Morphological differences of the internal thoracic artery in patients with and without coronary artery disease--evaluation by duplex-scanning.

OBJECTIVE: The internal thoracic artery is an established arterial graft for myocardial revascularisation, especially of the left anterior descending artery because of a higher patency rate compared to venous grafts. It has never been investigated, whether there are morphological differences in this vessel between patients with or without coronary artery disease or if they are comparable to morphological changes in the common carotid artery. METHODS: We investigated the internal thoracic artery and the common carotid artery of 24 patients (12 with coronary artery disease, 12 without coronary artery disease) with an ultrasonic system on both sides. The intima-media thickness and the diameter of both vessels were estimated. RESULTS: The intima-media-thickness of the internal thoracic artery was comparable in all patients, independent of the presence of a coronary artery disease (0.51+/-0.11 mm with coronary artery disease, 0.50+/-0.17 mm without coronary artery disease, P>0.05). Compared with this the intima-media-thickness of the common carotid artery was thicker in patients with coronary artery disease (0.84+/-0.13 mm with coronary artery disease, 0.73+/-0.07 mm without coronary artery disease, P< or or =0.014). There was no correlation between the thickness of the internal thoracic artery and the common carotid artery (r=0.018, P>0.05). CONCLUSIONS: It could be demonstrated for the first with non-invasive ultrasound, that the intima-media-complex of the internal thoracic artery is protected of the influence of arteriosclerosis. There are no morphological differences like the intima-media-thickness of the common carotid artery. The proven protective mechanism underlines the widespread use of the internal thoracic artery as a coronary artery bypass graft.     

Pseudoxanthoma elasticum: is the left internal mammary artery a suitable conduit for coronary artery bypass grafting?

Coronary artery revascularization remains a feasible and beneficial treatment for coronary artery disease in patients with pseudoxanthoma elasticum. Careful angiographic evaluation of the left internal mammary artery and coronary arteries is required in patients with pseudoxanthoma elasticum with suspected coronary artery disease. A nonstenosed left internal mammary artery at angiography may be used as a conduit for coronary artery revascularization; however, both the effect of harvest and anastomosis on the disease process in the left internal mammary artery and the long-term patency of left internal mammary artery grafts remain unknown.     

Greater vasopressin-induced vasoconstriction and inferior effects of nitrovasodilators and milrinone in the radial artery than in the internal thoracic artery

BACKGROUND: Vasopressin may be a potential cause of spasm in both the radial artery and the internal thoracic artery. This study compared the vasopressin-induced contraction and the effects of milrinone, nitroglycerin, and nitroprusside in vasopressin-induced contraction between the human radial artery and the internal thoracic artery to find effective antispastic methods for arterial grafts. METHODS: Concentration-contraction (normalized as force gram produced by each millimeter of the circumference tissue of the artery) curves for vasopressin with or without pretreatment of vasodilators and concentration-relaxation curves for the vasodilators listed were established in the human radial artery (n = 107) and internal thoracic artery (n = 122) segments. RESULTS: Vasopressin induced a greater contraction in the radial artery than in the internal thoracic artery (1.9 +/- 0.2 g/mm vs 0.6 +/- 0.1 g/mm, P < .001) with a higher sensitivity (lower EC(50): -9.28 +/- 0.11 vs -8.91 +/- 0.05 log(10)M, P = .006). Milrinone was less potent than nitroglycerin and nitroprusside with higher EC(50) (P < .05) in both the internal thoracic artery and radial artery. Pretreatment with milrinone and nitroprusside significantly inhibited vasopressin contraction in the internal thoracic artery but had little effect in the radial artery. Pretreatment with nitroglycerin did not significantly inhibit the maximum vasopressin contraction in either the internal thoracic artery or radial artery. CONCLUSION: The radial artery is more prone to develop spasm related to vasopressin than is the internal thoracic artery, and the effect of vasodilators in vasopressin-induced contraction is different in the radial artery from that in the internal thoracic artery. A more significant prophylactic antispastic effect of milrinone and nitroprusside is demonstrated in the internal thoracic artery than in the radial artery. Therefore, more intensive antispastic treatment is necessary in the radial artery than in the internal thoracic artery during coronary artery bypass grafting.     

Anomalous origin of the left coronary artery from the right pulmonary artery.

