Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting

Objectives: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.Methods: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 μg) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts.Results: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load) / (total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 ± 29% versus 5 ± 10%).Conclusions: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.

OBJECTIVES: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting. METHODS: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 micrograms) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts. RESULTS: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load)/(total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 +/- 29% versus 5 +/- 10%). CONCLUSIONS: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

微创冠状动脉旁路移植术处理前降支病变的围术期结果

目的研究胸腔镜辅助下经左胸小切口微创直视下冠状动脉旁路移植术(minimally invasive direct coronary artery bypass grafting,MIDCAB)处理前降支病变的围术期结果及其安全性。方法回顾性分析2014年5月至2018年10月在我院接受MIDCAB 92例患者的临床资料,其中男72例(78.26%),年龄42~78(61.29±7.48)岁,女20例(21.74%),年龄30~80(61.30±12.26)岁。分析围术期并发症发生率、血制品使用情况、左心功能变化情况、呼吸机使用时间、住ICU时间及住院时间等指标。结果2例(2.17%)患者中转正中开胸手术,5例(5.43%)术中输入血液制品,2例(2.17%)二次开胸止血,4例(4.34%)术后低氧血症,1例(1.08%)再次气管插管。呼吸机使用时间3~227(22.35±35.39)h,住ICU时间16~777(78.85±108.62)h,术后住院时间2~36(8.86±6.05)d。住院死亡1例(1.08%)。结论MIDCAB处理前降支病变具有较好的围术期结果,尤其适用于孤立性前降支病变,可缩短术后呼吸机使用时间、减少血液制品使用、缩短住ICU时间及住院时间。     

Significance of coronary artery bypass grafting to totally occluded left anterior descending coronary artery

The comparative studies on operative and hemodynamic results following coronary artery bypass grafting (CABG) were performed in 15 patients with totally occluded left anterior descending coronary artery (TOLAD) and 24 with partially occluded LAD (POLAD). There were two operative deaths and one whose graft was obstructed in POLAD. Four patients were revealed to have transmural myocardial infarction (TMI) in the region other than anterior segment on the preoperative electrocardiogram. Following results were obtained in 13 TOLAD (Group I) and 19 POLAD (Group II) with two subgroups, a: without TMI and b: with anterior TMI, whose all bypass grafts were patent. Left ventricular ejection fraction, Mean Vcf and left ventricular anterior, apical segmental wall motion significantly increased postoperatively in all groups, whereas postero-inferior segmental wall motion did not increase in all groups. Cardiac index and PLVSP/LVESV significantly increased postoperatively in all groups, but did not in Group Ib. Angina disappeared postoperatively in 12 patients (92.3%) in group I and 16 (84.2%) in Group II. In both groups, NYHA classification was improved from class III or IV preoperatively to class I or II postoperatively. Postoperative 10 years actuarial survival rate was 90.7% in Group I and 90.8% in Group II. In conclusion, it was proved that CABG to TOLAD offered significant increase in left ventricular contractility, better quality of life and satisfactory long term survival rate almost same as CABG to POLAD.     

Minimally invasive coronary artery bypass grafting for the left anterior descending coronary artery.

OBJECTIVE: A single surgeon conducted One hundred and twelve patients underwent minimally invasive direct coronary artery bypass grafting for the left anterior descending coronary artery 112 patients at Yamato Seiwa Hospital from September 1996 until August 1999. METHODS: All procedures were performed via left anterior short thoracotomy using a stabilizer during graft anastomosis. RESULTS: No operative deaths occurred but 3 patients died while hospitalized due to noncardiac events. Graft occlusion was seen in 3 patients early postoperatively. Other angiography graft failure such as stenosis was seen in 11 patients. Occlusive lesions of other coronary arteries occurred in 77 patients (69%) and 53 patients underwent percutaneous transluminal coronary angioplasty the pre/postoperatively for those lesions. CONCLUSIONS: These results suggest that minimally invasive direct coronary artery bypass grafting is seen by cardiologists as a reasonable form of revascularization in conditioned patients having left anterior descending artery lesion, and that minimally invasive direct coronary artery bypass grafting has a spectrum of candidates different from that of conventional surgical revascularization for the coronary artery.     

Off-pump coronary artery bypass grafting for the circumflex coronary artery via the left thoracotomy in redo CABG with the patent left internal thoracic artery graft to the left anterior descending artery.

Five patients had undergone off-pump coronary artery bypass grafting (CABG) as redo CABG via the left thoracotomy for the lesions of the left circumflex coronary arteries. In all patients, the internal thoracic artery (ITA) grafts to the LAD were well patent and acting significantly important in coronary circulation, however, ischemia due to the lesion of the LCX was significant. The saphenous vein grafts or the radial artery grafts were used as the materials of the grafts. The proximal ends of these grafts were anastomosed to the descending aorta. The procedures were completed successfully in all the patients and the excellent patency was shown angiographycally even in the long-term period after the surgery. Necessity of graft surgery only for the LCX lesion would be a rare occasion for a surgeon; however, these results suggest that the procedure is simple and less risky, which would encourage the surgeon to perform it in clinical situation.     

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 to left anterior descending coronary artery diagnosed by multidetector-row computed tomography

A 64-year-old male received coronary angiography because of chest pain. Although coronary angiography showed total occlusion of right coronary artery (RCA) # 2 and left anterior descending branch (LAD) #6, and a significant stenosis of left circumflex (LCx) #11, it could not visualize LAD distal to LAD # 6. Since coronary multidetector-row computed tomography (MD CT) could visualize the distal LAD, coronary artery bypass grafting (CABG) was indicated for this patient. Left internal thoracic artery (LITA) was anastomosed to LAD and saphenous vein graft (SVG) was used for distal anastomoses to obtuse marginal branch (OM) and 4-posterior descending branch (# 4 PD). Postoperative course was uneventful. LITA anastomosed to LAD and SVG to OM and # 4 PD were visualized by postoperative coronary angiography. MD CT in addition to coronary angiography was demonstrated useful to assess precise lesions of the coronary artery disease in this case.     

