Internal Thoracic Research Articles

Salvage of a massive esophago-tracheal fistula resulting from a stenting treatment

We report the successful surgical resolution of a case of massive esophago-tracheal fistula (ETF) caused by a stenting treatment for stricture of an esophago-gastric anastomosis. A 54-year-old man was admitted to our hospital due to serious pneumonia secondary to ETF. He had previously received esophagectomy and post-operative chemo-radiation therapy for esophageal cancer, followed by stenting treatments for a benign stricture of the esophago-gastric anastomosis. For surgical treatment of the resulting ETF, serial operations were required. The first operation, performed under percutaneous cardiopulmonary support, included removal of the stents followed by tracheotomy, were with the coverage of the tracheal defect achieved using both major pectoral muscle flaps. A salivary fistula was also generated and an enteral nutrition tube was placed. Six months after the first operation, a pedicled ileocolic interposition was performed in order to effect reconstruction of the digestive tube, with an additional microvascular anastomosis of the ileocolic and internal thoracic artery and vein. After the second operation, the patient's ability to ingest food was restored, and he was discharged from the hospital. Thus, ETF was successfully treated by successive surgical operations with delicate intra- and post-operative respiratory management.

Sampling of Internal Mammary Chain Lymph Nodes during Breast Reconstruction by Free Flaps from the Abdomen

The role of internal mammary chain lymph node removal in breast cancer is still not clarified. Although it has been proven that elective dissection of the internal mammary chain nodes does not improve survival, their selective treatment based on sentinel lymph node biopsy is under evaluation. There is another possibility to establish the status of internal mammary chain nodes--sampling of the nodes during the preparation of the site for microvascular anastomosis to the internal mammary artery and vein for free flap transfer. From August 2002 to December 2003, 54 free flaps were performed for breast reconstruction. In 11 cases, an internal mammary chain lymph node was harvested. A positive internal mammary chain node was found in only one case. In this case, the treatment policy was changed by adding irradiation to the internal mammary chain. The sampling of internal mammary chain nodes during preparation of the site for microvascular anastomosis to the internal mammary artery and vein should be a part of the reconstructive procedure after total mastectomy for invasive breast cancer because it could change the treatment plan.

Whole collateral bridge of an occlusion of the left internal thoracic artery graft

1010-7940/$ see front matter Q 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2005.04.045 * Tel.: C31 71 5262348; fax: C31 71 5248284. E-mail address: gtavilla@lumc.nl. no harvesting injury of the LITA reported, the pathophysiological basis was either a congenital anomaly or atheroma. A GEA to LAD and restrictive mitral annuloplasty resulted in a good outcome. European Journal of Cardio-thoracic Surgery 28 (2005) 493 www.elsevier.com/locate/ejcts

The free TRAM procedure in breast reconstruction: choice of vascular receptor site

In this study, 70 consecutive cases of breast reconstruction with the use of a free Transverse Rectus Abdominal Myocutaneous (TRAM) flap were reviewed with respect to the type of recipient vessels. We describe our evolution of choice of the receptor vessels. The deep inferior epigastric artery was anastomosed to the thoracodorsal artery in 15 cases. In 55 cases the internal mammary artery (IMA) was used as a recipient vessel. The deep inferior epigastric vein was anastomosed to the thoracodorsal vein in 15 cases, to the cephalic vein in eight cases, the external jugular vein in 16 cases and to the internal mammary vein (IMV) in 31 cases. Total flap necrosis occurred in four cases. In an additional four cases there was partial necrosis requiring minor operative correction. In six cases venous outflow problems were the cause of flap necrosis. The external jugular vein (n = 3) and cephalic vein (n = 2) were relatively frequently involved in cases of venous outflow problems. One flap was rescued 5 days after surgery following venous thrombosis by inserting a vein graft. The IMA and vein proved to be reliable and easy to access as recipient vessels for anastomosing the vessels of the free TRAM.

