Right internal mammary artery reimplantation into the left internal mammary artery. Y anastomosis. 25 cases]

Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.     

The free internal mammary artery bypass graft. Use of the IMA in the aorta-to-coronary artery position

Transposition of the internal mammary artery (IMA) into the aorta-to-coronary artery position is described, and 4 patients who underwent this operation are reported. Currently, this type of bypass graft is reserved for those patients who have unsuitable or stripped saphenous veins. The free IMA grafts can be connected to any of the major coronary vessels, and in most instances optical assistance is not necessary. There was no significant difference in recorded blood flow between these free grafts and a large group of in situ IMA-to-coronary artery bypass grafts.     

乳内动脉—冠状动脉和移植术53例

作者对１９９４年１月－１９９６年１２月本院所作的５３例乳内动脉（ＩＭＡ）－冠状动脉旁路移植术进行了总结。全部患者均为经内科治疗效果不满意者。其中４４例发生过一次以上的心肌梗塞;１６例合并室壁瘤形成。除１例为非体外循环单纯左ＩＭＡ与左前降支史合外,其余元首地左ＩＭＡＫ吻合前降支及大陷序惯“蛇形”桥。全组平均做冠脉吻合口４．２８支。同期左室壁瘤切除４例。３５例随访６个月－１年半,其中３０例症状消失,５     

乳内动脉-冠状动脉旁路移植术53例

作者对１９９４年１月～１９９６年１２月本院所作的５３例乳内动脉（ＩＭＡ）－冠状动脉旁路移植术进行了总结。全部患者均为经内科治疗效果不满意者。其中４４例发生过一次以上的心肌梗塞；１６例合并室壁瘤形成。除１例为非体外循环行单纯左ＩＭＡ与左前降支吻合外，其余均行左ＩＭＡ吻合前降支及大隐静脉序惯“蛇形”桥。全组平均做冠脉吻合口４．２８支。同期左室室壁瘤切除４例。手术死亡４例。３５例随访６个月～１年半，其中３０例症状消失，５例症状减轻，活动量增加。随访结果提示，ＩＭＡ冠脉旁路移植术可取得满意疗效。作者还对ＩＭＡ冠脉旁路移植术的技术要点、适应证等进行了讨论。     

Improved technique for the proximal anastomosis with free internal mammary artery grafts

A method for construction of the proximal aortic anastomosis using an autologous pericardial patch for free internal mammary artery bypass grafts is described. The use of pericardium allows for ease of suturing without the need for saphenous vein harvesting.     

Lambda graft with the radial artery or free left internal mammary artery anastomosed to the right internal mammary artery: flow dynamics

BACKGROUND: The aim of this study was to evaluate the outcome and flow dynamics of the lambda graft configuration, relative to a second arterial graft. METHODS: From 1998 to 2000, 47 patients (mean age 55.5 +/- 4.7 years) with triple-vessel disease underwent arterial revascularization using the lambda graft. The in situ left internal mammary artery (LIMA) and right internal mammary artery (RIMA) were anastomosed to the left anterior descending (LAD) and obtuse marginal arteries, respectively. In 21 patients (group I) presenting proximal or middle-third LAD or right coronary (RC) arterial stenoses, the lambda graft was constructed by anastomosing the distal LIMA, as a free LIMA graft, to the RC and proximally to the in situ RIMA. In the other 26 patients (group II) presenting with middle-distal third LAD or RC arterial stenoses, the radial artery (RA) was used to construct the lambda graft. All patients underwent transthoracic echo color Doppler before and after an adenosine test at 1 week and 3 months after operation. RESULTS: There were no hospital deaths. Overall, 47 lambda grafts were constructed. There was no difference between baseline and maximal flows and coronary flow reserve (CFR) between groups. CFR at IMA stems increased in both groups within 3 months versus 1 week [(LIMA)CFR = 2 +/- 0.3 vs 2.3 +/- 0.3 (p = 0.002) and (RIMA)CFR = 2.2 +/- 0.4 vs 2.5 +/- 0.3 (p = 0.009) in group I, and (LIMA)CFR = 2.12 +/- 0.33 vs 2.4 +/- 0.35 (p = 0.005) and (RIMA)CFR = 2.17 +/- 0.32 vs 2.52 +/- 0.26 (p = 0.001) in group II]. At 3 months versus 1 week, the (RIMA)diameter(i) (mm) at rest was 1.69 +/- 0.32 versus 1.48 +/- 0.2 (p = 0.015) in group I and 1.66 +/- 0.3 versus 1.47 + 0.2 (p = 0.01) in group II. At 6 +/- 2.4 months, all patients were free of angina. CONCLUSIONS: These data, almost identical for free LIMA and RA to RIMA using the lambda graft, demonstrate that RIMA flow reserve is adequate for multiple coronary anastomoses irrespective of the second arterial graft.     