Sequential revascularization of intramuscular left anterior descending coronary artery

We present a new technique for avoiding possible kinking or angulation of the sequential left internal mammary artery to left anterior descending artery (LIMA-LAD) anastomoses when the LAD follows an intramuscular course. A 3- to 5-mm cusp of saphenous vein segment is interposed between the intramuscular LAD segment and internal mammary artery (IMA) at the sequential anastomotic site, to which the distal portion of the IMA was anastomosed in standard end-to-side fashion.     

Complete revascularization of the left anterior descending coronary artery.

OBJECTIVE: To assess the efficacy of complete revascularization of the left anterior descending coronary artery. METHODS: To obtain such revascularization, 81 patients required the use of such complex techniques as the onlay patch technique or double bypasses during bypass grafting. RESULTS: The onlay patch technique was used in 39 (48%) and double bypasses in 42 (52%). The wall motion in all anterior segments of the left ventricle showed an improving trend postoperatively. The patency rate was 99% overall, and the bypass grafts to the left anterior descending coronary artery were all patent with flow in all left anterior descending coronary artery areas. Perioperative myocardial infarction occurred in only 1 patient (1.2%), and hospital mortality was 2.5% (2/81). Long-term results of 79 hospital survivors were as follows: the mean follow-up time was 77 months (3 to 236); the actuarial survival rate including all deaths and estimated by cardiac death was 90% and 95% at the eighth postoperative year respectively; the cardiac event free rate at the fifth and eighth postoperative year was 90% and 63% respectively. A total of 8 cardiac events were observed. Excluding 3 cardiac deaths, no cardiac events were clearly attributable to the left anterior descending coronary artery. CONCLUSIONS: Complete revascularization of the left anterior descending coronary artery using these techniques improved the anterior wall motion in the left ventricle and cardiac performance at low risk, and provided excellent long-term results.     

Stent-grafting to descending thoracic aorta during coronary artery bypass grafting.

We report on 2 patients who underwent successful concomitant operation of coronary artery bypass grafting and stent grafting to descending thoracic aortic aneurysms. The device was inserted through a small linear incision on the anterior wall of the aortic arch. Intraoperative stent grafting to descending thoracic aortic aneurysms is an alternative therapeutic option for patients who require concomitant coronary artery bypass grafting and descending aortic replacement.     

Limitations of right internal thoracic artery to left anterior descending artery bypass: a comparative quantitative study of postoperative angiography of the bilateral internal thoracic artery bypass grafts

BACKGROUND: It remains controversial whether right internal thoracic artery (RITA) to left anterior descending artery (LAD) bypass has qualitative limitations which cannot be evaluated based on the patency rate alone. METHODS: The 111 subjects underwent graft angiography after bypass grafting of the left or right internal thoracic artery (ITA) to the LAD. The vascular caliber was measured at the origin of the ITA, at an ITA site adjacent to the anastomotic site, and at an LAD site immediately below the anastomotic site, regarding the outer diameter of the catheter as a reference. RESULTS: The caliber of the ITA immediately above the anastomotic site of the LAD was significantly lower in the RITA group. In the left internal thoracic artery (LITA) group, no patient showed a caliber of less than 1.25 mm, but five patients (7.8%) did in the RITA group. The preoperative cardio-thoracic ratio was significantly higher than that in patients in whom the caliber of the ITA immediately above the anastomotic site was 1.25 mm or more, and the height was significantly lower. CONCLUSIONS: In many patients, the RITA is appropriate as a graft material to the LAD. However, in patients with a high cardio-thoracic ratio and those with a low height, the RITA may not reach the LAD in a favorable state, and the LITA should be anastomosed to the LAD in some patients.     

Bilateral internal thoracic artery T grafting for coronary artery revascularization

OBJECTIVES: We studied the early outcome of bilateral internal thoracic artery T grafting. METHODS: Coronary artery bypass grafting was studied retrospectively using bilateral internal thoracic artery T grafting in 51 patients. The T graft was made by anastomosing the free right internal thoracic artery to the in-situ left internal thoracic artery. Average patient age was 63.5 +/- 9.9 years, and the average number of anastomoses per patient was 3.6 +/- 0.9. In 35 patients, the right gastroepiploic artery (21 anastomoses in 20 patients), radial artery (1 anastomosis), free left internal thoracic artery (1 anastomosis) and saphenous vein graft (14 anastomoses in 13 patients) were used as additional bypass conduits. RESULTS: Hospital mortality was 0%. The morbidity of stroke was 1.9% (1 patient) and deep sternal infection 0%. Patency of the in-situ left internal thoracic artery was 49/50 anastomoses (98%) and that of the free right internal thoracic artery 81/84 anastomoses (96.4%). Mid-term coronary angiography in 7 patients demonstrated patent anastomosis of the T graft. Acute myocardial infarction unrelated to graft failure occurred in 2 patients during follow-up. Other patients were evaluated by exercise stress tests every year and none exhibited myocardial ischemia in the areas of T graft coronary revascularization. Three-year actuarial survival rate was 100% and freedom from cardiac events 96%. CONCLUSIONS: The bilateral internal thoracic artery T graft provides satisfactory early and mid-term outcomes in properly selected patients.