Noninvasive screening for asymptomatic carotid artery disease prior to cardiac operation. Experience with 500 patients

Five hundred patients scheduled for cardiac operations underwent preoperative screening for asymptomatic carotid artery disease by means of the Gee ocular pneumoplethysmograph (OPG). Only patients with abnormal OPG measurements (5 mm Hg difference or greater in ophthalmic artery pressures or 0.69 or less ophthalmic artery/brachial artery pressure ratio) had cerebral angiography regardless of the presence or absence of a carotid bruit. Thirty-two patients (6.4%) were found to have carotid bruits. Nine patients had abnormal OPG measurements. Cerebral angiograms disclosed that six of these patients had significant (greater than 50%) carotid artery stenosis, and endarterectomy was performed prior to cardiac operation without incident. Nine other patients without carotid bruits had abnormal OPG measurements, and they also underwent cerebral angiography. Angiograms revealed significant carotid artery stenosis in three patients and prophylactic endarterectomy was performed. Twenty-three patients with carotid artery bruits and normal OPG measurements did not have cerebral angiography prior to the cardiac procedure. The incidence of stroke in this series of 500 patients was 0.4% (two patients). The clinical management of patients with asymptomatic carotid artery disease and coronary artery disease was facilitated by the use of noninvasive screening for the evaluation of carotid artery bruits. Patients with hemodynamically insignificant carotid disease, verified by OPG measurements, can be spared the risk and cost of cerebral angiography. Patients without clinical signs of carotid artery disease can also be identified.     

Clinical Significance of the Interposition Graft for Reconstruction Between the Common Hepatic Artery and Gastroduodenal Artery for Arterial Patency of the Pancreas Graft in Pancreas Transplantation

BackgroundDue to the limited number of organ donations from deceased donors in Japan, pancreas grafts for pancreas transplantation (PTx) are frequently harvested from the donor in the same donation surgery as the liver graft. In such a situation, the common hepatic artery (CHA) and gastroduodenal artery (GDA) are dissected, resulting in decreased blood flow to the head of the pancreas graft. Therefore, GDA reconstruction using an interposition graft (I-graft) between the CHA and GDA has been traditionally performed to maintain blood flow. This study investigated the clinical significance of GDA reconstruction with the I-graft regarding the arterial patency of the pancreas graft in patients after PTx.MethodsFifty-seven patients underwent PTx for type 1 diabetes mellitus at our hospital between 2000 and 2021. Twenty-four cases in which GDA reconstruction was performed using the I-graft and artery blood flow of the pancreas graft was evaluated by contrast-enhanced computed tomography or angiography were included in this study.ResultsThe patency of the I-graft was 95.8%, and only one patient had a thrombus in the I-graft. Nineteen patients (79.2%) had no thrombus in the artery of the pancreas graft; the other five cases had thrombus in the superior mesenteric artery (SMA). The patient with the thrombus in the I-graft required graftectomy for the pancreas graft.ConclusionsThe patency of the I-graft was favorable. Furthermore, the clinical significance of the GDA reconstruction with the I-graft is suggested to maintain blood flow in the pancreas head if the SMA is occluded.     

Revascularization of the gastroepiploic artery in pancreas transplant.

Thrombosis accounted for 52.0% of all transplant failures in one recent large series and is felt to result from devascularization of the pancreas during organ procurement. A technique to revascularize the pancreas is described. The operative notes and angiograms of 110 consecutive pancreas transplants were reviewed. Eight pancreata were found deprived of blood supply to the head and the neck of the pancreas on indigocarmine-renograffin table angiograms. During back table reconstruction a distal branch of the superior mesenteric artery (SMA) was dissected and anastomosed end to end to the gastroepiploic artery using 8-0 monofilament suture. Repeated table angiogram showed excellent blood supply to the head of the pancreas, the duodenum and the body and tail of the pancreas. The pancreas transplantation proceeded with iliac artery graft inflow, portal venous outflow and enteric drainage. Simultaneous quadruple therapy with thymoglobulin, CNI, MMF and a 4-day course of steroids was used. All patients became insulin independent and euglycemic. No duodenal leak was observed in the entire series. In summary, 1-ligation of the gastroduodenal artery (GDA) is not a safe procedure, especially when arterial blood supply from the inferior pancreaticoduodenal artery is poor or inexistent, 2-table angiogram helps delineate the high risk hypo-perfused pancreas, 3-preservation of the right gastroepiploic artery and the branches of the SMA allows an easy revascularization of the pancreatic graft.     

