Complete evaluation of the cardiovascular lesions in 24 patients with Takayasu's aortitis using four-image, intravenous digital subtraction angiography

We studied the entire distribution of cardiovascular lesions with the use of intravenous digital subtraction angiography (DSA) in 24 patients having Takayasu's aortitis. The aorta, its branches, pulmonary vessels, and left ventricle were assessed by neck (anteroposterior), abdominal (anteroposterior), and chest (right and left anterior oblique) images. DSA showed multiple arterial lesions (n = 24) including proximal renal artery stenoses (n = 4), pulmonary arterial stenoses (n = 4), inferior-superior mesenteric arterial anastomoses (n = 3), brachiocephalic arterial aneurysms (n = 2), aortic root aneurysm (n = 1), diffuse left ventricular hypokinesis (n = 1), subclavian steal phenomenon (n = 1), and right aortic arch (n = 1). The incidence of total occlusion was highest in the right subclavian artery (n = 12). Average percent luminal stenosis (mean +/- S.D.) over the aorta and its branches tended to be smaller in patients with prior corticosteroid therapy (17.3 +/- 14.6%) than in those without (22.0 +/- 9.8%), but the difference was not significant. DSA (four-series) was useful in assessing the whole disease spectrum and often revealed subclinical lesions in this disease.     

Coronary artery bypass with 2 internal mammary arteries. Early clinical and angiographic results in 100 patients]

One hundred patients underwent coronary revascularisation with both internal mammary arteries between 1987 and 1990. The average age of the patients was 55 years. The left internal mammary was used in 97 of the 100 cases as a pediculated graft to revascularise the left anterior descending (66 cases), left lateral (27 cases) or a bissecting artery (4 cases). The right internal mammary was used as a pediculated graft in 51 cases and as a free graft to revascularise a left lateral (51 cases), left anterior descending (29 cases) or right coronary artery (20 cases). There was one death in the first 30 postoperative days. Morbidity was low with no cases of sternal infection. The average postoperative bleeding was 633 +/- 550 ml per patient. The incidence of phrenic nerve paralysis decreased from 36% in the first 50 patients to 6% in the second 50 patients. Angiography at the 10th postoperative day showed 4 occlusions out of 132 internal mammary arteries opacified (97% patency). Ninety four patients are asymptomatic and have negative exercise stress tests. Mortality and morbidity of coronary surgery using the two internal mammary arteries are therefore the same as those of conventional coronary surgery using saphenous veinar only one internal mammary artery, providing that it is reserved for patients in good general condition, under 65 years of age, without obesity or diabetes. This technique of coronary artery revascularization should provide better long-term results because of the high patency rate of the grafts.     

Coronary flow reserve provided by sequential internal mammary artery grafts

Although internal mammary artery bypass grafts have a high patency rate, the adequacy of blood flow through such conduits, particularly if used sequentially, has been questioned. To evaluate this issue, coronary flow reserve was studied in 20 patients after coronary bypass surgery. Nine patients had sequential internal mammary grafts to the diagonal and left anterior descending coronary arteries; five had a single internal mammary graft to the left anterior descending artery and six had sequential saphenous vein grafts. Fifteen additional single vein grafts were also placed in these patients. Coronary flow reserve was measured after contrast-induced hyperemia by a digital subtraction angiographic technique an average of 25 days after surgery. There was no difference in coronary flow reserve between the proximal and distal anastomotic regions in either the sequential internal mammary graft group (2.14 +/- 0.50 versus 2.29 +/- 0.68, n = 8, p = NS) or the sequential vein group (1.77 +/- 0.49 versus 2.08 +/- 0.78, n = 6, p = NS). In addition, the flow reserve provided to either vascular bed of the sequential internal mammary graft was not different from that provided by a single internal mammary graft (1.64 +/- 0.39, n = 5), a single vein graft (1.95 +/- 0.95, n = 15) or nonstenotic native coronary arteries (2.04 +/- 0.87, n = 34). No cases of intracoronary steal were observed. Although some patients had unequal flow reserves between the proximal and distal anastomotic zones, these occurred in the setting of residual coronary stenoses distal to the site of graft insertion or prior myocardial infarction in the grafted distribution.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiogenic Shock After Arterial Y-Graft Coronary Bypass Surgery Secondary to Critical Stenoses of the Left Subclavian and Left Main Coronary Arteries

We present a case of a 62-year-old man who was in cardiogenic shock. He had a history of coronary artery bypass grafting 4 years previously, with left internal mammary radial artery Y-grafting to a left dominant coronary circulation. Critical stenoses of the left main coronary and left subclavian arteries were seen at angiography. An occluded abdominal aorta precluded the use of mechanical circulatory support. The patient underwent high-risk stenting of the left subclavian artery with a successful outcome. The case highlights the unresolved issue of screening for subclavian stenoses in patients being considered for revascularization with arterial Y-grafting.     

