Coronary Artery Bypass Grafting in a 12-Year-old Girl with Familial Hypercholesterolemia

We present the case of a 12-year-old girl with familial hypercholesterolemia and coronary artery disease. She underwent triple-vessel coronary artery bypass grafting with bilateral pedicled internal mammary artery grafting without adverse events. Pediatric patients with familial hypercholesterolemia may present with premature coronary atherosclerosis requiring coronary artery bypass grafting. In situ internal mammary artery grafts should be the graft of choice.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

The coronary-subclavian steal syndrome: report of a case and recommendations for prevention and management

The coronary-subclavian steal syndrome involves the siphoning of blood from the myocardium through an internal mammary artery graft because of a proximal subclavian artery stenosis or occlusion, and results in myocardial ischemia. With the increased use of the internal mammary artery for myocardial revascularization, the potential exists for recurrence of angina pectoris in patients who have or in whom develops high-grade stenosis or occlusion of the subclavian artery, because of the coronary-subclavian steal syndrome. The coronary-subclavian steal syndrome can be prevented by the identification of patients with or at risk to develop subclavian artery occlusive disease. All patients undergoing cardiac catheterization prior to coronary artery bypass grafting in which use of the internal mammary artery is anticipated should be evaluated for the presence of upper extremity and cerebrovascular ischemia, the presence of cervical or supraclavicular bruits, and an upper extremity blood pressure differential of 20 mm Hg or greater. Patients with these findings or with evidence of diffuse atherosclerotic vascular disease should have brachiocephalic arteriography at the time of coronary arteriography to identify significant subclavian artery occlusive disease. When this is demonstrated, use of the internal mammary artery as a free graft instead of an in situ graft or use of saphenous vein grafts is indicated. Patients in whom recurrent angina develops following coronary artery bypass grafting that included an internal mammary artery graft should have coronary arteriography to evaluate the presence of coronary-subclavian steal syndrome, and brachiocephalic arteriography. Carotid-subclavian bypass grafting, probably best done with a prosthetic conduit, is the procedure of choice for management of the coronary-subclavian steal syndrome.     

非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

Expanding the use of the internal mammary artery to improve patency in coronary artery bypass grafting

To improve the early and late benefits from coronary artery bypass grafting, we have expanded the use of the internal mammary artery by bypassing three or more coronary arteries with mammary grafts. Experience with higher power magnification and the use of the single internal mammary artery are necessary prerequisites of this procedure. The first 100 patients who had three or more mammary artery-coronary artery anastomoses are reviewed. Eighty-six patients received three mammary-coronary anastomoses, 13 received four, and one received six. An average of 3.2 internal mammary artery grafts and 1.7 saphenous vein grafts per patient were placed. Twenty-five of 27 mammary grafts were open on postoperative graft visualization. There were no early deaths and only one patient died late of complications of gangrene of the lower extremities. None of the patients had significant left ventricular failure and only three had perioperative myocardial infarctions. None of the patients complain of angina and 58 of 59 postoperative stress tests were normal. This procedure should significantly reduce the late closure of bypass grafts and the complications thereof, including the need for reoperation.     

Myocardial revascularization with radial and mammary arteries: initial and mid-term results

BACKGROUND: The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS: Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS: An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS: Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.     

Routine use of the left internal mammary artery graft in the elderly

Left internal mammary artery (LIMA) grafts have better long-term patency rates than do saphenous vein grafts and result in improved late survival. The present study was undertaken to assess the results of LIMA grafting in the elderly. From 1980 through 1988, 723 patients 70 years of age or older had isolated coronary artery bypass grafting performed. During the first 5 years, only 11% of the elderly patients received LIMA grafts, whereas 86% having coronary artery bypass grafting since 1985 had LIMA grafts. Since 1986, LIMA use in the elderly has become routine, with 92% of patients receiving internal mammary artery grafts. During the first 5 years, elderly patients had a hospital mortality rate of 9.3%. Since 1985, the hospital mortality rate fell to 5.5%. In addition, the occurrence of major surgical complications was either unchanged or reduced in patients receiving LIMA grafts. Furthermore, late follow-up indicates a significantly improved 4-year survival rate in patients with internal mammary artery grafts compared with those without: 86 +/- 0.02% versus 77 +/- 0.03% (p less than 0.01). Analysis of multiple potential risk factors for early mortality was performed using multiple logistic regression and late survival using the Cox proportional hazards model. Although unmeasured predictor variables may confound retrospective analyses, LIMA grafting appears to be an independent predictor both of improved early and late survival.     

Occlusion of left internal mammary artery with intra-aortic balloon: clinical implications

Obstruction of the left internal mammary artery by a malpositioned intra-aortic balloon in patients undergoing coronary bypass grafting may erroneously preclude its use during the procedure or may cause a potentially fatal reduction in coronary flow postoperatively in patients with left internal mammary grafts.     