A previously unknown coronary artery anomaly is reported: origin of the left coronary artery from the right pulmonary artery. This unusual anomaly can probably be explained by the theory of dual embryonic development of the coronary arteries from angioblastic buds in the truncus arteriosus. It is thought that these buds anastomose with a capillary network that is developing on the surface of the ventricles. Complete repair of this lesion with restoration of a two-coronary artery system was accomplished in a 10-month-old baby. The coronary artery was detached from the pulmonary artery, with a button of pulmonary artery being retained around the coronary artery ostium. Direct systemic arterial flow to the left coronary artery was established by anastomosis of the left coronary to the right subclavian artery.     

Management of concomitant coronary and bilateral carotid artery disease: a case report

Patients with severe coexistent coronary and carotid artery stenosis represent a difficult and high-risk population. Herein we describe management of a patient with concomitant coronary artery and bilateral carotid artery disease. Firstly, left carotid artery stenting was done using a self-expandable monorail stent and a neurological protective device. Post-stent angiogram revealed satisfactory dilatation in the left carotid artery. Later, coronary artery bypass grafting to the four coronary arteries was done. Then right carotid endarterectomy was done. He had no neurological complication during or after any of the operation and he remains in good health since his last operation. We think the staged treatment, consisting of carotid artery stenting plus coronary artery bypass grafting plus carotid endarterectomy, in a patient with concomitant severe coronary artery and bilateral carotid artery disease is feasible, safe, and may be an alternative to combined coronary artery bypass grafting plus carotid endarterectomy.     

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.     

颈内动脉扭曲的血流动力学数值模拟和临床研究

目的 建立颈内动脉扭曲的血流动力学理论分析模型,研究扭曲动脉导致的血流动力学变化规律,初步探讨动脉扭曲和脑缺血的关系.方法 以颈内动脉的生理解剖参数为原型,建立动脉扭曲的几何模型,根据血液流动的边界条件,对扭曲动脉的血液流动进行有限元数值模拟.对颈内动脉扭曲患者和对照组患者各15例进行临床实测,用微导管和压力传感器测量颈内动脉扭曲前后的压力,用血管造影机计算扭曲动脉的直径和长度.结果 数值模拟结果显示随着动脉扭曲程度的加重,血流的压降增大,伸长长度增加;临床实测结果显示出相同的变化趋势.结论 颈内动脉扭曲可以造成动脉扭曲远端血压下降,在一定情况下,严重的动脉扭曲可能是脑缺血发作相关因素之一.     

Hypoplastic left heart syndrome with anomalous origin of the right coronary artery

Hypoplastic left heart syndrome in association with an anomalous origin of a coronary artery from the pulmonary artery is a very rare congenital malformation. In the few reported cases, the left coronary artery or the circumflex artery arises from the right pulmonary artery. We describe a newborn who presented with hypoplastic left heart syndrome, and at the time of operation had an anomalous origin of the right coronary artery from the right pulmonary artery that was detected. The patient underwent a successful modified Norwood procedure with direct reimplantation of the right coronary artery to the neo-aorta.     

Coronary artery aneurysm with systemic lupus erythematosus

Coronary artery aneurysms rarely develop in patients with systemic lupus erythematosus. We herein describe a case of a right coronary artery aneurysm associated with systemic lupus erythematosus. A 49-year-old woman with known systemic lupus erythematosus presented with an acute myocardial infarction. A coronary artery aneurysm and thrombo-occlusion in the right coronary artery necessitated percutaneous coronary intervention. She experienced three myocardial infarctions during the following two months. A coronary artery dissection occurred during the percutaneous coronary intervention at the time of the last myocardial infarction, and emergency coronary artery bypass grafting was successfully performed. Difficulties in treatment with percutaneous coronary intervention and the fact that arteritis is a possible cause of a coronary artery aneurysm may indicate that surgical therapy, including coronary artery bypass grafting with or without the obliteration of an aneurysm, is the treatment of choice for a coronary artery aneurysm with systemic lupus erythematosus.     

Axillocoronary bypass in a patient with a severely atherosclerotic aorta.

We report an axillocoronary bypass in a 70-year-old man with a severely atherosclerotic, calcified aorta. The patient had insulin-dependent diabetes mellitus and had 2-vessel coronary artery disease with a lesion in the left main coronary artery. He underwent an axillary artery-circumflex artery bypass with a saphenous vein graft combined with a bypass of the left internal thoracic artery to the left anterior descending artery without aortic cross-clamping. An easy, safe procedure, axillocoronary bypass is a viable option in coronary artery bypass grafting for patients with severely atherosclerotic, calcified aortas.     