Do changes in blood flow in the subclavian artery affect flow volume in IMA grafts after complete arterial revascularization with the T-graft technique?

BACKGROUND: The T-graft procedure achieves complete arterial coronary revascularization with only two conduits. In this technique, all the bypass anastomoses are supplied by the left internal mammary artery (IMA). Changes in flow conditions or flow redistribution in the subclavian artery may thus sigificantly influence coronary perfusion. The objective of this study was to determine whether changes in blood flow in the subclavian artery affect the flow in IMA grafts in patients who have undergone complete arterial revascularization with T-grafts. METHODS: Quantitative flow volume and flow profiles in the IMA graft and the proximal subclavian artery were measured with a flow-wire in 20 patients one week postoperatively. Following baseline measurements, brachial artery constriction was achieved by applying a blood pressure measurement cuff to the patient's left upper arm. After 5 minutes, quantitative flow in the IMA and in the proximal subclavian artery was assessed. The cuff was then released and the measurements repeated. RESULTS: Flow in the subclavian artery changed significantly (p < 0.01) from baseline (355.4 +/- 95.2 ml/ min) to constriction (171.2 +/- 61.3 ml/min) and hyperemia (679.3 +/- 195.1 ml/min). Flow in the IMA graft remained constant irrespective of subclavian artery flow (75.4 +/- 26.2 ml/min vs. 78.0 +/- 28.9 ml/min vs. 75.5 +/- 29.3 ml/min, respectively). The flow profile in the IMA was similarily unchanged. CONCLUSION: In patients in whom the coronary bypass blood flow is dependent on the left IMA, neither the quantitative flow volume nor the flow profile are altered by changes in blood flow of the subclavian artery.     

Pulmonary arterial anatomy in tetralogy of Fallot

We have searched for any abnormalities of the pulmonary arteries visualized by angiography in 200 consecutive patients with tetralogy of Fallot. All the patients were studied by conventional right ventricular angiography in the right and left anterior oblique views. Thirty six patients (18%) showed a total of 61 pulmonary artery stenoses, 32 being severe (52%), 17 moderate (28%) and 12 mild (20%). Bifurcational stenoses were the most common (31), followed by stenosis of the main pulmonary trunk, the right or the left pulmonary arteries (22), combined central and peripheral stenosis (6), and isolated peripheral pulmonary artery stenosis (2). Nine patients showed segmental stenosis involving both the right and left pulmonary arteries and three of them had atresia of the left pulmonary artery. The detailed preoperative evaluation of obstruction within the pulmonary arterial pathways is essential in tetralogy of Fallot to ensure normalisation of the right ventricular pressure following total correction.     

Pedicled right internal mammary artery for reoperative off-pump revascularization of left anterior descending coronary artery

In situ right internal mammary artery is the graft of choice in reoperative off-pump coronary artery bypass grafting, as well as in primary on-pump coronary artery bypass grafting, unless the vessel has been used previously. However, there are not enough data about postoperative angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting with the off-pump technique. From September 1993 through January 2004, we reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump coronary artery bypass grafting reoperation only for revascularization of the left anterior descending artery, by means of a pedicled right internal mammary artery graft. All patients were evaluated clinically and by postoperative coronary angiography. There were no early or late deaths during the mean follow-up period of 33.08 +/- 30.05 months (range, 1-77 months). The mean interval from the 1st operation to the 2nd operation was 74.1 +/- 57.01 months (range, 4.5-171 months). Postoperative coronary angiograms of all patients showed a 100% patency rate for both in situ grafts and composite grafts. We suggest that use of the in situ right internal mammary artery in off-pump coronary artery bypass grafting is a safe and reliable option for revascularizing the left anterior descending artery, especially in reoperation.     

Symptomatic angina secondary to coronary-subclavian steal syndrome treated successfully by percutaneous transluminal angioplasty of the subclavian artery.

Subclavian artery stenosis causing severely symptomatic angina in a patient with a previous left internal mammary artery bypass to the left anterior descending artery was treated successfully with percutaneous transluminal angioplasty. Baseline arteriography clearly revealed subclavian and coronary steal by evidence of competitive flow of nonopacified blood from the left vertebral artery. Although there was a difference of only 15 mm Hg between the right and left brachial arteries, there was a palpable difference in the upstroke of these pulses. The stenosis in the subclavian artery was successfully dilated with percutaneous transluminal angioplasty. Angiographic evidence of subclavian steal resolved following balloon dilatation, and the patient's angina was completely resolved.     

