Urgent surgical revascularization of unstable angina. Influence of double mammary arteries.

OBJECTIVE: Aim of this study was to evaluate retrospectively: (1) the outcome in patients with unstable angina (UA) refractory to the medical therapy undergoing urgent-emergent CABG; (2) the influence of both IMAs employment. PATIENTS AND METHODS: Between January 1995 and July 2000, 576 (28.5%) consecutive patients with UA underwent CABG procedure. 182 (31.6%, Group I) patients, presenting unstable hemodynamic or angina pectoris refractory to the maximal medical therapy, underwent urgent/emergent CABG. 397 (68.4%, Group II) patients, after the maximal medical therapy did not present angina's episodes or ECG alterations and underwent elective CABG procedure. Preoperative data were similar in the two groups. Both IMAs were used in 68 (37.4%) patients of I and 152 (38%) of II (P>0.05) to left side revascularization. RESULTS: CAD extension was greater in Group I: 45 (24.7%) patients presented ischemia in >1 area vs 53 (13.5%) in II (P<0.001). Incidence of anteroseptal ischemia resulted significantly higher in I (P=0.017); left main coronary artery stenosis was present in 68 (37%) patients in I vs 108 (27%) in II (P=0.01). LV function resulted significantly depressed in I, demonstrated by a significantly lower LVEF (P<0.001), higher NYHA class (P<0.001) and preoperative incidence of IABP (P<0.001). Intraoperative data analysis did not reveal any difference between groups. Hospital mortality was 13 (7%) and 21 (5.3%) patients in I and II respectively (P=ns). Multivariate analysis of all preoperative and intraoperative variables revealed the age >65 years (P=0.01), congestive heart failure (P<0.001), LVEF<35% (P=0.03), >1 ischemic area (P=0.02) as strong predictors for poor overall survival, and LIMA (P=0.006) and both IMAs (P=0.001) as strong predictors for good overall survival. Actuarial survival at 1, 3 and 5 years resulted to be 98.5, 96.5 and 90% in I and 99, 96 and 92% in II (P=ns). CONCLUSION: CABG has been associated with acceptable outcome in patients with UA which should be applied soonest possible in patients refractory to medical treatment. Total coronary revascularization and employment of both IMAs for left myocardial side are associated with low operative risk and incidence of complications, permit to have acceptable short and long-term outcome in this pool of patients.     

Skeletonized bilateral internal mammary artery grafting for patients with diabetes

To minimize sternal ischemia, skeletonized internal mammary artery (IMA) harvesting has been performed in the last few years. The benefits of skeletonization in high risk patients, such as diabetic patients undergoing bilateral IMA grafting, are unknown. A total of 99 patients underwent isolated coronary artery bypass grafting (CABG) using a pedicled bilateral IMA between 6/1/1997 and 5/31/2000 (group P), and 115 patients receiving a skeletonized IMA between 6/1/2001 and 3/31/2002 (group S). An ultrasonic scalpel was used for skeletonization. The perioperative and early angiographic results of CABG using these two techniques were collected prospectively and compared. There were two (1.7%) perioperative myocardial infarctions in group S and one (1.0%) in group P (P=NS), none of which were related to the IMA graft. The incidence of mediastinitis was one (0.9%) in group S and three (3.0%) in group P, P=NS, however, minor chest wound complications were observed in four (3.5%) in group S, which was significantly less frequent than the 12 (12.1%) in group P (P<0.05). Angiographic control was obtained in 87 patients in group S and 36 in group P, revealing no IMA occlusions in either group. Bilateral skeletonized IMA grafting for diabetic patients is safe and may decrease wound complications.     

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.     

Two-year assessment by exercise thallium scintigraphy of myocardial revascularization using bilateral internal mammary and gastroepiploic arteries.

OBJECTIVE: To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries. METHODS: Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients. RESULTS: During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy. CONCLUSIONS: Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.     

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.     

超声刀骨骼化获取双侧乳内动脉在冠状动脉旁路移植术中的应用

目的 总结超声刀骨骼化获取双侧乳内动脉在冠状动脉旁路移植术中的应用.方法 回顾性分析2016年1月至2020年5月我院54例采用双侧骨骼化乳内动脉进行搭桥患者的临床资料,其中男51例、女3例,平均年龄(62.37±9.56)岁.术前心功能分级(NYHA)Ⅱ级51例、Ⅲ级3例.结果 54例患者均顺利康复出院,平均搭桥(4...     

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.     

Off-pump awake coronary revascularization using bilateral internal thoracic arteries

Background

A new technique has been developed that permits complete arterial revascularization of the lateral and/or inferior wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, without cardiopulmonary bypass and mechanical ventilation, creates the least invasive revascularization method for the lateral and/or posterior wall of the heart yet described.

Methods

In 7 patients double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started one hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique by standard median sternotomy. Circumflex, or the right coronary artery, were anastomosed with bilateral internal thoracic arteries using a heart positioner. Six patients received double bypass grafting and one patient received triple bypass grafts (bilateral internal thoracic arteries and one radial artery).

Results

All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in three patients, but it was repaired in two. Only one patient completed the procedure with unilateral pneumothorax. There were no hemodynamic and pulmonary problems during lateral or posterior wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses.

Conclusions

Complete arterial revascularization by median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach gives a chance for awake revascularization of the right and/or circumflex coronary artery.     

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.     

Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries

Long-term follow-up data from several leading centers concerning patients undergoing coronary artery bypass clearly demonstrate the superiority of the internal mammary artery (IMA) with patency rates of 83 to 94% at 7 to 12 years compared with the saphenous vein and its patency rates of 41 to 53%. Our experimental studies provide a biological basis for understanding this difference. Thin-walled arterial autografts undergo no histological change after being implanted in the arterial system, while venous autografts undergo major changes with an initial scattered loss of endothelium and marked thickening due to a proliferative reaction. The challenge to the cardiac surgeon is to revascularize the entire left ventricle with the IMAs. We have found this possible in most patients with advanced three-vessel disease by using both IMAs either as in situ grafts or free grafts with as many sequential anastomoses as necessary to achieve full revascularization. Our use of the term in situ refers to the graft's origin from the subclavian artery as opposed to a free IMA graft arising from another site.     

Extended use of bilateral internal mammary arteries for coronary artery disease

The internal mammary artery is the conduit of choice for coronary artery revascularization. Wide angulation between the left anterior descending coronary artery and obtuse marginal branches and the diseased segments of the coronary arteries can prevent optimal positioning of the left internal mammary artery for sequential anastomoses for revascularization. We describe a technique using a segment of the left internal mammary artery as a free graft sewn in an end-to-side fashion to the in situ left internal mammary artery. This approach has technical and physiological advantages over previously described techniques.     

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impeding renal failure

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.