Coronary-coronary bypass using internal mammary artery

A free right internal mammary artery was used to bypass the right coronary artery in a patient with no available saphenous vein. The proximal end of the right internal mammary artery was anastomosed to the proximal right coronary artery, and the distal end of the free graft was anastomosed to the posterior descending coronary artery. Coronary-coronary bypass using a free internal mammary artery is an attractive approach to bypassing very distal vessels when other conventional grafting techniques are not possible.     

Coronary-coronary artery bypass: an alternative

Occasionally, a patient with calcification of the ascending aorta will be unsuitable for conventional saphenous vein aortocoronary bypass. Similarly, when a patient is seen with saphenous vein (or internal mammary artery) of inadequate diameter or quality, another method of revascularization must be selected. Two cases of coronary-coronary artery bypass are illustrative of one solution to these difficult and increasingly common problems.     

Right gastroepiploic artery: a third arterial conduit for coronary artery bypass

Experience with 39 patients (32 men, 7 women) undergoing coronary artery bypass grafting with the right gastroepiploic artery (RGEA) is reported. Indications initially included poor-quality or absent saphenous vein, ascending aortic atherosclerosis, and repeat coronary artery bypass grafting. The average number of grafts per patient was 4.10. Arteries bypassed were the posterior descending (22 patients), right coronary (12), diagonal (5), and marginal (4). Distal RGEA internal diameters of all grafts measured 1.5 to 3.25 mm (average diameter, 2.14 mm). Pedicled graft lengths measured 18 to 30 cm (average length, 23.7 cm), and free grafts, 8 to 24 cm (average length, 17.7 cm). In 6 patients, no vein grafts were used, and in all patients, at least one internal mammary artery graft was placed. Early postoperative cardiac catheterization (19 pedicled and ten free grafts) in 29 patients revealed all grafts to be patent without a kink or twist, but three of these free RGEA grafts had vasospasm. Advantages of RGEA grafts are as follows: (1) it is a third arterial conduit with artery-artery anastomoses of comparable sizes; (2) a shorter leg incision or no leg incision is necessary; (3) it can be harvested simultaneously with the internal mammary artery and the saphenous vein; (4) the proximal anastomosis (free grafts) is easy; (5) its use avoids bilateral internal mammary artery grafts in patients at high risk for sternal infection; and (6) atherosclerotic ascending aortas are not clamped. Subintimal hyperplasia and atherosclerosis of RGEA grafts are unlikely.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complete arterial coronary revascularisation using radial artery conduit for double thoracic artery inlet flow: arterial sling operation.

BACKGROUND: Coronary artery bypass graft surgery with arterial revascularisation of all diseased coronary vessels is considered highly efficient because arterial grafts have an excellent long-term patency compared with venous grafts. However, problems to reach the infero-lateral wall with the in situ internal thoracic arteries usually require alternative techniques. We present the first results of a new surgical principle using a free radial artery segment to complete the arterial coronary revascularisation and concomitantly connect the internal thoracic arteries. METHODS: In patients referred for coronary bypass surgery and three-vessel disease an end-to-end anastomosis of the right internal thoracic artery and the radial artery segment preceded cardiopulmonary bypass, during which side-to-side anastomoses of the radial artery segment were used to revascularise stenotic branches of the right coronary and circumflex arteries. The left internal thoracic artery was used for revascularisation of stenotic branches of the left anterior descending artery, and finally an end-to-side anastomosis of the radial artery segment to the left internal thoracic artery was performed. Coronary artery blood flow was measured in 41 patients with Doppler flow probe. RESULTS: One hundred and ninety-two coronary anastomoses (an average of 4.2 per patient) were performed in 46 patients. We measured a mean total blood flow in the arterial sling graft of 104ml/min (range 35-221ml/min), compared with 69 and 68ml/min of the single inlet right and left internal thoracic arteries, respectively (P<0.01). Flow capacities of 104 and 120ml/min of the right and left internal thoracic arteries were measured during clamp of both the aorta and the contralateral internal thoracic artery. The mean crossclamp duration was 77min (range 51-113min). Postoperative angiography demonstrated patent graft anastomoses to all coronary arteries. There were no perioperative deaths or myocardial infarctions. One patient had a minor postoperative stroke. DISCUSSION: Complete arterial revascularisation can be achieved by the arterial sling operation with an acceptable crossclamp time and a high early rate of graft patency. The double arterial inlet provides a 50% higher blood flow to the beating heart and two-fold increase in the flow reserve compared with a single inlet. Although further research including long-term follow-up of this new principle is required, the present findings seem promising and suggest that the arterial sling operation has a potential role for complete arterial coronary revascularisation.     