Evaluation of cerebrovascular spasm with transcranial Doppler ultrasound

The use of an ultrasonic transcranial Doppler technique for noninvasive evaluation of cerebral vasospasm is described. Middle cerebral arteries (MCA's), classified as spastic on angiography, demonstrated blood-flow velocity between 120 and 230 cm/sec. The flow velocities in these arteries had a clear inverse relationship to the diameter as measured from angiograms in 38 patients with recent subarachnoid hemorrhage. This relationship in the proximal anterior cerebral artery (ACA) was found to be more complicated to assess, due to the collateral channels in the anterior part of the circle of Willis. The authors conclude, however, that the new method of measuring vasospasm will also detect spasm in the ACA if it has a hemodynamically significant effect upon flow resistance.     

Carotid surgery under loco-regional anesthesia. Early results of 100 recent cases]

A prospective single-centre study was performed to evaluate the safety and efficacy of carotid revascularisation under local anesthesia. Between November 1, 1996 and March 30, 1998, 92 patients underwent surgery for 100 carotid artery stenoses under local cervical block anesthesia. Fifty-eight stenoses were asymptomatic and 42 were symptomatic. Duplex ultrasound scanning showed a tight (n = 17) or very tight carotid artery stenosis (n = 83); angiography showed 19 contralateral carotid artery stenosis and 30 hemodynamically significant stenosis of vertebral and/or subclavian arteries. Cerebral Magnetic Resonance Imaging (MRI) (N = 87) with circle of Willis Magnetic Resonance Angiogram (MRA) (n = 83) detected 29 ischemic defects (33%). Fifteen ischemic defects were found in 58 asymptomatic patients (26%). Circle of Willis was incomplete in 41%. Anesthesia was performed using superficial cervical block (n = 100). Endarterectomy was the most commonly used revascularisation technique in 86 cases with 5 eversion endarterectomies; carotid vein or prosthetic graft was used in 14%. In this study, there was no mortality, and no cardiac or neurologic complications, during the first postoperative month. Twelve patients experienced neurologic intolerance to carotid clamping. This clamping-related ischemia required 4 shunts. All patients with clamping intolerance had a good clinical outcome after revascularisation with no objective or MRI sequelae. Incomplete circle of Willis on MRA was a significant predictive test of clamping intolerance (p < 0.0001). Carotid artery surgery under local anesthesia reduces the cumulative mortality and morbidity rate (TCMM) to a very low level: 0% in this study. These recent results are the modern reference for current carotid artery surgery evaluation.     

Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures

PURPOSE: Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD). METHODS: Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis. RESULTS: Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant. CONCLUSION: In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.     

Giant celiac artery aneurysm: Treatment by transcatheter coil embolization

Celiac artery aneurysms (CAA) are one of the rarest forms of visceral artery aneurysms. Most patients are a symptomatic at the time of diagnosis and aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 42-year-old man who had an asymptomatic giant CAA detected incidentally by an abdominal ultrasound investigating an abdominal pain. A contrast enhanced computed tomography angiogram (CTA) revealed a large CAA measuring 7.1 cm × 4.3 cm with extensive collaterals from the superior mesenteric artery (SMA). The aneurysm sac was mostly filled with thrombus with the celiac artery branches occluded. Pre-procedural angiography and transcatheter embolization procedures were performed at the same session. Endovascular exclusion was performed by transcatheter coil embolization and packing of the aneurysm sack. Technical success was achieved by the absence of flow in the aneurysm, and preservation of the native circulation on angiograms obtained just after the transcatheter coil embolization procedure. One week postembolization, a CTA confirmed thrombosis of the aneurysm. The patient returned for a follow-up CTA 3, 6, 12 and 48 months after embolization. The aneurysm was thrombosed and the patient remained a symptomatic. The surgical mode of treatment of CAA is increasingly being replaced by endovascular embolization because of the lower morbidity and mortality and high success rate. The accepted endovascular approach is by coil embolization of the aneurysmal lumen, the proximal and distal aneurysmal neck, or both.     

