Treatment of a Left Internal Mammary Artery to Pulmonary Artery Fistula with Polytetrafluoroethylene Covered Stents: A Case Report and Review of the Literature

Internal mammary artery (IMA) to pulmonary artery (PA) fistula is a rare complication of coronary artery bypass grafting (CABG) that may present as myocardial ischemia. We describe a case of left IMA-to-PA fistula treated with balloon expandable coronary polytetrafluoroethylene (PTFE) graft stents and review previously reported cases of this entity.     

Coronary artery fistulae without adudible murmur in adults

Retrospective analysis of 4886 adults undergoing coronary arteriography for evaluation of angina between October 1988 and December 1991, revealed coronary artery fistulae in eight patients (all men, aged 36–69 years). No murmur was audible in any of these eight patients. Associated significant coronary artery disease was detected in five patients. The feeder arteries to the fistula were both the left main coronary artery and the left anterior desending artery (LAD) in two, the LAD in six, and the right coronary artery in two patients. The fistula terminated in the pulmonary artery in seven patients and in the right atrium in one patient. Successful operative treatment (coronary artery bypass grafting and ligation of the fistula) was undertaken in four patients with severe obstructive coronary artery disease with satisfactory results. Follow-up for up to 2 years of the three patients with coronary artery fistula and no associated coronary artery disease who did not undergo surgery revealed continuing good prognosis. We conclude that coronary artery fistula in adults is a distinct, though rare (incidence in present series 0.11%) entity, without audible murmur, commonly associated with coronary artery obstructive disease, and that the diagnosis is mostly incidental during routine coronary arteriography.     

Treatment of an Iatrogenic Left Internal Mammary Artery to Pulmonary Artery Fistula with a Bovine Pericardium Covered Stent

We report a case with an acquired fistula between the left internal mammary artery and the pulmonary artery following coronary bypass surgery treated with a bovine pericardium covered stent. We also reviewed similar cases reported previously.     

冠状动脉旁路移植术后心绞痛复发的桥血管造影分析

目的分析冠状动脉旁路移植术(CABG)后心绞痛复发患者的自体血管及桥血管的变化特点。方法对CABG术后因心绞痛复发的病例行选择性血管造影,检查冠状动脉和桥血管情况。结果24例均发现桥血管病变,血管病变以闭塞为主,占38.2%(26/68),狭窄占10.3%(7/68)。静脉桥24支完全闭塞,5支狭窄。乳内动脉桥完全闭塞和狭窄各2支。心绞痛复发还可由再血管化不完全和自体血管病变加重引起。结论CABG术后仍可以复发心绞痛,桥血管病变是主要原因,术后如发生心绞痛应该及时检查。     

先天性冠状动脉瘘的电子束CT诊断

目的探讨先天性冠状动脉瘘的电子束CT(EBCT)征象.材料和方法EBCT检查并手术证实的8例先天性冠状动脉瘘.EBCT采用单层增强扫描.结果EBCT提示4例右侧冠状动脉扩张迂曲,其中3例与心室、1例与主肺动脉沟通;4例源于左侧冠状动脉,其中1例对角支囊状扩张钙化与左室沟通,2例左圆锥支与主肺动脉连接,1例主干及回旋支扩张钙化,后者之左心房支与右心房沟通.结论无心脏手术史病例,EBCT提示冠状动脉及分支扩张迂曲,与心腔或其他血管异常沟通,应首先考虑先天性冠状动脉瘘.     

Postoperative Functional Outcome After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting Using Gated Myocardial SPECT: A Comparison by Propensity Score Analysis

Purpose

We evaluated the short-term and mid-term differences in perfusion and function after off-pump and on-pump coronary artery bypass grafting (CABG) using gated myocardial single photon emission computed tomography.

Materials and Methods

A total of 70 patients with coronary artery disease who underwent CABG were included based on the propensity score matching results from 165 patients. Thirty-five patients underwent off-pump and 35 patients on-pump CABG. Rest ²⁰¹Tl/dipyridamole stress ^99 mTc-methoxyisobutylisonitrile gated single photon emission computed tomographies were performed preoperatively and postoperatively at short-term (103 ± 23 days after surgery) and mid-term follow-up (502 ± 111 days after surgery). Changes in left ventricular ejection fraction, end systolic volume, stress and rest segmental perfusion, and segmental wall thickening were compared between the two groups. The segments with preoperative rest ²⁰¹Tl uptake under 60% of maximum uptake were included in the segmental analysis.