Postoperative mediastinitis after the coronary artery bypass grafting using internal thoracic artery graft

It has been pointed out in general that the resistance against infection is decreased in the diabetic patients. This problem is very important in patients undergoing major surgery. In cardiovascular surgery, the median wound infection may result in life threatening sequelae. We have used the internal thoracic artery as the appropriate graft for its excellent long-term patency. In this series of the diabetic patients who underwent coronary artery bypass grafting with bilateral internal thoracic artery grafts, the incidence of postoperative mediastinitis was significantly higher than other cases. Therefore the use of bilateral internal thoracic artery grafts should be avoided, if possible in the diabetic patients.     

Natural Y-grafting using internal thoracic artery branches for off-pump coronary artery bypass

The excellent long-term patency rates achieved utilizing the internal thoracic arteries (ITAs) have stimulated a variety of approaches to expand the use of these conduits in coronary revascularization. The ITA divides at the level of the fifth or sixth intercostal space into the superior epigastric and musculophrenic branches. If these terminal branches of the ITA are large and long enough for grafting, they can be used to construct a "Y" anastomosis to the coronary arteries. We experienced 2 patients who underwent multivessel off-pump coronary artery bypass (OPCAB) using these ITA branches. In both patients the bilateral ITAs and the right gastroepiploic artery were taken down using the skeletonization technique as in situ grafts. One patient had 5 grafts including the right ITA terminal branches which were used for the left anterior descending branch (LAD) and diagonal branch. Another patient had 6 grafts including the left ITA terminal branches which were used for the posterolateral branch (PL)1 and PL2. Postoperative angiography revealed widely patent grafts in both patients. We believe that one of the advantages of applying the off-pump technique when the ITA branches are used is that it might be easier to arrange the angle of constructing a natural "Y" configuration compared with conventional coronary artery bypass grafting (CABG). In conclusion, the terminal branches of the ITA, if of suitable size, should be considered for "Y" grafts to diseased coronary arteries when performing complete arterial revascularization with only in situ grafts.     

Radial versus right internal thoracic artery as a second arterial conduit for coronary surgery: early and midterm outcomes

OBJECTIVE: We sought to compare early and midterm clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second arterial conduit for myocardial revascularization. METHODS: Data prospectively collected for all patients who underwent coronary artery bypass surgery between April 1996 and May 2001 and who received both a left internal thoracic artery graft and either a right internal thoracic artery (n = 336) or a radial artery graft (n = 325) were analyzed. Patients in the radial artery group were older, with a greater body mass index, poorer ejection fraction, greater prevalence of diabetes, and higher New York Heart Association class than those in the right internal thoracic artery group. RESULTS: Odds ratios for perioperative myocardial infarction, atrial fibrillation, postoperative transfusion, and intensive care unit stay all showed a statistically significant benefit in the radial artery group compared with results in the right internal thoracic artery group (P 相似文献   

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.     

Coronary bypass surgery using the internal thoracic artery after reconstruction of occluded subclavian artery.