Unusual positioning of a central venous catheter

Central venous cannulation, with or without a flow-directed pulmonary artery catheter, is commonly performed in patients undergoing cardiac surgery to measure central filling pressure and cardiac output, and to administer medications and fluids. The complications of central venous cannulation are numerous and include malposition, arterial puncture, pneumothorax, hemothorax, chylothorax, extravasation of infusate, thrombophlebitis, and infection. We describe a single-lumen catheter that was placed through the hemostatic valve of a 9F percutaneous introducer, which inadvertently entered the left internal mammary (internal thoracic) vein. The current case is unique in that it was diagnosed by visualization of the catheter during surgical dissection.

Deviations of Placement / Function of Permanent Central Vein Catheters for Hemodialysis

Fourteen cases of malposition of a permanent central vein catheter for hemodialysis or poor blood flow associated with thrombosed central veins but correct catheter positioning, in 13 patients suffering from end stage renal disease, presented from September 1991 to December 2003 among 385 permanent central vein catheters for hemodialysis (3.6%). There were 8 episodes of catheter tip malplacement in the azygos vein (1 case), hemiazygos vein (1), left internal thoracic (mammalian) vein (1), contralateral innominate vein (5) and 6 cases with correct anatomical catheter tip placement but with blood inflow from the catheter through the collateral vein system because of thrombosis of a major vein trunk (hemiazygos vein system (2), azygos vein (2), ascending lumbar veins (1), or portal vein system (1)). The malposition was diagnosed using roentgenography, with or without contrast, and computer tomography. In 3 cases the catheter was removed, in 5 cases the position was corrected. In the remaining 6 cases its function was maintained using anticoagulation or/and thrombolytic therapy. In conclusion, the placement of a permanent central vein catheter for hemodialysis must be followed by simple or contrast medium x-ray evaluation of its correct position or function. The malposition must be corrected whereas in the case where there is no alternative solution the function of the catheter may be maintained in the incorrect position using a combination of anticoagulation or/and thrombolytic therapy.

Malposition of internal jugular catheter into internal mammarian vein in coronary artery bypass grafting