Use of 2 internal mammary arteries in coronary bypass. Combination with a bypass using the gastroepiploic artery in 2 cases

Coronary revascularisation by bilateral internal mammary artery grafting was performed in 39 patients. The left internal mammary was anastomosed to the left anterior descending (N = 22), the left lateral (N = 12) or diagonal artery (N = 5). The right internal mammary was implanted on the right coronary (N = 17), the left anterior descending (N = 16), the left lateral (N = 3) or diagonal artery (N = 3). In two cases, the inferior myocardial segments were revascularised by grafting the gastroepiploic artery. Three patients died and one patient had signs of postoperative myocardial infarction. Respiratory complications, usually mild, occurred in 5 patients. Bilateral internal mammary artery grafting should be reserved for: 1) young patients, 2) those without usable leg veins (varicose veins, previous stripping or coronary bypass surgery). The gastroepiploic artery is a useful arterial graft for revascularizing regions of the heart inaccessible to the internal mammary arteries.     

Quantitative angiographic analysis of right ventricular global function in normal incidences and in patients with coronary artery disease

At present right ventriculography data cannot be accurately estimated owing to the absence of software for quantitative analysis of the right ventricle (RV) volumes and function. The aim of this study was to use existing software for left ventriculography analysis to estimate right ventricular volumes and function in patients without coronary lesions and in those with coronary artery disease (CAD). Thirty-two patients without significant lesions of coronary arteries and 20 patients with CAD were examined with left ventriculography and right atriography. Each examination was performed in 2 projections: 30 degrees right anterior oblique (RAO 30 degrees) and 60 degrees left anterior oblique (LAO 60 degrees) projections. Correction factor (CF) was obtained by finding the ratio between stroke volumes of the left and right ventricles. The mean CF was 0.9243+/-0.2887 for patients without CAD and 0.8758+/-0.2232 for patients with CAD. Such calculation is the easiest and quite accurate method of determining RV volumes and function by using existing software of quantitative angiographic analysis.     

Symptomatic angina secondary to coronary-subclavian steal syndrome treated successfully by percutaneous transluminal angioplasty of the subclavian artery

Subclavian artery stenosis causing severely symptomatic angina in a patient with a previous left internal mammary artery bypass to the left anterior descending artery was treated successfully with percutaneous transluminal angioplasty. Baseline arteriography clearly revealed subclavian and coronary steal by evidence of competitive flow of nonopacified blood from the left vertebral artery. Although there was a difference of only 15 mm Hg between the right and left brachial arteries, there was a palpable difference in the upstroke of these pulses. The stenosis in the subclavian artery was successfully dilated with percutaneous transluminal angioplasty. Angiographic evidence of subclavian steal resolved following balloon dilatation, and the patient's angina was completely resolved. © 1992 Wiley-Liss, Inc.     

Retrograde internal mammary to coronary artery anastomoses

In an effort to expand the utilization of the internal mammary artery (IMA) for revascularization of the distal coronary artery branches, distally pedicled retrograde internal mammary arteries (retro-IMA) were evaluated in 10 mongrel dogs with a mean weight of 38 +/- 13 kg. One IMA was transected at it's origin (retro-IMA) and compared to the contralateral IMA which was transected at the level of the 5th intercostal space. At a mean systemic pressure of 68 +/- 15 mmHg the mean pressure measured at the tip of the IMAs with antegrade flow was 63 +/- 14 mmHg in the retro-IMAs with retrograde flow (p less than 0.05; pressure ratio 0.8). With the same mean systemic pressure, mean antegrade free flow of the IMAs was assessed 97 +/- 43 ml/min versus 48 +/- 13 ml/min in the retro-IMAs with retrograde flow (p less than 0.005; flow ratio 0.5). Left retro-IMA to coronary artery anastomosis was performed in 6 animals to the distal left anterior descending (LAD) coronary artery and in 2 animals to the distal left obtuse marginal branch. Right retro-IMA to coronary artery anastomosis to the right posterior descending coronary artery was performed in 2 animals. The LAD coronary artery was ligated proximally to the retro-IMA to coronary artery anastomosis while the retro-IMA remained crossclamped. After documentation of significant ischemia (EKG, left atrial pressure), the crossclamp of the retro-IMA graft was removed. Subsequent normalisation of EKG and left atrial pressure occurred in all animals. We conclude that the canine retro-IMA delivers significant retrograde flow and discuss a possible use in humans.     

