The Treatment of Multiple Coronary Occlusions by Internal Mammary Artery Implantation and Omental Graft: Report on Two Human Cases

The importance of triple coronary artery disease was evident in 125 patients undergoing internal mammary artery implantation, when some patients died from right coronary artery occlusion. This occurred even when the internal mammary artery was patent and revascularizing the left ventricle.

In 1961 the free omental graft operation was developed to revascularize both right and left ventricles. In animals this operation has proved most effective in preventing death after application of Ameroid constrictors to all three coronary arteries. Arteriolar or larger-sized vessels rapidly formed between the aorta and omentum and the pericardium and omentum and the heart and omentum.

Two patients with triple coronary artery disease underwent internal mammary artery implantation and free omental graft early in December 1962. Postoperative convalescence was uneventful. They have returned home and appear to be improved. Wrapping the entire heart with the free omental graft has produced little reaction, suggesting that, as in the animal, the grafts are surviving.

     

Right Internal Mammary Artery Implantation into Right Ventricular Myocardium for Revascularization of the Entire Heart: Experimental Data and Preliminary Report

The left internal mammary artery implant combined with epicardiectomy and free omental graft provides three extra-coronary sources of blood. This operation tested in dogs with 92% main-stem occlusion of three coronary arteries protected 75% of the animals. Applied clinically in over 100 patients, the operation resulted in 90% improvement. To obtain complete myocardial revascularization, the right internal mammary artery has been used as a fourth source of extra-coronary blood. In 57 animals, the right internal mammary arteries were implanted into the anterior walls of the right ventricle; in 80% this vessel formed anastomoses with the right coronary tree, and in 65% with the right and left coronary arteriolar systems. Six patients are described who underwent right internal mammary artery implantation; five of these in addition had the combined operation of left internal mammary artery implant, epicardiectomy and free omental graft. All patients had completely blocked right coronary arteries; in addition, five had advanced disease of the left coronary arterial tree.     

Implantation of the Right and Left Internal Mammary Arteries with Epicardiectomy and Free Omental Graft: A Preliminary Experimental Report

In animal experiments the right internal mammary artery was implanted into the outflow tract of the right ventricle during performance of left mammary artery implantation with epicardiectomy and free omental graft. The effect of double mammary artery implantation operation was tested by triple coronary artery ameroid constriction in 24 animals. In 20 animals studied both implanted arteries remained open and had commenced to bud and branch at the time of examination. The double implant operation is still an experimental procedure.     

Results of 14 Years' Experience in the Surgical Treatment of Human Coronary Artery Insufficiency

Atherosclerosis obstructs the main stems of coronary arteries, restricting the coronary artery inflow tract. Nature develops intramyocardial collaterals but fails to form extracoronary collateral channels. It is only through surgical measures that extracoronary collateral channels may be formed, for example, by internal mammary artery implantation and omental graft without pedicle operations. Preoperative assessment, with particular reference to anginal pain, disease activity, indications for and contra-indications to surgery, is outlined. The importance of cine coronary arteriography is stressed. The results of internal mammary artery implantation with or without omental graft in patients followed up for two to 14 years are presented. Operative mortality in 103 consecutive patients was 2.9%. There was marked improvement in over 70% of 115 patients reviewed. Post-operative examination of 29 implanted internal mammary arteries showed that 76% were open when examined up to 10 years postoperatively; many of these were studied by cineangiography.     

Total Arterial Revascularization with Internal Mammary Artery or Radial Artery Graft Configuration