Results

Left ventricular ejection fraction (P = 0.001) and end systolic volume (P = 0.008) showed significant improvement in both groups. There were no significant short-term and mid-term differences between the two groups in terms of left ventricular ejection fraction (P = 0.309) and end systolic volume (P = 0.938). Likewise, segmental rest (P = 0.178) and stress perfusion (P = 0.071), and systolic wall thickening (P = 0.241) showed significant improvement in both groups with similar time courses.

Conclusion

Off-pump CABG resulted in significant improvements in left ventricular ejection fraction, end systolic volume, and regional myocardial perfusion and function that are comparable to on-pump CABG at short-term and mid-term. Gated myocardial SPECT successfully revealed that off-pump CABG is as good as on-pump CABG from the viewpoint of myocardial perfusion and function.     

左冠状动脉异常起源于肺动脉的影像学诊断

目的评价影像学对左冠状动脉起源于肺动脉的诊断价值。资料与方法回顾性分析1995至2004年的3例经手术治疗患者,全部行心血管造影及彩色多普勒超声心动图检查,2例行MRA检查。结果心血管造影（逆行主动脉造影2例,选择性右冠状动脉造影1例）均显示良好,并明确诊断。彩色多普勒超声心动图,1例明确诊断,2例误诊为右冠状动脉-右心室瘘。MRA1例显示良好,另1例未能清晰显示。结论左冠状动脉起源于肺动脉罕见,心血管造影仍然是诊断的金标准,但MRA及彩色多普勒超声心动图是有用的非创伤性的诊断方法。     

Coronary to Bronchial Artery Fistula Causing Massive Hemoptysis in Patients with Longstanding Pulmonary Tuberculosis

We report on three cases of longstanding pulmonary tuberculosis patients with coronary to bronchial artery fistula (CBF) who presented with recurrent massive hemoptysis. The first and second patients died because of decreased functional pulmonary volume plus massive hemoptysis and cannulation failure of CBF due to hypovolemic vasospasm, respectively. When recurrent hemoptysis occurs despite successful embolization treatment, CBF should be considered as a potential bleeding source. Moreover, a coronary angiography should be performed, especially in patients with longstanding cardiopulmonary disease such as pulmonary tuberculosis.     

Noninvasive perfusion control by thallium-201 myocardial scintigraphy after coronary artery bypass surgery

Thallium-201 myocardial scintigraphy, which has been shown accurate in the assessment of myocardial perfusion, was employed in the evaluation of 34 patients after coronary artery bypass surgery. In 28 patients (82.4%), there was a clear correspondence in the postoperative studies between the defects shown on scintigraphy and the coronary artery stenosis documented by arteriography. Thallium imaging after coronary artery bypass revealed an increased or newly developed scintigraphic defect in eight of 10 patients with recurrent angina. Follow-up arteriography in these 10 patients revealed occlusion or stenosis of the bypass graft in five, perioperative myocardial infarction in two, and increased stenosis of a preoperatively less occluded artery in two. In 24 patients with postoperative clinical improvement or relief of angina,²⁰¹Tl scintigraphy revealed complete normalization of thallium uptake in three, improvement of uptake in 17, and unchanged uptake defects in four. Presented at the 5. Herbsttagung der Deutschen Gesellschaft für Kreislaufforschung, October 28, 1978, Berlin.     

Comparison of flow capacities of arterial and venous grafts for coronary artery bypass grafting: evaluation with exercise thallium-201 single-photon emission tomography

