study we investigated the incidence of patent LIMA graft side branches in our coronary angiography series, and compared LIMA flow rate changes by means of the thrombolysis in myocardial infarction (TIMI) frame count in patients with and without LIMA graft side branches.Patients with a history of CABG surgery and who were scheduled for coronary angiography in our centre between 1 January and 15 December 2006 were enrolled in the study. We compared LIMA graft TIMI frame counts between patients with and without side branches. The incidence of LIMA graft side branches in our study was 18% (seven patients). Mean TIMI frame count was 27.28 ± 3.4 in patients with LIMA graft side branches and 15.67 ± 2.3 in patients without. There was a significant difference between the two groups (p < 0.0001). Patients with LIMA graft side branches were more likely to have anterior ischaemia, determined by myocardial perfusion scintigraphy.We suggest that TIMI frame count may be helpful in evaluating the effect of side branches on LIMA graft flow rate. The increased TIMI frame count of a LIMA graft with side branch is associated with insufficient LIMA flow.     

Routine intraoperative angiography improves the early patency of coronary grafts performed on the beating heart

OBJECTIVES: The techniques of performing coronary revascularization without cardiopulmonary bypass are rapidly evolving. However, concern remains regarding the accuracy of coronary artery anastomoses performed on the beating heart. This report reviews the use of intraoperative angiography in the critical appraisal of "off-pump" coronary artery bypass graft (CABG) surgery. PATIENTS: Intraoperative angiography was performed in 24 consecutive patients undergoing CABG surgery without cardiopulmonary bypass. In all, 24 left internal mammary artery (LIMA) grafts and 18 saphenous vein bypass grafts were assessed for patency, anastomosis quality, distal and proximal runoff, and correct placement. RESULTS: All of the saphenous vein-to-coronary artery anastomoses were widely patent, although two patients (8%) required revision of their LIMA grafts on the basis of angiographic findings. CONCLUSION: Intraoperative angiography permits the surgeon to immediately appraise the CABG and to revise, if necessary, any graft abnormality, thus potentially eliminating the need for early repeated surgery. The practice of routine intraoperative angiography is likely to improve the outcome of CABG surgery on the beating heart.     

Subclavian-coronary steal through a LIMA-to-LAD bypass graft

Eighteen months after coronary artery bypass grafting with a left internal mammary artery (LIMA) graft, a 58-year-old woman had a change in the character of her angina to include pain in the left arm, especially with upper extremity work, culminating in an episode of prolonged rest pain. Cardiac catheterization revealed retrograde flow through the LIMA graft to the subclavian artery and stenosis of the left subclavian artery at its origin from the aorta. Restoration of antegrade flow through the LIMA graft to the coronary arteries was achieved by a carotid-subclavian bypass resulting in a resolution of symptoms. The evaluation of recurrent angina after LIMA bypass grafting should exclude the possibility of subclavian artery stenosis as well as disease of the native and graft coronary anatomy.     

Perioperative rupture of the LIMA graft leading to cardiogenic shock,emergency angiography,and stenting with a polytetrafluoroethylene‐covered stent

A 58‐year‐old man underwent an elective coronary bypass graft for severe four‐vessel stenosis. Cardiogenic shock developed just after coronary bypass grafting with a left internal mammary artery (LIMA) to left anterior descending (LAD) artery and superficial venous graft to 1^st and 2^nd obtuse marginal (OM1/OM2) arteries the posterior descending artery (PDA) was too small to graft. Despite significant inotropes and an intra‐aortic balloon pump, the patient deteriorated in intensive care unit with cardiogenic shock and ventricular arrhythmia. Urgent coronary angiography revealed a rupture or torn LIMA graft with extravasation of contrast into the left pleural cavity. There was no distal LIMA to LAD flow probably due to graft thrombosis. Revascularisation was performed on the severe ostial native LAD stenosis with a drug eluting stent. The rupture graft was then stented with a polytetrafluoroethylene‐covered stent, which stopped the bleeding, and latter, led to total graft thrombosis. The patient improved significantly and supportive inotropes could be weaned down. At 11 month follow‐up, the patient had mild left ventricular dysfunction, widely patent ostial LAD stent and thrombosed LIMA graft. © 2011 Wiley Periodicals, Inc.     

