Internal Mammary Artery Dissection Research Articles

Iatrogenic Dissection of the Left Internal Mammary Artery During Percutaneous Coronary Intervention of Jump Radial Artery Graft Bifurcation Disease: A Case Report

Iatrogenic Dissection of the Left Internal Mammary Artery During Percutaneous Coronary Intervention of Jump Radial Artery Graft Bifurcation Disease: A Case Report

Blue-Blood Pig Thorax Model Increases Residents' Confidence in Internal Mammary Dissection.

Preparation of the recipient vessels is a crucial step in autologous breast reconstruction, with limited opportunity for resident training intraoperatively. The Blue-Blood-infused porcine chest wall-a cadaveric pig thorax embedded in a mannequin shell, connected to a saline perfusion system-is a novel, cost-effective ($55) simulator of internal mammary artery (IMA) dissection and anastomosis intended to improve resident's comfort, safety, and expertise with all steps of this procedure. The purpose of this study was to assess the effect of the use of this chest wall model on resident's confidence in performing dissection and anastomosis of the IMA, as well as obtain resident's and faculty's perspectives on model realism and utility. Plastic surgery residents and microsurgery faculty at the University of Wisconsin were invited to participate. One expert microsurgeon led individual training sessions and performed as the microsurgical assistant. Participants anonymously completed surveys prior to and immediately following their training session to assess their change in confidence performing the procedure, as well as their perception of model realism and utility as a formal microsurgical training tool on a five-point scale. Every participant saw improvement in confidence after their training session in a minimum of one of seven key procedural steps identified. Of participants who had experience with this procedure in humans, the majority rated model anatomy and performance of key procedural steps as "very" or "extremely" realistic as compared with humans. 100% of participants believed practice with this model would improve residents' ability to perform this operation in the operating room and 100% of participants would recommend this model be incorporated into the microsurgical training curriculum. The Blue-Blood porcine chest wall simulator increases trainee confidence in performing key steps of IMA dissection and anastomosis and is perceived as valuable to residents and faculty alike.

An Interesting Case of Right Sided Haemorrhagic Pleural Effusion

Hemorrhagic pleural effusions is common in our clinical practice and its usually due to trauma, malignancy and pulmonary embolism. Other rare causes are Bleeding diathesis, Spontaneous hemopneumothorax, Aortic dissection or rupture, Aneurysm rupture or dissection of internal mammary artery, Post-cardiac injury syndrome, Infections like dengue hemorrhagic fever, pulmonary tuberculosis, etc. Aortic dissection is uncommon, a high index of suspicion for acute aortic dissection must be kept in mind when evaluating patients with unexplained chest or back pain. Here by presenting a case of elderly male patient with acute onset right sided chest pain with right haemorrhagic effusion and whose CT thorax revealed aortic dissection. Pleural effusion in aortic dissection is mainly due to inflammation and is a rare presentation. Keywords: Hemorrhagic pleural effusion, Pancreatitis, Cause.

Left Internal Mammary Artery Dissection and Bleeding: A Matter of Trial Design, Not Technique

In this issue of The Annals of Thoracic Surgery, Mazur and colleagues1 present the results of a small single-center randomized trial of 62 patients comparing the impact of skeletonized vs pedicled left internal mammary artery (LIMA) harvesting on bleeding after coronary artery bypass grafting. The primary outcome was cumulative mediastinal drainage 12 hours postoperatively, which was found to be 28% lower in patients with skeletonized vs pedicled LIMA. The effort of the Polish group is commendable, but several important issues related to their trial’s methodology must be considered.

Surgical delay of anterior chest wall prior to open coronary arterial bypass grafting surgery may decrease postoperative sternal complications

Open coronary arterial bypass grafting (CABG) procedures are inherently risky in regards to the healing capacity of the subsequent sternal wound. Patients often have underlying risk factors for poor healing and the procedure itself often reduces vascularity to the anterior chest with internal mammary artery (IMA) dissection. Currently unrelated is the surgical delay procedure. It is a well-established technique for augmenting vascularity and ultimatelytissue survival. It involves partial disruption of the blood supply to a flap for a period of time prior to fully elevating the flap (usually between 3 and 21 days). Recently, endoscopic robotic IMA dissection has become possible as a part of totally endoscopic CABGs for left-sided vessel disease. We are proposing a new technique, using surgical delay for patients who require open sternotomies for CABGS to reduce the rate of postoperative sternal wound complications. To delay the CABG, the majority of a robotic internal IMA dissectionwould be performed prior to an open CABG via a midline sternotomy. We hypothesize that this may decrease sternal wound complication rates. Potential pitfalls include consequences of disrupting the normal anatomic location of the IMAs and causing inflammation before the open CABG. Animal models will be the next step, as they will evaluate the feasibility of the delay as well as help to determine the optimal timing for the procedure.