To investigate the clinical use of π graft in total arterial revascularization and its outcomes, a retrospective analysis of 23 patients out of 1000 patients undergoing total arterial coronary bypass surgery with a π graft between September 1994 and December 2004 was performed. In the selected patients for the management of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip with the left internal mammary artery (LIMA) or radial artery (RA),the main stem of π graft, to the left anterior descending coronary artery (LAD) will not work and the right internal mammary artery (RIMA) or right gastroepiploic artery (RGEA) cannot pick up the diagonal/intermediate ramus, hence the LAD and diagonal/intermediate ramus were grafted with a mini Y graft using the distal segment of LIMA, RIMA, RA or RGEA, together with the bilateral internal mammary artery (BIMA) or LIMA-RA T graft to compose π graft. Twenty-three patients (18 males, 5 females) underwent the π graft procedure. There were no deaths or episodes of myocardial infarction, stroke, and deep sternal wound infection. One patient required reopening for controlling bleeding. Until the end of 2004, during a mean follow-up of 81.0 ±28.4 months, no angina needing re-intervention or operative therapy or coronary related death occurred. In conclusion, in patients with specific coronary artery anatomy/stenosis, the BIMA (sometimes LIMA with RA or RGEA) π graft can be successfully performed for total arterial revascularization with good midterm outcomes.     

Total Arterial Revascularization with Internal Mammary Artery or Radial Artery π Graft Configuration

The superior short-and long-term patency ofthe left internal mammary artery(LI MA)hasmade it the conduit of choice in myocardial revas-cularization.Abandonment of traditional pedicleharvestingtechniqueinfavor of a semi-skeletonizedone[1,2]allows for maxi mal utilizable LI MAlength.In the selected patients for the manage-ment of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip withthe LI MAto the LAD will not work and the RI MAcannot pick upthe diago…     

非体外循环冠状动脉旁路移植术的临床应用

目的总结非体外循环冠状动脉旁路移植术的治疗经验。方法整理并分析2003年5月~2006年2月148例非体外循环冠状动脉旁路移植术的临床资料。其中陈旧性心肌梗塞71例,三支病变110例,左主干病变58例,急诊及亚急诊手术18例。结果全组手术死亡4例。平均移植桥血管3.12±0.66支,采用左乳内动脉147例,选用桡动脉为桥血管48例。术后心绞痛均消失,心脏功能改善。结论非体外循环冠状动脉旁路移植术安全、有效;取得满意手术效果的关键是把握手术适应证、术中配合、手术技巧和围手术期处理。     

Revascularization of the Entire Heart by Internal Mammary Artery Implantation, Epicardiectomy and Free Omental Graft

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author's experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were “bed-chair cripples” (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.     

Total Arterial Revascularisation in Left Ventricular Dysfunction

Despite the excellent results achievable withcoronary artery bypass operations using a singlein-ternal mammary artery(I MA)graft to the left an-terior descending coronary artery(LAD)and addi-tional saphenous vein grafts,the long-term paten-cy of vein grafts in the coronary artery circulationhas beenless than that of arterial grafts.Choosingthe conduit with the highest early and long-termpatency for all of the diseased coronary arteries isone way to i mprove outcomes of coronary arterybypass …     

冠状动脉旁路移植术56例报道

目的总结分析56例冠状动脉旁路移植术(CABG)的临床经验.方法 1999年10月～2003年11月,我院对56例冠心病患者行冠状动脉旁路移植术.左主干病变4例,单支病变3例,双支病变13例,三支病变36例.全部胸骨正中切口,42例在体外循环下进行,17例在非体外循环下进行.乳内动脉搭桥26根,大隐静脉搭桥128根,人均搭桥2.8支.结果全组死亡1例,其余患者痊愈出院,术后心绞痛完全消失或明显减轻.随访2～48个月效果良好.结论 CABG是治疗冠心病的一种安全有效的方法,合理选择病人,妥善围手术期管理,术中良好的心肌保护及不断提高外科操作技术是提高手术成功率的关键.     

Criteria for Internal Mammary Artery Implantation Based on Cine Coronary Arteriography

Preoperative coronary arteriograms were correlated, in a group of 50 patients, with left internal mammary angiograms obtained from 11 to 32 months, with a mean of 17 months, after mammary artery implantation. In all patients in whom the internal mammary artery was patent and considered functional with good angiographic opacification of the anterior descending coronary artery, the preoperative coronary angiogram showed total or subtotal obstruction of the latter vessel, with indirect evidence of decreased flow and pressure distal to the obstruction. This evidence was provided by the presence of a collateral circulation or, in a few cases of subtotal obstruction, delayed opacification of the vessel distal to the obstruction.