Surgical treatment for innominate artery aneurysm with a coronary pulmonary artery fistula: a case report.

A 50-year-old woman complained of hoarseness and chest X-ray demonstrated a widening of the superior mediastinum. Computed tomography scanning and aortography demonstrated aneurysmal dilatation at the innominate artery. Coronary arteriography showed a coronary pulmonary artery fistula originating from the left anterior descending artery. The surgical procedure was prosthetic bifurcated bypass grafting from the ascending aorta to the right common carotid artery and right subclavian artery. During the period of innominate artery occlusion, the patient was cooled to 25 degrees C with selective cerebroperfusion and circulatory arrest. Pathologic diagnosis of the specimen was that of a true aneurysm with atherosclerotic plaque and calcification. The coronary pulmonary artery fistula was closed inside the pulmonary artery. There were no signs of neurologic deficit noted. Innominate artery aneurysm is uncommon and the surgical approach varies in each case. A coronary artery fistula is also an uncommon congenital malformation but has been recognized more often with the improvement in diagnostic techniques such as selective coronary arteriography. We performed successful surgical treatment for a rare case of innominate artery aneurysm with a coronary pulmonary artery fistula.     

Anastomosis of the superior thyroid artery to the vertebral artery for vertebrobasilar insufficiency

Anastomosis of the superior thyroid artery to the cervical vertebral artery was performed with good results in a case of vertebrobasilar insufficiency caused by proximal occlusion of the vertebral artery. As a donor artery the superior thyroid artery is moderate in size, long, and easy to anastomose. It is emphasized that this cervical procedure is simpler and safer than the intracranial procedures. The authors believe this case to be the first in which the superior thyroid artery was used as a donor artery for anastomosis to the vertebral artery.     

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.     

A quantitative study of postoperative luminal narrowing of the internal thoracic artery graft in coronary artery bypass surgery.

We used quantitative angiography to determine the postoperative diameter of the internal thoracic artery graft at the point close to the anastomosed site in 147 patients who received the graft for the left anterior descending coronary artery. We performed generalized multiple linear regression analysis (Type I quantification method) to assess the effects of the following factors on the internal thoracic artery graft diameter: age, gender, time of angiography, laterality of the internal thoracic artery used, presence of an undivided major side branch of the internal thoracic artery, presence of a saphenous vein graft having blood flow competition with an internal thoracic artery graft, presence of distal stenosis of the recipient left anterior descending coronary artery, severity of postoperative left anterior descending coronary artery stenosis, and presence of coronary risk factors. The standardized category scores for 25% left anterior descending coronary artery stenosis, 50% left anterior descending coronary artery stenosis, and presence of a saphenous vein graft having blood flow competition with an internal thoracic artery graft were -1.418, -0.767 and -0.622, respectively. Thus, the internal thoracic artery diameter was smaller in patients with well-preserved flow of the recipient coronary artery. The internal thoracic artery diameter had a particularly strong correlation with the degree of left anterior descending coronary artery stenosis (partial correlation coefficient: 0.670). The other factors seemed to have little or no correlation with the postoperative internal thoracic artery diameter. With the criterion that the internal thoracic artery diameter below 1.0 mm represents the "string sign" of internal thoracic artery graft, this phenomenon was observed in nine patients (6.1%). In all of these patients, left anterior descending coronary artery flow was well-preserved, and no ischemia was disclosed in the left anterior descending coronary artery-perfused area. These results indicate that internal thoracic artery grafts have flow adaptability responding to the flow demand of the recipient coronary artery and that the string sign of internal thoracic artery grafts is mainly an outcome of its physiologic characteristics.     

Flow capacity of the canine internal mammary artery

The internal mammary artery has excellent long-term patency when used as a conduit for coronary artery bypass, and clinical and experimental studies have shown that blood flow through an internal mammary artery graft is satisfactory for most coronary artery branches. Multiple distal anastomoses from a single internal mammary artery, either with sequential anastomoses or with a Y-graft, might require additional blood flow through the vessel, and there has been concern that the flow capacity of the internal mammary artery is insufficient with these techniques. To better define the immediate postoperative flow capacity and pattern of the internal mammary artery, we performed experiments in seven dogs in which the left internal mammary artery was anastomosed to the circumflex coronary artery. In situ, blood flow in the internal mammary artery was 27 ml/min. Blood flow was 63 ml/min in the circumflex coronary artery and 42 ml/min in the left anterior descending coronary artery. After anastomosis of the left internal mammary artery to the circumflex coronary artery, the left main coronary artery was ligated; flow through the bypass graft increased to 92 ml/min, and systemic hemodynamics remained stable. Isoproterenol stimulation further increased flow through the left internal mammary artery graft to 160 ml/min. This study suggests that the canine internal mammary artery is capable of substantial early increase in flow and can, in fact, support the entire left coronary circulation.     