Case report: recurrent metastatic breast cancer in internal mammary dissection bed discovered at the time of coronary bypass

IntroductionMany patients who undergo coronary artery bypass surgery have a prior history of cancer and potentially chest radiation which is a known risk factor for coronary atherosclerosis. Prior radiation increases fibrosis and can make the dissection of the left internal mammary artery (LIMA) more challenging.Case reportA 72-year-old woman with a history of stage IIA pT2N0M0 left breast intraductal carcinoma treated with lumpectomy, adjuvant chemotherapy and radiation therapy 11 years prior presented to the emergency room with a non-ST elevation myocardial infarction and was taken for cardiac catheterization followed by three-vessel coronary artery bypass grafting. The LIMA was found to be encased in scar tissue and was deemed unsuitable as a conduit, and a saphenous vein graft was bypassed to the left anterior descending artery in its place. Pathologic review of the LIMA showed nests of tumor cells infiltrating within dense fibrous tissue with areas of necrosis and calcifications consistent with recurrent breast cancer. Interestingly the patients original breast cancer was positive for estrogen receptors (ER) and progesterone receptors (PR) ER and PR and negative for HER2 and she had therefore been treated with 5 years of hormonal therapy. The recurrent cancer found in the LIMA dissection bed at the time of bypass surgery was ER, PR, and HER2 negative, suggesting hormonal therapy driven clonal selection of these metastatic tumor cells.Discussion and conclusionsScarring in the LIMA dissection bed in patients with a history of cancer and prior chest radiation should be carefully evaluated for the possibility of recurrent cancer. The gross appearance of tissue can be misleading and sending a biopsy for a formal frozen section histologic evaluation should be considered if there is any question of recurrent malignancy.

Reoperative aortic valve replacement through upper hemisternotomy.

Reoperative aortic valve replacement (AVR) has become increasingly common (1). In patients with previous coronary artery bypass grafting (CABG), minimally invasive reoperative AVR is the preferred approach since it allows the performance of no-touch technique for left internal mammary artery (LIMA) and minimal dissection around the vein grafts (2,3). Here, we present an 83-year-old man with symptomatic severe aortic stenosis and a positive history of coronary artery disease (CAD), hypertension, dyslipidemia, chronic renal disease, peripheral vascular disease and carotid stenosis. He has had a CABG and carotid endarterectomy and was found to be ineligible for transcatheter aortic valve replacement (TAVR) due to severe iliofemoral calcification. Coronary grafts were proven patent by angiography, while left ventricular function and wall motion were proven normal by echocardiography. The patient was scheduled for a minimally invasive isolated AVR reoperation through upper hemisternotomy.

Unstable angina due to spontaneous left internal mammary artery dissection seventeen years after coronary artery bypass graft surgery: A case report and literature review

A 64 year-old male was admitted to the emergency department for multiple episodes of chest pain at rest. His cardiac history began seventeen years before when a coronary artery bypass grafting (CABG) was performed. This included left internal mammary artery (LIMA) graft to left anterior descending artery (LAD) and saphenous vein graft (SVG) to the diagonal branch. Since then the patient was subjected to numerous percutaneous coronary angioplasties on LAD, circumflex artery and SVG. The last angiographic control showed LIMA graft patency. The coronary angiography showed LAD, circumflex and right coronary artery occlusion and LIMA graft critical stenosis with evidence of dissection. Then, the lesion was crossed and intravascular ultrasound (IVUS) evaluation was performed to investigate the extent of the dissection. IVUS demonstrated dissection with an intramural hematoma and presence of intimal tear. Therefore, a coronary angioplasty with multiple direct drug eluting stents implantation completed with post-dilatation was performed. Good angiographic and IVUS results were achieved. Spontaneous LIMA graft dissection is a rare condition. We reported the ninth case in literature and the one with the highest latency period between CABG and LIMA graft dissection. This situation may lead to an acute coronary syndrome, an unstable angina in our report, therefore prompt treatment, percutaneous or surgical, is decisive. Spontaneous arterial graft dissection is sometimes seen in women, especially in the post-partum period, it usually occurs during the fifth and sixth decade in patients affected by arterial hypertension, vasculitis, connective tissue disorders or atherosclerotic disease.