We present two cases with an occluded left subclavian artery requiring coronary artery bypass grafting. A preoperative angiogram confirmed that the subclavian artery, including the internal thoracic artery distal from the occlusion, was thoroughly intact, in both cases. Immediately after reconstructing the subclavian artery using an aortoaxillary bypass with an 8 mm ring-reinforced polytetrafluoroethylene graft, each patient underwent double coronary artery bypass grafting using the affected left internal thoracic artery with either the right internal thoracic artery or a saphenous vein in the same anesthetic setting. Symptomatic relief was excellent. In both cases, a postoperative angiographic study showed good function of the left internal thoracic artery graft supplying blood to the coronary artery through the aortoaxillary bypass graft.     

Free right internal thoracic artery as a second arterial conduit: modification of proximal anastomosis for improvement of graft patency.

The applicability of the right internal thoracic artery (RITA) for coronary artery bypass grafting is higher when used as a free graft than as a pedicled graft. However, the technical difficulty of directly connecting the proximal end of the free RITA to the much larger aorta leads to poor patency. To overcome this technical limitation, we have used a modification that places the proximal end of this artery onto the hood of an accompanying vein graft at the aortic anastomosis instead of directly onto the aorta. We performed isolated coronary artery bypass grafting on 43 patients using the free RITA as a second arterial graft following pedicled left internal thoracic artery grafting. The mean patient age was 60 years and 38 patients were male. There was no mortality and no incidence of morbidity related to free RITA use. Postoperative coronary angiography performed in all patients revealed that all proximal anastomoses were widely patent, making the patency rate of the free RITA 100%. With these encouraging results, the free RITA graft with the described modification is thought to be a more promising second arterial graft with greater versatility than the pedicled graft. The long-term evaluation of a large patient population will determine the significance of this modification.     

Left internal thoracic artery composite grafting with the right internal thoracic versus radial artery in coronary artery bypass grafting

Abstract Background: The aim of this study was to compare the results of all arterial multivessel coronary artery bypass grafting using the left internal thoracic artery composite bypass graft constructed with the right internal thoracic artery or radial artery. Methods: Patients undergoing coronary artery bypass grafting with a left internal thoracic artery constructed as a composite bypass graft with either a right internal thoracic artery (n = 45; RITA group) or radial artery (n = 352; RA group) between 2003 and 2009 were included in the present study. Results: The three‐year patency rates for the RITA and RA groups were 91.8%± 4.3% and 78.6%± 3.4%, respectively (p = 0.12). Adjustments for covariates revealed the radial artery patency to be significantly inferior to the right internal thoracic artery graft (hazard ratio 4.35, 95% confidence interval 1.05 to 18.0; p = 0.043). Reintervention for target coronary artery occlusion was required in two patients in the RA group over a mean follow‐up period of 35.5 ± 21.5 months. There were 43 deaths in the entire cohort of which 20 were cardiac. After adjustment for significant variables, the risk of all‐cause mortality, cardiac death, and the composite of adverse events (death, reintervention, myocardial infarction, and stroke) were similar for the two groups (p = 0.98, 0.99, and 0.21, respectively). Conclusions: Although superior patency was observed with the right internal thoracic artery over the radial artery graft, a significant commensurate benefit in reducing the incidence of major adverse clinical outcomes was not necessarily shown. (J Card Surg 2011;26:579‐585)     

Extrathoracic subclavian internal thoracic artery bypass grafting.

Interval development of a significant stenosis at the origin of the left internal thoracic artery (LITA) after this vessel has been used to revascularize the anterior descending coronary artery may be an indication for reoperation. We present an extrathoracic approach to bypass the proximal segment of the LITA that allows patients with this lesion a quick recovery, short hospital stay, and early resumption of normal activity.     

Postoperative internal thoracic artery spasm after coronary artery bypass grafting

Spasm of the left internal thoracic artery in the perioperative period represents a life-threatening complication after coronary artery bypass grafting. We present a case in which graft spasm was treated with the administration of intra-arterial nitroglycerin and verapamil. Although vasospasm is more often seen in radial artery grafts, this case demonstrates that left internal thoracic artery grafts are also prone to spasm.