An experimental in vivo study of the canine internal mammary artery and its response to vasoactive drugs

The internal mammary artery is clearly the preferred conduit for most patients undergoing coronary artery bypass grafting. However, the hemodynamic responses of this graft to vasoactive agents immediately after bypass have not been documented. We have therefore studied blood flow in the canine internal mammary artery after anastomosis to the left anterior descending artery, and its response to epinephrine, metaraminol, isoproterenol, and calcium chloride. Blood flow in the internal mammary artery clearly paralleled changes in systolic blood pressure with perfusion pressure being of prime importance in maintaining flow in the internal mammary artery. No deleterious effect of systemic vasoconstricting agents was demonstrated. We suggest that the administration of these drugs is safe in patients with internal mammary artery grafts.     

Robotic totally endoscopic triple coronary artery bypass grafting on the arrested heart: report of the first successful clinical case

Robotic technology enables "port only" totally endoscopic coronary artery bypass grafting (TECAB). During early procedure development only single bypass grafts were feasible. Because current referral practice for coronary bypass surgery mostly includes multivessel disease, performance of multiple endoscopic bypass grafts is desirable. We report a case in which a patient received a right internal mammary artery bypass graft to the left anterior descending artery and a left internal mammary artery jump graft to 2 obtuse marginal branches. The procedure was performed through 5 ports on the arrested heart using the daVinci S robotic surgical system. This is the first reported triple bypass grafting procedure using an arrested heart approach.     

Coronary bypass grafting with totally calcified or acutely dissected ascending aorta

From August 1984 through November 1988, 10 of 2,658 patients undergoing coronary artery bypass grafting had ascending aortic disease that was not amenable to proximal anastomoses for coronary bypass grafting. This was due to a calcified aorta in 6 and acute aortic dissection in 4. There were 5 male and 5 female patients with a mean age of 71 years. Cannulation site was the femoral artery in 5, ascending aorta in 3, and aortic arch in 2. Profound hypothermia and ventricular fibrillation, with no cross-clamp or cardioplegia, was used in 9 patients, and circulatory arrest in 1. In 8 patients a single internal mammary artery was used as the total inflow with a saphenous vein graft brought off the internal mammary artery to one or more distal left-sided coronary vessels. Bilateral internal mammary arteries were used in 2 other patients. Operative mortality was zero. There was one perioperative myocardial infarction and one transient stroke without sequelae. All patients have done well from 1 to 6 years postoperatively. These data support the use of internal mammary arteries as single or bilateral proximal conduits for other venoarterial bypass grafts when the aorta is extensively diseased either by calcification or dissection.     

Diagnosis and management of the coronary-subclavian steal syndrome

A patient is presented with recurrent angina due to a coronary-subclavian steal syndrome 3 years after left internal mammary to left anterior descending coronary artery bypass grafting. Myocardial ischaemia could easily be provoked by selective exercise of the left upper limb. Coronary angiography showed reversal of flow in the left internal mammary artery. Suggestions are given for prevention of the coronary-subclavian steal syndrome by identification of patients who are at risk of developing subclavian artery occlusive disease. Performance of coronary and brachiocephalic angiography is indicated in recurrence of angina in patients with internal mammary artery bypass grafts. Doppler spectral analysis may be a valuable technique for detection of a haemodynamically significant stenosis of the left subclavian artery. Carotid-subclavian bypass grafting is the procedure of choice for management of the coronary-subclavian steal syndrome.     

Combined internal mammary artery graft for coronary artery revascularization

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.     

Sequential internal mammary-coronary artery bypass

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.     

Fifteen-year results of coronary artery bypass for isolated left anterior descending coronary artery disease

During 1971 through 1975, 266 patients underwent primary coronary artery bypass grafting for occlusive disease confined to the left anterior descending coronary artery. Actuarial survival at 15 years was 72.7% with 60% of survivors being free from angina. Although the cause of death was cardiac related in 50% of the patients who died, survival was comparable with that of an age-matched and sex-matched general population. During follow-up, 48 secondary or tertiary repeat coronary artery bypass as well as 44 percutaneous transluminal coronary angioplasty procedures were performed. Acute event-free status (freedom from acute myocardial infarction, repeat coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, or death) persisted at 15 years in 43.2% of patients. The differences in survival when patients were segregated according to age, sex, number of grafts performed, or graft conduit (internal mammary artery versus vein) were not significant. However, comparison of graft conduits revealed a significantly better (p = 0.02) overall acute event-free survival when the internal mammary artery was used.     

Coronary artery bypass grafting in dialysis patients.