Left Internal Mammary Artery Dissection during Percutaneous Coronary Intervention in Hypertensive Patients

Left Internal Mammary Artery (LIMA) dissection is a potential catastrophic complication of percutaneous coronary intervention (PCI) rarely observed in hypertensive patients. There are very few reports but the paucity of data regarding the incidence capture the imagination more than other coronary dissections. Additionally, for the management of this iatrogenic complication there are no evidence-based guidelines to assist the operator. We present a case of two diagnostic catheter-induced dissections of LIMA successfully resolved with long multiple stenting, and review the existing literature. In our opinion, these case reports describe a very rare condition in hypertensive patients with some practical tips on how to avoid them, whereas there are very few published data. Moreover, we have shown that stenting has been used to solve a potentially deadly procedural complication, in a basal extremely serious clinical situation.

Outcomes of middle cardiac vein arterialization via internal mammary/thoracic artery anastomosis.

ObjectiveCardiac vein arterialization is seldom applied for treating right coronary artery disease. This study aimed to improve outcomes of cardiac vein arterialization in a porcine model using intramammary artery anastomosis.MethodsA chronic, stenotic coronary artery model was established in 12 of 14 Chinese experimental miniature pigs of either sex, which were randomly divided into equal control (n = 6) and experimental (n = 6) groups. In experimental animals, blood flow was reconstructed in the right coronary artery using intramammary artery. Arterialization involved dissection of right internal mammary artery from bifurcation to apex of thorax followed by end-to-side anastomosis of internal mammary artery and middle cardiac vein plus posterior descending branch of right coronary artery. Intraoperative heart rate was maintained at 110 beats/min. Graft flow assessment and echocardiography were performed when blood pressure and heart rate normalized.ResultsThe experimental group had significantly higher mean endocardial and epicardial blood flow postoperatively than control group (mean endocardial blood flow: 0.37 vs. 0.14 ml/(g*min), p<0.001; mean epicardial blood flow: 0.29 vs. 0.22, p = 0.014). Transmural blood flow was also higher in experimental group than in control group (0.33 vs. 0.19, p<0.001); ejection fraction increased from 0.46% at baseline to 0.51% (p = 0.0038) at 6 hours postoperatively, and mean blood flow of internal mammary artery was 44.50, perfusion index 0.73 at postoperative 6 months, 43.33 and 0.80 at 3 months.ConclusionSuccessful cardiac vein arterialization via intramammary artery in a porcine model suggests that this may be a viable method for reconstructing blood flow in chronic, severe coronary artery disease.

Internal mammary artery dissection sans application of ligaclips

Internal mammary artery dissection sans application of ligaclips

Internal mammary artery harvesting and antibiotic concentrations in sternal bone during coronary artery bypass

The concentrations of two antibiotics (vancomycin and cefuroxime) in sternal bone during coronary artery bypass surgery were analyzed to examine whether antibiotic penetration is impaired after dissection and harvesting of the left internal mammary artery for grafting. Bone samples (250 mg of cancellous sternal bone from both halves of the dissected manubrium) were obtained at the time of sternal opening and closure. Twenty patients undergoing primary coronary artery bypass grafting with the left internal mammary artery were randomized so that ten received 1.5 g of vancomycin over 180 minutes and ten 3 g of cefuroxime over 30 minutes beginning at the time of induction of anesthesia. Serum samples were collected at the same time as the bone samples and 12 h after the start of the infusions. There was a slight difference in vancomycin concentration between two sternal halves after IMA dissection at the time of sternal closure (median difference, 0.2 µg/g, and 95% confidence interval, -0.55 to 0.1). This difference was not statistically significant at the P = 0.05 level (P = 0.15, Wilcoxon matched-pair test). The cefuroxime concentration of the bone was below the detection limit (7.6 to 9.2 µg/g) in all ten patients at the time of sternal closure. Harvesting the internal mammary artery for coronary artery bypass grafting may influence the concentration of vancomycin in the manubrium of the sternum.

Thromboaspiration Leading to Complete Coronary Artery Stripping in Acute Myocardial Infarction After Blast Injury

A54-year-old man without medical history was admitted in our hospital with hemorrhagic shock caused by left compressive hemothorax (Figure 1) after a suicidal gunshot. The entrance site of the projectile was in the 4th left intercostal space. Figure 1. Chest radiograph (posteroanterior view, white arrow shows the bullet). Surgical exploration performed within the 1st hour revealed dissection of the left internal mammary artery and multiple injuries of the lung parenchyma, which could be successfully repaired. Extensive superficial epicardial dilacerations were observed at the level of the mid left anterior descending coronary artery, without penetrating myocardial or coronary artery injury and without pericardial effusion. Coronary flow appeared to be preserved. On transfer into the intensive care unit of the sedated and mechanically ventilated patient, routine 12-lead ECG showed signs of anterior …