Stress thallium-201 tomography was performed to compare the flow capacities of arterial and saphenous vein grafts in patients with coronary artery bypass grafting (CABG). One hundred and seven consecutive patients (95 male and 12 female; mean age 58±9.1 years) underwent exercise-redistribution ²⁰¹Tl myocardial single-photon emission tomography 4–5 weeks after CABG. When a reversible perfusion defect was present in the area covered by a patent bypass graft, the flow capacity of the graft was defined as insufficient. Of all 285 grafts, 211 were considered as complete bypass. Reversible perfusion defects were present in 29 (27%) of 108 myocardial areas supplied by patent arterial grafts but in only 5 (5%) of 103 myocardial areas supplied by patent saphenous vein grafts (P<0.0001). In the LAD area reversible defects were observed in 22 of 82 areas covered by arterial grafts, in contrast to only 1 of 29 areas covered by venous grafts (P<0.01); in the RCA area reversible defects were observed in 7 of 17 and 4 of 41 areas respectively (P<0.01). There was no difference between the native coronary artery stenosis bypassed by patent arterial and venous grafts (88%±12% vs 86%±14% respectively, P=0.27). In conclusion, flow capacities during peak myocardial demand were more frequently insufficient in arterial bypass grafts than in saphenous vein grafts. Received 23 May and in revised form 7 August 1997     

非体外循环下冠状动脉搭桥术30例

目的总结非体外循环下冠状动脉搭桥术(OPCAB)的手术体会及术后处理经验。方法采用左乳内动脉、桡动脉和大隐静脉作为移植材料,共实施OPCAB30例,搭桥79支,术后加强呼吸道管理,保持循环稳定。结果本组除1例死亡外,其余随访3~24个月心绞痛症状均消失,无心肌缺血事件发生,患者生活质量明显提高。结论非体外循环下冠状动脉搭桥术创伤小,恢复快,效果良好,安全经济,是一种理想的手术方法。术后保持循环稳定,加强呼吸道管理可减少并发症。     

Subclavian Artery Occlusion and Pseudoaneurysm Caused by Lung Apex Mucormycosis: Successful Treatment with Transcatheter Embolization

Subclavian artery pseudoaneurysm and occlusion in young patients are usually post-traumatic. We report the case of a 33-year-old diabetic woman with subclavian artery occlusion and pseudoaneurysm formation caused by pulmonary mucormycosis infection. The patient presented with diabetic ketoacidosis, Horner’s syndrome, and absent left arm pulses. A cystic lesion of the left lung apex was found by imaging, was surgically resected, and was histologically diagnosed as mucormycosis infection. Magnetic resonance angiography depicted a left subclavian artery pseudoaneurysm and occlusion adjacent to the mucormycosis lesion. To protect against thromboembolic complications and rupture, the pseudoaneurysm was embolized with coils. The patient is clinically well 1 year after the intervention with no perfusion of the pseudoaneurysm.     

重症患者CABG手术及共围术期处理

报道重症患者冠状动脉旁路移植 (CABG)手术及其围术期处理的经验。 45例重症患者施行CABG手术 ,男 32例 ,女 13例 ,年龄 41～ 78岁。其中冠心病合并病变包括左室功能重度减退 (EF <30 % ) 7例 ,心脏瓣膜病 13例 ,心肌梗死后巨大左室室壁瘤 6例 ,75岁以上伴有高血压、糖尿病和肾或肺功能重度不全者 8例。瓣膜置换或升主动脉瘤术中左冠脉开口血供受影响而行急症CABG术 6例。全组择期CABG手术 40例 ,急诊手术 5例。冠状动脉旁路 1～ 4支 ,人均 2 .9支。 45例中单纯CABG术 2 0例 ,余 2 5例同期处理合并病变。术后早期并发症包括 :低心排综合征 6例 ,肾衰 3例 ,呼吸衰竭 2例 ,多器官功能衰竭 1例。 6例低心排综合征者应用I ABP后 5例痊愈 ,3例肾衰行腹透或血透治疗后均康复。全组早期死亡 2例 ( 4 4% ) ,分别死于低心排综合征和多器官功能衰竭 ,43例康复出院。晚期死亡 1例。术前控制好冠心病患者的血压、心率和糖尿病 ;术中使缺血心肌完全再血管化 ,加强有效的心肌保护 ;术后及时处理低心排与肾衰等 ,能显著地提高重症患者CABG手术的疗效。     

Abnormal Motion of the Interventricular Septum after Coronary Artery Bypass Graft Surgery: Comprehensive Evaluation with MR Imaging

Objective

To define the mechanism associated with abnormal septal motion (ASM) after coronary artery bypass graft surgery (CABG) using comprehensive MR imaging techniques.