EDITOR: We report a case of misplacement of an internal jugular catheter into the internal mammary vein before coronary artery bypass grafting (CABG). Internal jugular vein catheterization is commonly used in anaesthesiology and critical care, but its appropriate application is unknown. Proper placement is essential for the use of central venous catheters (CVC). It has been reported that the incidence of catheter malposition depends on a number of factors including the site of insertion and the type of material used but not on the experience of the physician who inserted the catheter [1]. Proper positioning of the catheter with the tip just above the superior vena cava (SVC) and right atrial junction is important to minimize associated complications such as dysrhythmias, thrombus formation and perforation with associated hydrothorax, pneumothorax, hydromediastinum, bleeding and tamponade. Malpositioning of the catheter occurs approximately 2% of the time when subclavian or internal jugular vein approaches are used [2]. Malpositioning in the left mediastinum is a rare event. A case of left internal thoracic vein cannulation is described. This 76-yr-old and obese female had a long history of effort dyspneoa and angina. At cardiac catheterization it was shown that the left anterior descending and right coronary arteries (RCx) were occluded. She was therefore scheduled for CABG. Anaesthesia was induced with etomidate 20 mg, fentanyl 2 μg kg−1 and endotracheal intubation was facilitated with vecuronium bromide 0.01 mg kg−1. Anaesthesia was maintained with isoflurane 2%, nitrous oxide 50% in oxygen and fentanyl. Venous access in obese patients may be difficult. Initial difficulty with cannulation of the right internal jugular vein was encountered and so the left internal jugular vein was used instead. Correct cannulation using a Secalon T 16 G® (Becton Dickinson Critical Care Systems - Franklin Lakes, New Jersey, USA) cannula initially appeared to be obtained without any difficulty. Return of venous blood was observed and intravenous (i.v.) fluid flowed easily into the catheter. Central venous pressure (CVP) was measured as 4 mmHg. Following a median sternotomy, the exact anatomical location of the catheter was seen. The surgeons informed us that the catheter had entered the left internal mammary vein (Fig. 1) and they used the catheter as a guide during dissection of the internal mammary artery. After the dissection we withdrew the catheter and inserted another catheter into the right femoral vein. Surgery was completed without any complication and the patient was transferred to the intensive care unit (ICU). One week later the patient was discharged from the hospital.Figure 1.: Internal Jugular catheter in left internal mammary vein.Proper positioning of CVC is important to ensure optimal catheter function and to decrease complications. Malposition can lead to inaccurate CVP evaluation, inability to aspirate blood samples, dysrhythmias, thrombus formation and perforation with associated hydrothorax, pneumothorax, hydromediastinum, bleeding and tamponade. Catheter malpositioning utilizing subclavian and internal jugular vein approaches is uncommon occurring 2% of the time. Many of the cases of left superior intercostal vein cannulation in the literature document the findings with no report of patient symptoms, catheter function, or management. Smith described an asymptomatic patient with a normal functioning catheter [3]. Although in our patient there was no unexpected anatomical aberration, we discovered a malpositioned catheter. A case has been reported of a pulmonary artery catheter being inserted via the left internal jugular approach without complication although it was later found to have passed through an unknown residual ventricular septal defect into the left ventricle, aorta and right carotid artery [4]. Although left-sided catheter malpositioning is a rare event [5], Şekerci and colleagues [6] reported inadvertent malpositioning of a drum catheter in the left internal mammary vein following an attempt at central venous cannulation via the right antecubital fossa. Similar to this, we report misplacement of an internal jugular catheter into the internal mammary vein. Although different type of catheters had been used, we should not forget that internal mammarian vein cannulation is possible. In CABG, this can be complicated by injury to the internal mammary vein and artery thus compromising an important graft source. To use X-ray imaging to assist correct replacement would be an alternative. Intraoperative trans-oesophageal echocardiography is gaining acceptance as a diagnostic tool for controlling the proper placement of catheters. Fortunately, our patient was undergoing open heart surgery and we had a chance to see the placement of it directly during the operation. M. Kanbak A. H. Karagöz M. Öç İ Uçar B. Çelebioglu R. Dogan 1Department of Anaesthesiology and Reanimation, Hacettepe University Faculty of Medicine, Ankara, Turkey 2Department of Cardiovascular and Thoracic Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey

Internal Mammary Perforators: A Cadaver Study

Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.

Accelerated intimal hyperplasia in aortocoronary internal mammary vein grafts in minipigs

Objectives: More than 50% of aortocoronary saphenous vein grafts are occluded 10 years after surgery. Intimal hyperplasia is the initial critical step in the progression toward occlusion. Internal mammary veins, which are physiologically prone to less hydrostatic pressure, may undergo an accelerated progression to intimal hyperplasia and thus be suitable for investigation of the mechanisms of aortocoronary vein graft disease.

Expression of cellular repressor of E1A-stimulated genes in vascular smooth muscle cells of different phenotypes

The phenotypic modulation of vascular smooth muscle cells (VSMC) plays a central role in the pathogenesis of arteriosclerosis. The purpose of this study was to investigate the expression of the cellular repressor of E1A-activated genes (CREG) at the transcriptional and protein level in human internal thoracic artery smooth muscle cells (HITASY), which express different patterns of differentiation markers after serum withdrawal. After cloning and recombining the CREG vector, the antiserum against the CREG protein was produced from the rabbits immunized by the purification CREG protein. The specificity of purified polyclonal antibody was detected by Western blot assay. The DNA synthesis of HITASY cultured in serum-free and serum-supplemented medium was measured by the [(3)H]-thymidine incorporation. Western blot analysis detected the expression of smooth muscle-specific markers (smooth muscle alpha-actin, calponin). The localization of CREG in cells was examined with immunohistochemistry staining and expression of CREG mRNA and protein were analyzed by RT-PCR and Western blot in HITASY after serum withdrawal. The high specificity of polyclonal antibody against CREG obtained from rabbits was confirmed by Western blot assay. In response to serum withdrawal, cultured HITASY cells exhibited phenotypic conversion from synthetic into contractile one as evidenced by the data of [(3)H]-thymidine incorporation and Western blot. The DNA synthesis of HITASY precipitously dropped to background levels after serum withdrawal and nearly restored after reintroduction of serum to culture medium 2 days later. Western blot revealed a reversible upregulation of smooth muscle alpha-actin and calponin in HITASY after serum deprivation. Moreover, serum withdrawal also induced a prominent increase of CREG mRNA and protein expression which reached a peak on 3 days and decreased gradually on 5 approximately 7 days after serum withdrawal. Immunohistochemistry stain indicated the CREG protein mainly localizes in a perinuclear pattern in HITASY cells. Those data provide evidence that the coordinated changes in CREG gene and protein expression as well as smooth muscle-specific markers may take place in connection with the process of phenotypic modulation of VSMC in vitro.