Mysterious abdominal pain

A man presented to the emergency room with recurrent episodes of abdominal pain. He had a history of coronary artery bypass grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and the right gastroepiploic artery to the posterior descending artery. After numerous gastrointestinal evaluations, a stress test was performed, which was positive. Coronary angiography showed a proximal occlusion of the LAD and right coronary artery and a normal functioning LIMA bypass. Aortography showed a 95% stenosis of the celiac trunk. Angioplasty and stent implantation of the celiac trunk was successfully performed. Six months later the patient was completely asymptomatic with a negative stress test. In conclusion, abdominal pain in patients who have undergone coronary artery bypass surgery using the right gastroepiploic artery should raise suspicion not only of a stenosis of the arterial conduit but also of a potential stenosis of the celiac trunk.     

Involvement of the coronary artery in a patient with thromboangiitis obliterans. A case report

 We report a case of coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA) and a saphenous vein graft in a 36-year-old man with Buerger's disease. He was hospitalized in the coronary intensive care unit with a diagnosis of acute myocardial infarction. His coronary angiography showed total occlusion of the proximal segment of the left anterior descending artery (LAD) and right coronary artery. Left ventricular dysfunction was detected by ventriculography. The patient had undergone bilateral sympathectomy of the lumbar branches for distal arterial occlusions due to thromboangiitis obliterans 12 years previously. Under cardiopulmonary bypass and aortic cross-clamping, we performed endarterectomy and a complex bypass procedure to LAD. Aorta-right coronary artery bypass was also applied. A histopathological study of an endarterectomy specimen showed characteristic features of thromboangiitis obliterans. The postoperative course was uneventful and the patient was discharged on the ninth postoperative day. Received: November 19, 2001 / Accepted: February 16, 2002     

Assessment of left internal mammary artery graft patency and flow reserve after minimally invasive direct coronary artery bypass.

Despite its merits, minimally invasive direct coronary artery bypass surgery (MIDCAB) has been criticized for variable left internal mammary artery (LIMA) graft patency rates, prompting the frequent use of postoperative LIMA angiography. Noninvasive transthoracic Doppler interrogation of LIMA grafts has recently been shown to have utility for assessing patency and flow reserve after conventional bypass surgery, but data after MIDCAB has been limited. The objective of this study was to assess LIMA graft anatomy and physiology in 54 patients after MIDCAB using angiography and noninvasive LIMA Doppler imaging. The right internal mammary artery (RIMA) was studied as a control. LIMA flow reserve in response to adenosine was evaluated in a subgroup of 18 randomly chosen patients with patent grafts. LIMA angiographic patency was 93%. Forty-four patients (81%) had obtainable LIMA Doppler data. Patent grafts had a diastolic dominant flow pattern with a peak diastolic/systolic velocity ratio of 1.3 +/- 0.6 and a percent diastolic time-velocity integral (TVI) of 70 +/- 11%. These data were significantly different than the RIMA control values of 0.2 +/- 0.1 and 30 +/- 10%, respectively (p <0.05). Occluded grafts had absent flow or a systolic dominant pattern. Adenosine-induced increases in LIMA peak diastolic velocity from 48 +/- 20 to 105 +/-28 cm/s (p <0.05 vs baseline) and diastolic TVI from 21 +/- 10 to 37 +/- 19 cm (p <0.05 vs baseline), yielding adenosine/baseline ratios of 2.4 +/- 0.9 and 2.0 +/- 0.7, respectively, which was consistent with normal flow reserve. The diastolic flow velocity reserve response was inversely related to baseline diastolic flow (r = -0.69). In conclusion, MIDCAB can be associated with a high rate of LIMA potency and favorable physiologic Doppler flow patterns. Correlation of these findings to long-term patient outcome after MIDCAB is warranted.