Long-Term Results of Aorta-Superior Mesenteric Artery Bypass Using a New Route

Purpose Several methods of revascularization after mesenteric ischemia have been proposed. Using a new route, we performed retrograde loop bypass grafting to the superior mesenteric artery (SMA) with a ringed expanded polytetrafluoroethylene (ePTFE) graft.Methods We anastomosed the graft to the infrarenal aorta, which ran behind the left renal hilum, turned ventral, and was anastomosed to the SMA in an antegrade fashion hemodynamically. Five patients underwent this procedure, which resulted in remarkable symptomatic relief.Results There were no postoperative deaths or serious complications, although some patients suffered paralytic ileus. All of the grafts remained patent during long-term follow-up, ranging from 17 to 72 months (mean: 37.8 months). Postoperative angiograms showed good configuration of the graft, which did not compress the renal vessels.Conclusion Infrarenal aorta-SMA bypass relieved mesenteric ischemia and achieved good long-term graft patency. Thus, we consider it to be an effective and durable vascular procedure to reduce postoperative mortality and morbidity.     

A comparison of digital subtraction angiography and noninvasive testing in the diagnosis of cerebrovascular disease

Among the 1,892 patients who underwent cerebrovascular digital subtraction angiography at our hospital over the past 18 months, there was a subgroup of 34 patients (65 carotid arteries) for whom noninvasive cerebrovascular test results and standard cerebral arteriograms were also available. These patients were reviewed retrospectively and the ability of both methods to detect hemodynamically significant lesions, defined as a greater than 50 percent reduction in the diameter of the carotid artery, was determined using the arteriograms as the "gold standard." Noninvasive cerebrovascular tests had a sensitivity of 81 percent, a specificity of 95 percent, a positive predictive value of 92 percent, a negative prediction value of 88 percent, and an overall accuracy of 89 percent. Digital subtraction angiography had a sensitivity of 84 percent, a specificity of 92 percent, a positive predictive value of 88 percent, a negative predictive value of 89 percent, and an overall accuracy of 89 percent. If the four cases of hemodynamically significant stenosis of the carotid siphon not detected by digital subtraction angiography had been considered as false-negatives, its sensitivity would have been reduced to 72 percent. In patients with hemispheric cerebral ischemia, we found noninvasive cerebrovascular tests neither necessary nor cost-effective. Digital subtraction angiography, on the other hand, often provided definitive diagnostic information in such patients if the intracranial circulation was well defined and the extracranial lesion corresponded to the patients' symptoms. Noninvasive cerebrovascular testing was the safest and most cost-effective technique for screening patients with asymptomatic bruits, atypical, nonhemispheric cerebral symptoms, and those who have undergone carotid endarterectomy. If the noninvasive cerebrovascular test result was positive or equivocal, digital subtraction angiography was performed to localize the responsible lesion and exclude carotid occlusion.     

Concurrent treatment of acute pancreatitis and multiple visceral artery aneurysms using endovascular techniques

Multiple aneurysms involving the celiac axis are extremely rare. Celiac artery aneurysms account for only 4% of all visceral aneurysms with 40% having concomitant aneurysms such as gastroduodenal artery (GDA) aneurysms. Development of a GDA aneurysm is associated with pancreatitis. If a GDA aneurysm ruptures, traditional repair is through open surgical techniques with significant morbidity and mortality as up to 50% occur in the setting of chronic pancreatitis. However, a ruptured GDA aneurysm causing pancreatitis has not been described previously. We report a case of successful endovascular treatment of a ruptured GDA aneurysm and concomitant celiac artery aneurysm leading to the resolution of acute pancreatitis.     

重症急性胰腺炎时胰腺血管造影的影像学表现及其临床意义

目的 探讨重症急性胰腺炎时胰腺血管造影的影像学表现及其临床意义。方法 对25例重症急性胰腺炎病人和20例胰腺无疾患志愿者,按Seidinger法将导管插入至胃十二指肠动脉行胰腺血管造影。结果 重症急性胰腺炎时胰腺血管造影的影像学表现为：(1)主干动脉／分支动脉的直径比增大;(2)“树枝状”结构的“树枝”数目明显减少;(3)“网络状”结构模糊;(4)胰腺“轮廓”的消失,或成片状、模糊不清。结论 (1)胰腺血管造影是一种比较客观、直观地反映胰腺血供情况的影像学手段;(2)重症急性胰腺炎时,胰腺血管造影有较明显的影像学异常表现;(3)其临床意义在于：对重症急性胰腺炎病情严重度有一定的评估作用;预测区域动脉灌注治疗的疗效;为临床应用改善胰腺微循环药物提供客观的影像学证据。     