BACKGROUND: To analyze the characteristic problems of coronary artery bypass grafting in patients with chronic renal failure. METHODS: Fifty-one consecutive dialysis patients who required isolated coronary bypass grafting over a 9-year period were studied retrospectively. RESULTS: Nine patients (18%) had emergent operation, 4 of whom had intraaortic balloon counterpulsation instituted preoperatively. A mean of 3.3 +/- 1.0 bypasses per patient were grafted; 14 patients (27%) had bypass with two arterial grafts, 13 (25%) of which used left internal mammary artery and gastroepiploic artery and one of which used bilateral internal mammary artery grafts. A mean of 4.2 +/- 2.6 coronary artery segments were calcific according to American Heart Association classification. Eight patients (16%) required operative modifications to avoid manipulating calcific plaques on the ascending aorta. Four patients (7.8%) died, and 15 had nonlethal complications. The actuarial survival rates in 47 hospital survivors at 1, 3, and 5 years were overall 89%, 84%, and 71%, respectively, and estimates for cardiac deaths 93%, 93%, and 82%, respectively. Cardiac event-free rates after coronary artery bypass grafting were 83% and 65% for 3- and 5-year periods, respectively. CONCLUSIONS: Calcification of coronary arteries and the ascending aorta is a serious problem in long-term dialysis patients. However using arterial grafts, preferentially, in situ, seems to provide a practical alternative to minimize manipulating the ascending aorta during coronary artery bypass grafting, with acceptable perioperative morbidity and mortality rates and long-term survival.     

Expanded use of internal mammary artery graft for myocardial revascularization

To improve the early and late benefits of coronary artery bypass grafting, use of internal mammary artery grafts was expanded. The first 60 patients to receive two mammary artery-coronary artery anastomoses and supplemental saphenous vein grafts are reviewed. Altogether 210 grafts (3.5/patient) were performed, including 54 mammary artery grafts in situ, six of them as free grafts. In 12 patients the right internal mammary artery was placed through the transverse sinus to revascularize the circumflex artery, and the left mammary artery was placed to the left anterior descending artery. In the remaining 48 patients both internal mammary arteries were used to revascularize the left anterior descending and the right coronary artery. There were no perioperative deaths and no sternal infections. Postoperative complications included re-exploration for bleeding and diaphragmatic dysfunction. Late follow-up was complete. Of 60 patients observed for 1/2 to 4 years, 57 were asymptomatic. Exercise stress tests were performed in 58 cases and were normal in 56.     

Port-Access coronary artery bypass grafting: technical considerations and results

BACKGROUND: This study reviews the results of an initial experience with minimally invasive coronary bypass surgery using the Port-Access approach in terms of early outcome and safety. METHODS: Between October 1996 and July 1997 49 Port-Access minimally invasive coronary artery bypass grafting procedures were performed at our institution. The patients' mean age was 59.8 years (range 34 to 82 years). Sixteen patients received single vessel and 37 patients received multivessel bypass grafts. RESULTS: There were no operative deaths and no perioperative myocardial infarctions, neurological deficits, or conversions to sternotomy. Early complications included reoperation due to bleeding in 4 patients, reoperation for a pulmonary embolus in 1 patient, and angioplasty for occlusion of a right coronary artery graft in 2 patients. Postoperative angiograms were obtained in 86% (42/49) of the patients and showed 100% patency for left internal mammary artery to left anterior descending artery grafts and 96% patency for all grafts. CONCLUSIONS: These results demonstrate that Port-Access coronary artery bypass grafting using endovascular techniques for cardiopulmonary bypass and cardioplegic arrest can be performed safely with minimal morbidity and mortality. This technique allows multivessel revascularization on a protected, arrested heart with excellent anastomotic precision and reproducible early graft patency. Expanded use of Port-Access techniques is indicated in patients with multivessel coronary artery disease and the technique should be considered for patients with left anterior descending artery restenosis and patients with complex left anterior descending artery lesions where angioplasty results are suboptimal.     

The internal mammary artery binds more 125I-albumin than the aorta]

The internal mammary artery is currently the arterial replacement of choice for coronary artery bypass grafts. The authors studied the permeability of the vessel wall of the internal mammary artery and the ascending aorta in 12 patients undergoing coronary artery bypass grafts by comparing the 125I-albumin binding profiles. Their results suggest that albumin crosses the internal mammary artery more easily than in the aorta.     

Bypass of the right and circumflex coronary arteries with the internal mammary artery.

Our experience with the internal mammary artery (IMA) for coronary bypass grafting in the past 3 years includes 323 grafts in 253 patients. After an initial group of IMA to left anterior descending (LAD) coronary artery grafts, we began using the IMA to bypass circumflex and small right coronary arteries (RCA). This report describes our experience with IMA bypass of coronary vessels other than the LAD. A total of 96 patients have had an IMA graft to the circumflex or RCA. Most of these patients had two or more bypasses. The mortality rate for this group has been 7 per cent, 7 of 96 patients. Postoperative angiography in 82 of 89 survivors has shown a patency rate of 98 per cent in 83 of 85 grafts studied. We conclude that the IMA is the vessel of choice for coronary artery bypass and that it can be used to bypass any of the main coronary arteries.