多排螺旋CT冠脉成像与冠脉造影对冠心病诊断的对比研究

目的初步评价多排螺旋CT（MSCT）在冠状动脉成像中的临床应用价值。方法18例疑诊冠状动脉狭窄患者行MSCT扫描,利用影像曲面重建,3D重建,了解冠状动脉病变情况,并与冠状动脉造影（CAG）对比。结果18例76支血管同时经MSCT和CAG成像。CAG发现狭窄27支,其中左前降支（LAD）病变11支,回旋支（LCA）病变3支,左主干（LMA）2支,右冠（RCA）病变9支,桥支病变2支。MSCT发现狭窄24支,其中LAD病变11支,LCA病变3支,LMA病变1支,RCA病变7支,桥支病变2支。MSCT与CAG结果相符的病变血管22支,MSCT成像的敏感性为82%（22/27）,特异性96%（47/49）。结论在控制心率的情况下MSCT可作为冠状动脉狭窄的一种无创筛选检查方法。     

Renal artery angiography: "the right ipsilateral oblique" myth.

BACKGROUND: Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. OBJECTIVE: Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. METHODS: MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. RESULTS: The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). CONCLUSIONS: MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.     

Non-selective intra-arterial digital subtraction angiography for the assessment of coronary artery bypass grafts

Non-selective intra-arterial digital subtraction angiography (DSA) was performed immediately before selective coronary and bypass angiography in 33 consecutive symptomatic patients 48± 30 months after coronary surgery, for the assessment of 75 coronary bypass grafts. Forty ml of non-ionic, low-iodine content contrast medium (iohexol) were injected into the ascending aorta at 10–20 ml/sec through a 7 or 8 F femoral pigtail catheter.Electrocardiogram-triggered images were acquired on a Siemens Digitron II apparatus in multiple projections in 24 patients and in a single projection in 9 patients. The results of this technique were compared by two independent angiographers with those of selective graft angiography in the same patients. Patency was shown by DSA in 45 of 54 grafts confirmed to be open by selective angiography (sensitivity 83%). Of 21 occluded grafts, stumps were clearly visible at selective angiography in 18 and at DSA in 9 (sensitivity for graft stumns = 50%, p<0.01) Of 54 patent grafts with selective angiogranhy. the distal anastomosis could be visualized by DSA in 28 (52%), but the resolution was comparable to selective angiography in 20 grafts (37%) only. A non-significant difference in the sensitivity of DSA was observed between patent saphenous grafts to the left anterior descending coronary artery versus all other coronary arteries (95 vs 85%, respectively), while only 1 of 5 patent left internal mammary artery grafts to the left anterior descending coronary artery was visualized. In 16 of 50 grafts (32%) visualized in a second projection substantial additional diagnostic information was obtained. In conclusion, non-selective intra-arterial electrocardiogram-triggered DSA can visualize patent saphenous grafts with a high sensitivity and may be a useful screening tool for bypass grafts patency; false negatives, however, and poor visualization of distal anastomoses limit its routine clinical use.     

Percutaneous transluminal laser guide wire recanalization of chronic subclavian artery occlusion in symptomatic coronary-subclavian steal syndrome.

Treatment of subclavian artery stenosis by percutaneous balloon angioplasty and adjunctive stent placement was shown to be safe and efficacious, but it may be limited in tight stenoses and long occlusions. We describe the case of a patient who experienced progressive angina pectoris associated with signs of cerebrovertebral insufficiency 9 yr after bypass surgery, including left internal mammary artery (LIMA) grafting to the left anterior descending coronary artery. Angiography showed reversed flow through the LIMA graft into the subclavian artery and a 4-cm occlusion beginning at the origin of the left subclavian artery, representing a rare coronary-subclavian steal syndrome. After a conventional approach failed, recanalization was performed successfully using laser guide wire angioplasty with adjunctive stent placement in a combined radial and femoral approach.     

Regional myocardial blood flow and left ventricular diastolic properties in pacing-induced ischemia

