Return of the Left Internal Mammary Artery

Competitive flow from a non-critical native vessel leading to longitudinal narrowing/atresia of the left internal mammary artery (LIMA) is described as “the string phenomenon.” We describe spontaneous recanalization of an atretic LIMA following coronary artery bypass grafting for multivessel coronary artery disease.     

药物洗脱支架治疗左乳内动脉桥血管病变的临床研究

目的:评价药物洗脱支架(DES)治疗左乳内动脉(LIMA)桥血管病变的临床效果。方法:回顾性分析从2004年5月到2006年5月我院对LIMA桥血管病变连续行经皮冠状动脉介入治疗(PCI)13例患者。结果:患者基线特点:年龄(57.5±10.2)岁;男性10例(76.9%);既往心肌梗死8例(61.5%);既往PCI7例(53.8%);糖尿病6例(46.2%);左心室射血分数0.466±0.312。病变基线特点:远端吻合口12例(92.3%);体部1例(7.7%)。参照血管直径(2.95±0.47)mm;病变长度(14.0±14.6)mm。置入DES100%;支架直径(2.92±0.49)mm;支架长度(18.8±6.2)mm;支架释放压力(13.5±2.5)atm。介入成功率100%。所有患者完成6个月临床随访,有3例完成造影随访。主要心脏不良事件0%;无死亡、急性心肌梗死、靶血管再血管化治疗。有3例患者因非靶病变再次行PCI治疗。结论:DES治疗LIMA桥血管病变是安全可行的。     

Multiple Left Internal Mammary Artery-to-Pulmonary Artery Fistulae 15 Years after Coronary Artery Bypass Grafting

Left internal mammary artery (LIMA)-to-pulmonary artery fistulae rarely develop after coronary artery bypass grafting. Fewer than 30 cases of these fistulae have been reported since 1947. Nevertheless, this entity should be considered as a cause of recurrent angina after bypass surgery, in the absence of other causes. We present the case of a 67-year-old man with cardiac symptoms in whom multiple LIMA-to-pulmonary artery fistulae were found, 15 years after he had undergone coronary artery bypass grafting. The diagnosis was confirmed by means of coronary angiography with selective catheterization of the LIMA and by computed tomographic angiography of the heart. The patient underwent reoperative 2-vessel coronary artery bypass grafting and ligation of multiple fistulae; 16 months postoperatively, he was asymptomatic and doing well. In addition to reporting this case, we discuss relevant diagnostic and treatment considerations.Key words: Arteriovenous malformations/physiopathology, coronary artery bypass/adverse effects, fistula/etiology, internal mammary-coronary artery anastomosis/adverse effects, mammary arteries/surgery, myocardial ischemia/etiology, pulmonary artery/surgery, vascular fistula/complications/etiology/surgeryAs a bypass-graft conduit to the left anterior descending coronary artery (LAD), the left internal mammary artery (LIMA) is the vessel of choice because of its proven longevity and long-term patency. The formation of a LIMA-to-pulmonary artery (PA) fistula after coronary artery bypass grafting (CABG) is a rare complication: fewer than 30 reports have appeared in the medical literature.¹ We report a case of multiple LIMA-to-PA fistulae that we found 15 years after a patient had undergone CABG.     

Left Main Coronary Angioplasty: Assessment of a "Risk Score" to Predict Acute and Long-Term Outcome

Due to the recent emergence of adjunctive techniques such as cardiopulmonary bypass support, left main angioplasty may become more routinely applied in the near future. In order to choose the best possible therapy, a precise risk assessment will be desirable. Twenty-two left main angioplasties were thus reviewed and patients were divided in two groups according to a risk score adapted from a previously published jeopardy score. Group I included patients with a risk score ≤ 6 and group II patients with a risk score > 6. A cutoff criterion of six points was chosen because it represents the maximal amount of myocardium put at jeopardy from a single coronary stenosis. The success rate of the procedure was 77% and was similar in both groups. Of the 12 patients in group I, two patients underwent in-hospital bypass surgery and one of them died. Among the ten patients of group II, one sustained a myocardial infarction, three underwent acute surgery, and one patient died postoperatively. After a mean follow-up of 41 months, the total mortality rate was 17% in group I and 30% in group II. The long-term event-free survival rate was 75% in group I and 10% in group II (P = 0.004). The risk score was found to be a potentially important predictor of sustained success (long-term success: 4.4 ± 2.9 vs no long-term success: 8.3 ± 3.4; P = 0.01), although sophisticated statistical analysis was limited by the small number of patients. Thus, in patients with a low risk score, angioplasty seems to be an appropriate treatment while it appears that surgery should remain the standard therapy for patients with a calculated high risk score. However, the clinical significance of this new risk score remains to be determined with more elaborate statistical analysis applied to a larger number of patients.     

Guidewire Facilitation of Internal Mammary Artery Cannulation

With the advent of widespread use of the internal mammary artery for coronary revascularization, high quality delineation of this conduit during angiography is necessary. We describe herein a safe, easy method to selectively cannulate the internal mammary artery based on a steerable angioplasty guidewire technique.