Definitive test to diagnose median arcuate ligament syndrome: injection of vasodilator during angiography

The diagnosis of median arcuate ligament (MAL) syndrome and its correlation with symptoms has been controversial since the disease entity was described. The authors describe a technique that will identify patients who will benefit from intervention. Eight patients with isolated celiac artery compression from MAL were identified by the authors. Their technique involved selective cannulation of the superior mesenteric artery (SMA) and injection of a vasodilator during angiography. Symptom reproduction and loss of collateral filling of the celiac territory represented a positive test: 4 of the 8 patients had a positive test and underwent successful surgical treatment of the condition; 3 of them remained asymptomatic at follow-up; 1 patient continues to have mild abdominal discomfort. Of the 4 patients with a negative test, 2 were found to have other conditions causing their symptoms. Vasodilator injection into the SMA is a useful diagnostic test to identify patients with symptomatic MAL syndrome.     

Changes in intracranial stenotic lesions after extracranial-intracranial bypass surgery

The natural history of intracranial arterial stenosis is not well understood. The lesions are pathologically quite diverse, and are subject to resolution, progression, or occlusion. The authors undertook an investigation to examine what effects, if any, extracranial-intracranial (EC-IC) bypass surgery had on the evolution of intracranial arterial stenosis in 18 patients undergoing EC-IC bypass procedures for ipsilateral hemispheric ischemia. There was inaccessible internal carotid artery stenosis in 14 patients, and middle cerebral artery stenosis in four patients. Early (within 2 weeks) and late (at 6 months) postoperative angiography was performed in all patients. During the period of the study, there was a significant change in the arterial stenosis in 50% of the patients (nine of 18). The stenotic artery became occluded in four patients while the grafts were widely patent. The occlusion occurred within a few days after the operation in three of the four cases, and was accompanied by an ischemic stroke in these patients. There was improvement or resolution of the stenotic lesion in five patients; the graft became occluded in two of these cases and was patent but showed poor cortical artery filling in the other three. All these patients remained asymptomatic and the change was detected on routine late postoperative angiograms. It is concluded that arterial stenoses should not be viewed as static or inflexible lesions, and that EC-IC bypass procedures can modify the hemodynamic parameters across stenotic lesions, predisposing them to improvement or worsening. This, in turn, may affect bypass patency. Such hemodynamic interactions are accompanied by ischemic symptoms in some patients, and contribute to the relatively higher morbidity associated with EC-IC bypass surgery in the setting of arterial stenosis.     

Evaluation of the color coded Doppler ultrasound in detecting carotid bifurcation disease

The color coded continuous wave doppler ultrasound was compared with angiography in 201 arteries, 83 with greater than 50% diameter stenosis and 118 with less than 50% stenosis. Overall accuracy in identifying hemodynamically significant (greater than 50% diameter stenosis) was 87% in the presence of peak velocities greater than 5000 Hz and a blue color coded image. Negative predictive value was 94.5%. False positives were mainly due to the presence of severe external carotid stenosis and increased flow due to contralateral carotid occlusion. Within the limitations of the test being an indirect method, it is a reliable screening method for detecting hemodynamically significant carotid artery disease.     