Materials and Methods

Eighteen patients (mean age, 58 ± 12 years; 15 males) were studied with comprehensive MR imaging using rest/stress perfusion, rest cine, and delayed enhancement (DE)-MR techniques before and after CABG. Myocardial tagging was also performed following CABG. Septal wall motion was compared in the ASM and non-ASM groups. Preoperative and postoperative results with regard to septal wall motion in the ASM group were also compared. We then analyzed circumferential strain after CABG in both the septal and lateral walls in the ASM group.

Results

All patients had normal septal wall motion and perfusion without evidence of non-viable myocardium prior to surgery. Postoperatively, ASM at rest and/or stress state was documented in 10 patients (56%). However, all of these had normal rest/stress perfusion and DE findings at the septum. Septal wall motion after CABG in the ASM group was significantly lower than that in the non-ASM group (2.1±5.3 mm vs. 14.9±4.7 mm in the non-ASM group; p < 0.001). In the ASM group, the degree of septal wall motion showed a significant decrease after CABG (preoperative vs. postoperative = 15.8±4.5 mm vs. 2.1±5.3 mm; p = 0.007). In the ASM group after CABG, circumferential shortening of the septum was even larger than that of the lateral wall (-20.89±5.41 vs. -15.41±3.7, p < 0.05)

Conclusion

Abnormal septal motion might not be caused by ischemic insult. We suggest that ASM might occur due to an increase in anterior cardiac mobility after incision of the pericardium.     

Subclavian atherectomy and angioplasty for coronary subclavian steal syndrome post CABG

Coronary subclavian steal syndrome is an uncommon complication occurring in patients with coronary artery bypass graft (CABG). We describe a case of a 69-year-old male with a remote history of CABG who presented with exertional left arm pain and angina. Computed Tomographic Angiography of the chest demonstrated a severe left proximal subclavian artery stenosis. The case demonstrates successful application of subclavian atherectomy with use of embolic protective device, alleviating the need of stent, for treatment of Coronary subclavian steal syndrome in patient with remote history of CABG.     

冠状动脉搭桥术后磁共振桥血管成像的初步探讨

目的 以ＭＲ成像评价桥血管开通及功能,探讨适用于国人冠状动脉搭桥（ＣＡＢＧ）术后的影像学随访手段,方法 用１．５ＴＭＲ机检查２７例ＣＡＢＧ术后患者的７４支桥血管,行屏气快速场回波（ＦＦＥ）序列扫描观察桥血管的开通。其中１６例４２支桥血管行相位对比磁共振血流成像（ＰＳＭＲＡｆｌｏｗ）,得出血流速度和流量曲线,对桥血管的开通进行再评价。结果 本组桥血管ＦＦＥ成像开通率为８９．２％（６６／７４）。以ＰＳ     

Preoperative extracranial carotid artery examination with ultrasonography in patients undergoing coronary artery bypass grafting in Japan

Purpose We investigated the incidence, degree, and plaque characteristics of extracranial carotid stenosis with carotid ultrasonography (CUS) in patients undergoing coronary artery bypass grafting (CABG). Materials and methods Preoperative CUS was performed on 221 patients (442 carotid arteries) undergoing CABG. The degree of extracranial carotid stenosis was calculated based on the area stenosis, and it was classified into six grades as follows: grade (G) 0, G1 (1%–29%), G2 (30%–49%), G3 (50%–69%), G4 (70%–99%), and G5 (occlusion). Results The incidence of G4 was 4.1% and G5 1.6%. There were 48 arteries rated G3 or G4. Hypoechoic plaque was detected in 28 of the 48 arteries (58%), and heterogeneous plaque was detected in 37 arteries (73%). Ulcerative plaque was detected in 27 arteries (56%); when comparing the G3 and G4 groups, ulcerative plaque was found more frequently in G4 than in G3 (14/18 vs 13/30 arteries, P < 0.02). Conclusion Our study demonstrated that patients undergoing CABG with extracranial severe carotid stenosis tend to have heterogeneous, hypoechoic, and ulcerative plaque. We believe that preoperative CUS should be used to evaluate the plaque characteristics of extracranial carotid stenosis.     