Endothoracic Injection of Room Air for Internal Mammary Artery Harvest

Arterial spasm is described as an event occurring after internal mammary artery (IMA) harvesting. Endothoracic papaverine and carbon dioxide application have been used to prevent IMA spasm before surgical dissection. This technique may make harvest quicker and easier. The aim of this study is to evaluate the effect of room air injection into the endothoracic fascia on IMA blood flow and harvest time. Eighty-four consecutive ischemic patients were randomly assigned to four groups: group 1 (n = 21, no treatment), group 2 (n = 21, papaverine), group 3 (n = 21, air), group 4 (n = 21, air and papaverine). The room air was injected with a blunt needle through the endothoracic fascia before harvest. Each dissection time was recorded and the flows were measured before cardiopulmonary bypass. Mean blood flows and harvest time were: group 1 = 65.7 +/- 16.3 mL/min, 37.2 +/- 8.5 minutes; group 2 = 86.6 +/- 16.4 mL/min, 25.6 +/- 5.5 minutes; group 3 = 85.7 +/- 13.1 mL/min, 22.4 +/- 4.8 minutes; and group 4 = 90.2 +/- 16.4 mL/min, 21.7 +/- 5.7 minutes. IMA flow and harvest time in groups 2, 3, and 4 were different than the control group (p < 0.001), but there was no significant statistical difference between treatment groups (2, 3, and 4) (p > 0.05). Injection of room air beneath the endothoracic fascia before IMA dissection may prevent spasm and shorten harvest time, which avoids any risk of intimal injury.

Aortic valve surgery in patients with patent internal mammary graft

Redo Aortic valve replacement after previous Coronary Artery Bypass Grafting (CABG) in patients with patent internal mammary pedicled grafts poses a high risk because of the dual nature of the underlying ischaemia and valvular heart disease. The surgery is challenging because of the extensive internal mammary artery (IMA) dissection required which can result in a small but significant risk to injury to the graft resulting in high mortality. Various techniques are now being described to perform such high risk surgeries without IMA dissection. We report two cases who had undergone CABG with Left internal mammary artery (LIMA) to Left anterior descending artery (LAD) as one of the grafts presented subsequently for aortic valve repair (AVR) for calcific aortic stenosis.

Chronic dissection of internal mammary artery graft

We report a case of internal mammary artery graft dissection. Cardiac catheterization showed a spiral dissection in the anastomotic site of internal mammary artery graft with TIMI 3 flow. Percutaneous stenting for native coronary artery lesions was performed. Cardiac catheterization, performed 2 years after the stenting, showed no change in the internal mammary artery dissection. This is the first case of unhealed chronic dissection of internal mammary artery graft.

Robotic telesurgery: a real‐world comparison of ground‐ and satellite‐based internet performance

Telesurgery was performed with ground vs. satellite networks, and differing satellite bandwidths. The networks were compared during internal mammary artery (LIMA) dissection in pigs (n = 8). Length of LIMA dissected and surgical quality (five-point scale) were recorded. Also, satellite bandwidth was decreased (n = 7) to determine a limit for telesurgery. No significant differences existed in LIMA dissection during the ground (4.3 +/- 0.5 cm) and satellite phases (5.4 +/- 1.1 cm; p > 0.05) or in quality of surgery, although latency on satellite was 10 times greater (55 vs. 600 ms). With decreasing satellite bandwidth, surgery was not possible below 3 Mb/s, and quality of surgery was significantly decreased comparing 9 Mb/s (4.38 +/- 0.66/5) to 3 Mb/s (4.10 +/- 0.80/5; p < 0.05). Satellite communication is a viable telesurgical modality. Satellite bandwidth should be above 5 Mb/s during telesurgery if used primarily or as back-up.

Technique of Lung Retraction During Internal Mammary Artery Harvesting

We describe a novel technique for lung retraction during dissection of the internal mammary artery for its use in coronary artery bypass grafting. The lung is retracted using the blades of the Octopus (Medtronic Inc, Minneapolis, MN) suction stabilizer, without the suction connected. This technique can be used when the internal mammary artery is harvested by widely opening the pleura or by the extrapleural approach. This technique makes mammary artery dissection easy, and it can be used for harvesting internal mammary arteries bilaterally. The method described is simple, causes no impairment in gas exchange, and offers no additional expense, because the same stabilizer would be used later for the off-pump coronary artery bypass surgery.

Multisclice computed tomographic angiography of a spontaneous left internal mammary graft dissection

A 67-year-old man, with a history of coronary artery from the first third of the artery (Fig. 1, panel B) and bypass graft surgery 10years ago and percutaneous coronary intervention with stent implantation in the left circumflex artery 10months ago, was referred to our department after a non-ST elevation myocardial infarction a month ago and post-myocardial infarction angina. The patient was unresponsive to medical treatment and underwent a coronary arteriography, which revealed an extensive left internal mammary artery (LIMA) dissection starting

Invited commentary

Invited commentary