扩大胰十二指肠切除术中联合肝动脉、肝固有动脉与髂内静脉切除重建应用的可行性研究

目的探讨在行扩大胰十二指肠切除联合血管切除术中应用肝动脉(HA)或肝固有动脉(PHA)与肠系膜上动脉(SMA)吻合、髂内静脉(IIV)与肠系膜上静脉(SMV)或门静脉(PV)吻合应用的可行性。方法解剖20具成人尸体的HA、PHA、SMA、SMV、PV、左IIV及右IIV,测量各血管长度、血管壁厚度和血管直径;用多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影检测20例胰头癌患者和本组5例患者的上述血管,并进行比对。根据比对结果,对5例已经发生血管浸润的胰头癌行扩大胰十二指肠切除术,行HA或PHA与SMA、IIV与SMV或PV吻合重建。结果尸体的HA-PHA长度为(5.50±1.50)cm,血管壁厚度为(0.20±0.01)mm,血管直径为(5.02±1.32)mm;SMA长度为(4.00±1.00)cm,血管壁厚度为(0.21±0.01)mm,血管直径为(6.05±1.06)mm。左IIV、右IIV及PV主干或SMV血管直径分别为(11.06±0.16)mm、(11.10±0.13)mm及(11.56±0.20)mm;左IIV、右IIV及PV主干或SMV的管壁厚度分别为(0.10±0.01)mm、(0.10±0.02)mm和(0.10±0.02)mm。活体多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影显示HA或PHA和SMA管壁厚度及血管直径分别稍比尸体解剖大0.1 mm和0.3 mm,差异均无统计学意义(P>0.05),而HA-PHA的长度比SMA长1～2 cm(P<0.05)。5例行扩大胰十二指肠切除术同时联合HA或PHA和SMA、IIV和PV或SMV切除重建患者的生存期均长于同期姑息性或放弃手术者,无一例发生远期并发症。结论有血管侵犯的胰头癌不是根治术的绝对禁忌证;就本组5例扩大胰十二指肠切除联合血管切除重建的患者比同期发生血管浸润的胰头癌仅施行探查或姑息性手术的33例患者生存时间而言,前者生存时间明显延长;HA或PHA和IIV是最好的自体血管代用材料,没有明显增加术后并发症;熟识尸体局部解剖结构对手术医生有一定的指导性意义。     

肝动脉外科解剖在肝动脉置管术中的应用及意义

目的 目前术中肝动脉置管术(IHAC)已广泛应用于肝脏恶性肿瘤的综合治疗，但多采用盲目插管的方法，影响了IHAC的疗效。通过术中肝动脉的外科解剖结合肝动脉造影，了解肝总动脉及其主要分支的行径及相互关系，证明肝动脉外科解剖在IHAC中的意义。方法 采用电凝锐性解剖技术对116例肝脏或胆道疾病患者行肝动脉外科解剖，详细记录肝总动脉(CHA)、肝固有动脉(PHA)、肝左、右动脉(LHA、RHA)及胃十二指肠动脉(GDA)的位置和相互间的成角(锐角或钝角)，并在术中观察自然状态下导管经胃网膜右动脉插入后的走向。部分病例结合肝动脉造影资料进行分析。结果 (1)GDA与CHA呈水平或钝角72例(62％)。其中20例行IHAC，导管经胃网膜右动脉插入时全部进入CHA；(2)GDA与CHA呈锐角，而与PHA呈水平或钝角36例(31％)，13例行IHAC，导管或进入PHA或RHA；(3)PHA缺如8例(7％)。此外，116例中RHA起源于肠系膜上动脉9例(7．7％)，肝左动脉源于胃左动脉7例(6．0％)，肝左、右动脉之间在肝门部存在明显异常交通支2例(1．7％)。结论 影响IHAC准确性的关键是GDA与CHA的成角，以及肝动脉解剖异常。由于绝大多数GDA与CHA成角为钝角，加上一定比例的肝动脉解剖异常，因此，非肝动脉外科解剖的盲目插管其成功率不足25％，应引起临床的高度重视。     

The asymptomatic carotid bruit

Management of the asymptomatic carotid bruit remains a controversial subject. The purpose of this study is to determine whether or not such bruits are important risk factors in the evolution of stroke. Since April 1977, 87 patients with 131 asymptomatic carotid bruits were evaluated with the Gee oculoplethysmography (OPG). Eleven bruits (8.4%) were hemodynamically significant (ophthalmic artery/brachial artery systolic pressure index below 0.69 or a difference of 5 mm Hg or more between the eyes). The patients were reevaluated at 6-month intervals. The mean follow-up was 34 months (range, 1-60 months). During this period, 14 bruits (11.6%) that initially were nonhemodynamically significant (NHS) later became hemodynamically significant (HS). Patients with asymptomatic carotid bruits had a stroke incidence of 10.3 per cent. Patients with HS bruits had a stroke incidence of 24 per cent and a transient ischemic attack (TIA) incidence of 16 per cent, which were significantly higher (P greater than 0.01) compared to the patients with NHS bruits (4.8% incidence of stroke and 3.2% incidence of TIA). Nine patients (10.3%) developed strokes without antecedent TIA and six patients (6.9%) developed TIA. The strokes occurred in the cerebral hemisphere supplied by the carotid artery with HS bruit in three of six patients. The strokes in three patients with NHS bruits were on the same side of the bruits. The TIAs developed in four patients with HS bruits and in two patients with NHS bruits. The authors conclude that the patient with an asymptomatic HS carotid bruit has a high risk of developing a stroke and that surgical treatment is warranted.     

Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm

A 72-year-old man was admitted because of progressive right upper-abdominal distension and pain as well as concurrent remittent fever for 5 months. He had undergone a radical gastrectomy and catheter intubation in the common hepatic artery for chemotherapy 12 months before admission. The diagnosis of giant infected hepatic-celiac artery pseudoaneurysm was established. Coils embolotherapy was given in another hospital, but it failed. After admission, a computed tomographic aortogram showed a mass 10.3 x 8.5 x 8.1 cm in size in the right upper abdomen that originated from the common hepatic artery and the celiac artery. A celiac-super mesenteric artery (SMA) double catheter simultaneous digital subtraction angiography (DSA) further revealed that the entrance of the aneurysm opened directly from the abdominal aorta, the distance between the orifice of SMA and celiac axis was only 0.5 cm, and the diameter of the celiac trunk had been aneurysmally enlarged to 2.0 cm. A blood culture was positive for Bacillus pyocyaneus. After detailed discussion and preparation, a stent-graft complex was negotiated through the left femoral artery and deployed successfully into the abdominal aorta to seal the orifice of celiac trunk under the dynamic supervision of DSA. Completion angiography revealed that the hepatic-celiac pseudoaneurysm was completely excluded from aortic flow by the endoluminal stent-graft complex, while the SMA and renal arteries remained perfectly patent. The patient recovered uneventfully and was discharged without any residual symptoms. At a 5-year follow-up, the patient remained asymptomatic and was leading a normal life.     

Severity of coronary artery stenosis at preoperative angiography and midterm mammary graft status

BACKGROUND: The purpose of this study was to evaluate the correlation between the midterm angiographic results of mammary artery grafts and the preoperative stenosis of the target vessel. METHODS: We analyzed preoperative and postoperative angiograms of 93 patients who underwent postoperative midterm (> or = 3 years) angiograms of an internal mammary artery (IMA) to left anterior descending artery graft for clinical or study purposes. Patients were divided into three groups on the basis of the percentage of the coronary artery stenosis at preoperative angiography: < 70%, 70% to 90%, and > 90% stenosis. RESULTS: Preoperative characteristics were similar in the three groups. The overall incidence of IMA occlusion was 19% in the entire population, without significant differences between groups (19% versus 29% versus 14%). The mean mammary artery diameter significantly increased in direct proportion to the severity of the coronary stenosis (2.0 +/- 0.2 mm in the < 70% versus 2.5 +/- 0.3 mm in the 70% to 90% and 2.7 +/- 0.4 mm in the > 90% series; p < 0.05). CONCLUSIONS: Chronic native competitive flow does not significantly affect midterm graft status but does influence mammary graft diameter.     

The prevalence of steal-prone coronary anatomy in patients with coronary artery disease: an analysis of the Coronary Artery Surgery Study Registry

Coronary steal requires a specific anatomic arrangement of coronary occlusion, collateral vessels, and stenosis of the artery supplying the collaterals. The prevalence of this anatomic variant, steal-prone coronary anatomy, was investigated in 16,249 patients with coronary artery disease whose angiograms were carefully recorded as part of the Coronary Artery Surgery Study (CASS). Almost half of the angiograms had one or more total occlusions, and, of these, about 80% had angiographically visible collateral supply to the area distal to the occlusion. Of subjects with an occlusion and collaterals, about 60% had a hemodynamically significant stenosis of the artery supplying the collateral vessels. In summary, 23% of the patients in the CASS Registry demonstrated steal-prone coronary anatomy. Thus, coronary steal could possibly affect almost a quarter of the patients with coronary artery disease having anesthesia. Studies that seek clinical evidence of harm from coronary steal must be done in that subset of patients with coronary artery disease with steal-prone anatomy.