冠状动脉瘘

研究分析冠状动脉瘘的临床和影像诊断。材料和方法：收集３９例冠状动脉瘘,年龄５岁～６４岁（平均２５．２岁）;均有主动脉根部或（和）冠状动脉造影（ＤＳＡ １９例,电影造影１２例,大片快速换片８例）。结果：听诊有连续性或双期性杂音２８例,ＥＫＧ正常或大致正常心电图１８例,单支形成瘘３７例,双支形成瘘２例,瘘口在右心室１５例（ＲＣＡ８例,ＬＣＡ７例）,右心房７例（ＲＣＡ４例,ＬＣＡ３例）,肺动脉８例（ＲＣ     

非体外循环跳动心脏上冠脉旁路术治疗观察

目的　总结非体外循环跳动心脏上冠脉旁路术治疗体会。方法　我院自 2 0 0 1年 3月— 2 0 0 2年 5月对 6例有心绞痛 ,内科药物治疗无明显好转 ,冠脉造影确诊为 3支病变 ,不适合冠脉腔内支架治疗的病人行非体外循环跳动心脏上冠脉旁路术。女 3例 ,男 3例。年龄 5 6 6 8岁 ,平均年龄 6 1 5岁。心功能 (NYHA)ⅢIV级。左室射血分数 (LVEF) 0 4 0 6。病人均伴有陈旧性心梗。前胸正中切口 ,采用左乳内动脉和大隐静脉为移植材料。结果　本组病人术后全部存活 ,平均搭桥2 6 7根。左乳内动脉桥 6根 ,其余为大隐静脉桥。采用“蛇形桥”2例 ,近端“Y”型吻合 2例。所有病人术后心绞痛消失 ,活动量增加 ,生活质量明显提高。对手术表示满意。结论　非体外循环跳动心脏上冠脉旁路术安全 ,经济 ,有效 ,病人容易接受 ,并可应用于多支血管病变     

Comparison of dobutamine stress echocardiography and technetium-99m sestamibi single-photon emission tomography for the diagnosis of coronary artery disease in hypertensive patients with and without left ventricular hypertrophy

Stress echocardiography has been considered an accurate method for the diagnosis of coronary artery disease in hypertensive patients and in patients with left ventricular hypertrophy. In contrast, the specificity of myocardial perfusion scintigraphy in these patients has been questioned. The aim of this study was to compare the accuracy of these two imaging modalities in conjunction with dobutamine stress test for the diagnosis of coronary artery disease in hypertensive patients with and without left ventricular hypertrophy. Dobutamine (up to 40 μg kg^–1min^–1) stress echocardiography in conjunction with sestamibi (MIBI) single-photon emission tomography (SPET) was performed in 84 patients with the diagnosis of systemic hypertension who had been referred for evaluation of myocardial ischaemia. Ischaemia was defined as new or worsened wall motion abnormalities at echocardiography and reversible perfusion defects at SPET. Significant coronary artery disease (≥50% luminal diameter stenosis) was detected in 66 patients (79%). The sensitivity, specificity and accuracy of the ischaemic pattern at echocardiography for the diagnosis of coronary artery disease were 73% (CI 63%–82%), 83% (CI 75%–91%) and 75% (CI 66%–84%), those for MIBI were 67% (CI 57%–77%), 83% (CI 75%–91%) and 70% (CI 60%–80%) respectively (P = NS vs echocardiography). Significant stenosis was detected in 123 (49%) of the 252 analysed coronary arteries. The sensitivity, specificity and accuracy of echocardiography for the regional diagnosis of coronary artery disease were 63% (CI 56%–69%), 90% (CI 86%–94%) and 77% (CI 72%–82%). Those for MIBI were 58% (CI 51%–64%), 91% (CI 87%–94%) and 75% (CI 69%–80) respectively (P = NS vs echocardiography). Left ventricular hypertrophy was detected in 59 patients (70%) by echocardiography and did not influence the overall or regional specificity of echocardiography or MIBI SPET. It is concluded that in hypertensive patients, dobutamine stress echocardiography and MIBI SPET have a comparable accuracy for the overall and regional diagnosis of coronary artery disease. Hypertensive patients with or without left ventricular hypertrophy should not be considered unsuitable candidates for stress myocardial perfusion scintigraphy. Received 10 July and in revised form 19 September 1997