The relation between left ventricular diastolic abnormalities and myocardial blood flow during ischemia was studied in eight open chest dogs with critical stenoses of the proximal left anterior descending and circumflex coronary arteries. The heart was paced at 1.7 times the heart rate at rest for 3 min. In dogs with coronary stenoses, left ventricular end-diastolic pressure increased from 8 +/- 1 to 14 +/- 2 mm Hg during pacing tachycardia (p less than 0.01) and 16 +/- 3 mm Hg (p less than 0.01) after pacing, with increased end-diastolic and end-systolic segment lengths in the ischemic regions. Left ventricular diastolic pressure-segment length relations for ischemic regions shifted upward during and after pacing tachycardia in dogs with coronary stenoses, indicating decreased regional diastolic distensibility. In dogs without coronary stenoses, the left ventricular diastolic pressure-segment length relation was unaltered. Pacing tachycardia without coronary stenoses induced an increase in anterograde coronary blood flow (assessed by flow meter) in both the left anterior descending and circumflex coronary arteries, and a decrease in regional vascular resistance. In dogs with coronary stenoses, regional vascular resistance before pacing was decreased by 18%; myocardial blood flow (assessed by microspheres) was unchanged in both the left anterior descending and circumflex coronary artery territories. During pacing tachycardia with coronary stenoses, regional coronary vascular resistance did not decrease further; subendocardial myocardial blood flow distal to the left anterior descending coronary artery stenosis decreased (from 1.03 +/- 0.07 to 0.67 +/- 0.12 ml/min per g, p less than 0.01), as did subendocardial to subepicardial blood flow ratio (from 1.04 +/- 0.09 to 0.42 +/- 0.08, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

The VB-1 catheter: an improved catheter for difficult-to-engage internal mammary artery grafts.

As patients with prior coronary artery bypass grafting age, internal mammary artery grafts are more frequently encountered in the cardiac catheterization laboratory. Angiography and interventions involving these grafts are often difficult, particularly in patients with tortuous subclavian anatomy and/or proximal internal mammary artery origins. We describe a new catheter shape, the Cordis Behar Internal Mammary, VB-1, which allows selective intubations of both right and left internal mammary arteries that are not possible with conventional catheters.     

Skeletonized bilateral internal mammary arteries for total arterial myocardial revascularization

BACKGROUND: Bilateral internal mammary artery (IMA) grafting is associated with an improved long-term survival, low rates of recurrence of angina and late myocardial infarction. However, because of the inadequate length of the conduit, use of bilateral internal thoracic artery grafting occasionally is not suitable for complete revascularization. To overcome this limitation, extra length can be obtained by skeletonization of both IMAs. We decided to prospectively assess the safety of this technique. METHODS: One hundred patients with a mean age of 52.5 +/- 13.1 years underwent complete revascularization with skeletonized bilateral internal mammary arteries on cardiopulmonary bypass (CPB). The right internal mammary artery (RIMA) was used as a free graft connected to the in situ left IMA (LIMA) in 88 patients. A free LIMA was attached to in situ RIMA in 12 patients. The average number of grafts was 3.2 per patient (range: 2-4 grafts per patient). Mean left ventricular ejection fraction was 60% (range: 25-80%). RESULTS: No patient required reexploration for bleeding, and no patient died within 30 days after operation. On the basis of electrocardiographic changes, three patients sustained a perioperative myocardial infarction. One patient had a sternal wound infection. Mean follow-up was 24 months (range: 6-36 months). The actuarial survival rate was 99 +/- 1% at 3 years. No myocardial infarctions were reported during the follow-up. Three patients had recurrent angina with conduit occlusion diagnosed on coronary angiography. CONCLUSION: Complete myocardial revascularization with skeletonized bilateral internal mammary arteries is a safe and reliable technique with excellent early and mid-term results.     

Left ventricular dysfunction in acute myocardial infarction due to isolated left circumflex coronary artery stenosis

The characteristics of regional and global left ventricular dysfunction due to isolated left circumflex (LC) artery stenosis were determined from the contrast ventriculograms of 52 patients studied during acute myocardial infarction. In patients with a left dominant coronary circulation (35%), the severity, circumferential extent and location of hypokinesia resembled those of right coronary artery stenosis. However, in patients with a right dominant or balanced circulation (65%), the location of LC artery-related hypokinesia varied over the entire left ventricular contour, overlapping with the territories of the left anterior descending and right coronary arteries. The method for measuring the severity of hypokinesia was adjusted to take into account the wide territory of the LC artery. This enhanced the sensitivity of the method, particularly in the right anterior oblique view, as indicated by the greater severity of hypokinesia measured (-2.5 +/- 0.9 vs -1.8 +/- 1.1 standard deviations by our previously published method, p less than 0.001). However, the overlap of the artery territories may make it difficult to selectively measure the dysfunction due to stenosis of an artery of interest in patients with multiple infarctions. The circumferential extent of hypokinesia due to LC artery thrombosis was greater in the left than the right anterior oblique view. When averaged over both views, the size of the dysfunctional segment approached that due to left anterior descending coronary artery thrombosis, exceeding the size previously reported. These results suggest that current eligibility criteria for thrombolytic therapy select patients with extensive LC artery beds.