In patients in whom the internal mammary artery was patent but showed no anastomotic connection with the anterior descending coronary artery or only opacification of small coronary branches, the degree of coronary obstruction was, in most cases, less than 90% of the lumen of the coronary artery in the absence of any collateral circulation or delayed opacification of the vessel distal to the obstruction.

Occlusion of the internal mammary artery was seen as often in the presence of total or subtotal obstructions as with lesser degrees of anterior descending coronary artery obstruction, and is believed unrelated to the degree of pre-existing coronary artery disease.

Successful internal mammary artery implantation can be related to specific coronary angiographic patterns recognizable before operation; these may serve as reliable criteria for the selection of patients.

     

The Continuity of Right and Left Ventricular Myocardial Sinusoidal Spaces and its Relation to Right Ventricular Implants

Evidence is presented which indicates that blood leaving side branches of an internal mammary artery implanted into the anterior wall of the right ventricle flows from the tunnel in which it lies through myocardial sinusoidal spaces of the anterior right ventricular wall across the midline to fill corresponding spaces in the anterior wall of the left ventricle and thence is carried to the left coronary sinus. The myocardial sinusoidal spaces of right and left ventricles have been well outlined, using injections of polyvinyl acetate and the technique of digestion casts. We have been able to show that there is no barrier between the myocardial sinusoids of the right circulation and those related to the anterior descending branch of the left coronary artery. In structure, these myocardial sinusoidal spaces are quite different from the intramyocardial coronary arteriolar zones which, in 93% of human hearts, are separated from one another without collateral communication.

The continuity of the right and left ventricular myocardial sinusoids explains why implantation of a right internal mammary artery into the anterior wall of the right ventricle combined with a corresponding left implant, epicardiectomy and free omental graft, has been so effective in our hands in the treatment of far-advanced human coronary artery insufficiency.

     

Multiple coronary artery bypass grafting in dextrocardia: case report

This is a case report of an unusual case of a patient with dextrocardia and "situs inversus totalis" who presented with unstable angina. Coronary angiography revealed severe main stem and severe triple vessel coronary artery disease. The patient later underwent successful emergency coronary artery bypass graft surgery. To the authors' knowledge this is the first reported case in Malaysia and also, the first ever report in the literature of multiple vessel coronary artery grafting, including the use of the right internal mammary artery.     

冠状动脉旁路移植术治疗冠心病25例

目的 :回顾冠状动脉旁路移植术 ( CABG)治疗冠心病的早期效果和经验。方法 :2 5例冠心病病人92 %为多支冠状动脉病变。 1 0例左室射血分数 ( EF)≤ 45 % ,其中 4例 <30 %。所有患者均有心绞痛症状 ,CCS ～ 级。 1 0例在非体外循环、心脏不停跳下手术 ,余为低温体外循环 ( CPB)下手术。 1 4例采用左乳内动脉与左前降支搭桥 ,余均为大隐静脉桥 ,人均搭桥 3.0 8支。同期行激光心肌血管重建术 ( TMLR) 3例。结果 :2 5例 CABG临床效果良好 ,无手术死亡。术后 96%的患者心绞痛症状完全消失。结论 :CABG是一种治疗冠心病安全和有效的方法 ,近期临床效果满意。     