Patency of the internal mammary artery used as sequential graft.

In 28 patients with the left internal mammary artery (IMA) used as a sequential coronary artery graft, clinical and angiographic evaluation was made 19-47 months postoperatively. Patency was 96% in the proximal anastomoses and 93% in all the anastomoses. Angiography, however, showed optimal function in only 75% of the distal graft ends. These observations indicate that routine use of left IMA as a sequential graft should be restricted to experienced surgeons. Clinical and angiographic findings did not always correlate, emphasizing that evaluation of IMA-graft patency should include angiography.     

Coronary revascularization using an internal mammary artery-saphenous vein composite graft in a patient with severely calcified ascending aorta

A 52-year-old woman with angina pectoris resulted from complete obstruction of left coronary ostium required double-vessel bypass. Because of severely calcified ascending aorta, avoidance of aortic cross-clamping was needed for the prevention of embolic injury and aortic dissection. Internal mammary artery (IMA)-saphenous vein (SV) composite graft under hypothermic ventricular fibrillation was successfully performed without any complication. IMA-SV composite graft is a good alternative in a case of insufficient IMA length and limited site for proximal vein graft anastomosis, which can avoid or reduce the manipulation of diseased ascending aorta.     

Late spontaneous revascularization of an internal mammary graft onto the anterior interventricular artery

The authors report a case of internal mammary artery graft anastomosed to the left anterior descending coronary artery (LADC) which was found to be non functional in the early post-operative period (one month) but second catheterization at one year revealed the graft to be patent with thrombosis of the LADC. This case shows the flow adjustment possibilities of internal mammary artery graft.     

The internal mammary artery free and flap aortoplasty in coarctation of the aorta

A technique for correction of aortic coarctation is described in which the left internal mammary artery (IMA) is distally divided for integration in the repair. After resection of the internal coarctation ridge, the distal end of the freed IMA is obliquely severed, opened to required length and thus fashioned as a widening flap suitable fro aortoplasty. IMA free end flap aortoplasty gave promising early results in seven patients aged 10-15 years with aortic coarctation and IMA of good quality and calibre.     

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.     

Retrophrenic location of the internal mammary artery graft

A technique of locating the internal mammary artery behind the phrenic nerve is described, which extends the application of internal mammary artery grafting to the lateral wall of the left ventricle. The technique also facilitates the performance of the posterolateral anastomosis between the internal mammary and circumflex coronary arteries.     

Coronary reoperations in patients with a patent internal mammary artery graft

OBJECTIVE: Analysis of short and long term results, clinical, functional and subjective status of patients, with a patent arterial graft, after coronary reoperation (RECABG). METHODS: Perioperative and follow-up data of 71 patients, undergoing coronary reoperations (1987--8) were studied. A cross-sectional follow-up was conducted, functional evaluation by the Duke Activity Status Index (DASI), and patient's evaluation of his life situation were registered. RESULTS: Perioperative mortality was 7%. Eleven patients died during follow-up. The 12-month and 60-month survival was 96% and 80%. Event-free survival was 86% and 51%. Family doctors declared that 55/66 (83%) had benefitted from the coronary reoperations. New York Heart Association decreased significantly from 3.4 +/- 0.5 preoperative versus 1.5 +/- 0.4 postoperative. The mean DASI was 38.06 +/- 10.42. At the moment of the cross-sectional follow-up, 45/55 patients (82%) declared to have benefitted from the coronary reoperations. CONCLUSION: Improvement in New York Heart Association-class, good postoperative functional capacity, and patients positive evaluation, justify coronary reoperations in patients with a patent internal mammary artery graft.