Renal autotransplantation for complex renal arterial disease: a case report

A renal artery aneurysm in a stenotic renal artery is a rare clinical entity with an incidence of 0.015% to 1% in patients with renovascular hypertension. Interventional stent placement is the first line of treatment for simple aneurysms of the proximal renal artery. However, renal autotransplantation has been used as an alternative treatment for complex lesions and for lesions originating from the distal renal artery. We present a patient with a renal artery aneurysm, renal artery stenosis of the segmental branches of the left kidney, and occlusion of the right renal artery. The surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the 2 renal artery branches, and renal heterotopic autotransplantation. We conclude that renal autotransplantation is a safe and effective surgical procedure for patients with complex renal arterial disease.     

A case of basilar artery occlusion of traumatic vertebral artery dissection successfully managed by endovascular treatment

The author describes a case of basilar artery occlusion caused by vertebral artery dissection with vertebral fracture. A 61-year-old man was admitted with neck pain after a traffic accident. His symptoms suddenly deteriorated and cerebral angiography revealed an occlusion of the right vertebral artery, and complete occlusion of the basilar artery. Local-arterial fibrinolysis with urokinase for basilar artery occlusion and angioplasty with the use of a self-expandable stent for the site of the vertebral artery dissection was performed, and the basilar artery was partially recanalized. The patient's symptoms gradually improved. It should be emphasized that in cases of acute cervical spine injury after major trauma, vertebral artery dissection should be considered. Local-arterial fibrinolysis and angioplasty using a self-expandable stent was regarded as a useful treatment for basilar artery occlusion caused by vertebral artery dissection, in the acute stage.     

The tentorial meningioma fed by "marginal tentorial artery" arising from the external carotid artery--a case report and review of literature (author's transl)

It is well known that a Bernasconi-Cassinari artery is an important finding at diagnosis of the abnormality in tentorium. Since Bernasconi and Cassinari reported the artery in 1956, many reports have been presented and showed that the artery arose from the intracavernous portion of the internal carotid artery. We presented a 54-year-old female with tentorial meningioma. In selective external carotid angiography, the artery feeding the tumor was revealed arising from the accessory meningeal artery, which came off the internal maxillary artery and passed into the carnium through the foramen ovale, and took the same course of "Bernasconi-Cassinari artery". This angiographic finding suggests that it is possible for marginal tentorial artery to arise from an external carotid arterial system. It is said in the anatomical studies, when the trunk of primitive maxillary artery which is one of maxillo-carotid anastomotic arteries in fetus regresses, "marginal tentorial artery" usually remains linked to the internal carotid artery. But, if this transition of "the artery" from the external to the internal carotid artery failed, it is easily conceived the artery results in the origin of accessory meningeal artery, a branch of the external carotid artery.     

Left subclavian artery free graft as a salvage technique after failed coronary artery transfer in arterial switch operation.

Coronary artery transfer in transposition of the great arteries with single coronary artery or intramural coronary artery is still a technically demanding procedure. We present a technique of left coronary bypass using a free graft of left subclavian artery for the management of failed coronary artery transfer of left intramural coronary artery.     

邻近非主干动脉重建椎动脉的应用解剖

目的 探讨采用邻近非主干动脉重建椎动脉的解剖学基础。方法 20具（40侧）成人防腐固定尸体标本,观察甲状腺上动脉、甲状腺下动脉、颈横动脉、甲状颈干及椎动脉颅外段的形态学参数,并在2具尸体标本上模拟行吻合血管椎动脉重建术。结果 甲状腺上动脉、甲状腺下动脉及颈横动脉均有2mm以上的外径及合适的可游离长度,具备进行端侧吻合重建椎动脉的解剖学条件。甲状颈干的外径与椎动脉相似,适合端端吻合,但仅有38.5％具有合适的血管干（大于10mm）。模拟手术示这些邻近非主干血管重建椎动脉可行。结论 邻近非主干重建椎动脉具有良好的解剖学基础,适合椎动脉第1、2段疾患的治疗。