使用桡动脉和乳内动脉桥材料全动脉化冠状动脉旁路移植手术的近中期结果

目的评价使用桡动脉和乳内动脉作为惟一桥材料进行全动脉化冠状动脉旁路移植手术的近期和中期结果。方法从1999年1月到2005年1月共123例患者[男114例,女9例,平均年龄（51．9±9．4）岁]采用全动脉化冠状动脉旁路移植手术,目标血管桥在两根以上。术前左心室EF值30％～78％,24例患者（21．1％）心室收缩功能较差（EF〈50％）。64例患者有陈旧性心肌梗死病史,4例患者因不稳定性心绞痛进行了急诊手术。36例左主干病变患者。74％的患者使用非体外技术进行吻合,每个患者平均吻合口数为2．6±0．4。结果早期死亡率0．8％。术后并发症包括,7例患者出现一过性房颤（5．7％）,1例患者因为低心排安装主动脉球囊反搏（IABP）,3例患者因为心力衰竭、再发心绞痛和心律失常在术后1个月内再次入院。20例患者（1999--2001年）进行了5年随诊[平均随诊（62±13）个月]。3例患者在随诊中死亡,均为心脏原因。1例患者因再次心肌梗死而行二次冠状动脉旁路移植手术,另1例患者因原先动脉桥狭窄而行经皮冠状动脉内球囊扩张术（PCI）。结论使用桡动脉和乳内动脉作为桥材料进行全动脉化冠状动脉旁路移植近期效果较好,中期手术并发症较低。     

ANALYSIS OF 312 CASES OF REPEAT CORONARY ARTERY BYPASS GRAFTING

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Saphenous vein bypass grafting for coronary atherosclerosis: clinical experience

Saphenous vein bypass grafting is a recent and important procedure in the management of atherosclerotic coronary artery disease. A review of the first 150 patients operated on to July 1971 at the Toronto General Hospital is presented. Many had multiple bypass grafts and some had additional procedures including internal mammary artery implantation, valve replacement and scar tissue resection. There were five operative deaths (3%) and an additional five hospital deaths; the majority were related to myocardial infarction.

A clinical review of the results six months to three years after operation indicates marked improvement in over 80% of the survivors. Postoperative hemodynamic studies were performed in many. It is suggested that patients with poor myocardial function presenting in failure may not benefit from the operation.

     

双侧乳内动脉在冠状动脉搭桥中的应用

目的：探讨双侧乳内动脉在冠状动脉搭桥中的应用及效果。方法：自1998年1月到2001年3月,运用双侧乳内动脉连续为51例患者行冠状动脉搭桥手术。所有患者均为男性,年龄36-65岁（平均49.9岁）,48例患者为3支病变,3例为左主干病变,37例术前有心梗,4例合并室壁瘤。47例在体外循环下行冠状动脉搭桥手术,4例在非体外循环下行冠状动脉搭桥手术。39例行左侧乳内动脉（LIMA）到钝缘支、右侧乳内动脉（RIMA）到前降支;9例行LIMA到前降支、RIMA到右冠状动脉手术;LIMA到前降支、RIMA到钝缘3例。运用胃网膜右动脉或桡动脉行其他病变血管搭桥手术。4例同时行室壁瘤切除。1例行冠状动脉内膜剥脱。人均搭桥3支。结果：手术早期死亡3例（手术早期死亡率5.9％）。死亡原因：1例术后围术期心梗导致低心排,1例顽固性心律失常,1例因脑栓塞在术后40d死亡。4例需主动脉球囊反搏支持。2例术后出现切口感染,再次清创处理。随访2-39月（平均15.5个月）,患者均无心绞痛再次发作。B超检查显示双侧乳内动脉均通畅。结论：双侧乳内动脉在冠状动脉搭桥中具有较好的应用效果,近期效果比较满意,远期效果尚待进一步随访。     

Coronary subclavian steal syndrome: a rare cause of acute myocardial infarction

The coronary subclavian steal syndrome (CSSS) leading to an acute myocardial infarction (AMI) post-coronary bypass is a rare occurrence. We describe an 83-year-old Indian man who presented with AMI and was subsequently found to have CSSS. The patient had severe stenosis of his left subclavian artery ostium with retrograde flow up his left internal mammary artery graft. Angiographical steal from the left anterior descending artery was demonstrated during coronary angiogram and was thought to be the main contributing cause of his AMI. Percutaneous transfemoral angioplasty and stent implantation was performed to the left subclavian artery, with resolution of myocardial blood flow steal and anterior ischaemia.