General session III Moderated by Takehisa Iwai: Muscular Flap Treatment for Intractable Ulcer with Artificial Vessel Exposure After a Surgery for Thoracic Aortic Aneurysm

Aim: To heal an exposed artificial vessel due to mediastinitis after the replacement of thoracic aortic aneurysm.Methods: The exposed vessel is washed thoroughly, wrapped in a muscular flap, and a free skin graft is grafted over it to close.Results: An 81‐year‐old male repeatedly had mediastinum after the replacement of aneurysm, and it was not cured with muscular fillings, and a rubor on the chest developed to a subcutaneous hematoma. The lesion was closed with a patch on the artificial vessel, the mediastinal abscess was washed, and the opening was closed by using latissimus dorsi muscular flap and split‐thickness skin graft. No recurrence has occurred for 3 years. A 69‐year‐old male developed mediastinitis after the replacement of thoracic arch aortic aneurysm, and the wound reopened and the vessel exposed. Because conservative treatment did not help, pectoralis major muscular flaps with the perforating branches of the internal thoracic artery and vein as the pedicle were elevated from the both sides, filled the mediastinal space and a split‐thickness skin graft was grafted. No recurrence has occurred for one year.Conclusions: Artificial vessels that developed infections are usually removed. However, we had good results by washing the lesion and wrapping it with muscular flap. By considering the size of surgical invasion and high death rate associated with the re‐replacement of artificial vessel or the opening of omentum, utilization of muscular flap should be considered as the first choice treatment.

Changes in Sternal Blood Flow after Different Methods of Internal Thoracic Artery Harvesting

The study was designed to assess the early changes in sternal perfusion after midline sternotomy and different (skeletonized versus semiskeletonized) techniques of internal thoracic artery (ITA) harvesting. The experiments were performed in the swine model. After midline sternotomy, ITA harvesting (skeletonized technique) was performed unilaterally in Group I (6 animals). The ITA and the internal thoracic vein (ITV) were harvested (semiskeletonized technique) in Group II (5 animals). The contralateral sternal half served as a control. Using a thermographic camera with a 0.06 degrees C sensitivity, sternal perfusion was assessed 2 and 5 hours after surgery. Midline sternotomy alone did not affect sternal blood flow. A statistically significant ( p < 0.05) reduction in perfusion of the involved sternal half in comparison to the control side was detected at 2 and 5 hours after surgery. The degree of perfusion deficit was not related to the harvesting technique. Skeletonized and semiskeletonized ITA harvesting techniques caused a similar acute reduction in sternal perfusion during the early postoperative period and this effect lasted for at least 5 hours.

A New Needle Driver for Minientry Coronary Artery Bypass

This article describes our clinical experience with a new needle driver (Olympus, Tokyo, Japan), which we have produced to facilitate minithoracotomy or port-access coronary artery anastomosis with the running suture technique. The needle driver is 21 cm long, weighs 38 g, and has a grip shaft 1.4 cm in diameter. The device is held like a pencil. A side lever and a revolving disk in the shaft are manipulated with the fingers; a fine needle with a 7-0/8-0 monofilament suture can be grasped/released and driven to penetrate the coronary arterial wall. This device was employed in 10 consecutive patients (8 men, 2 women, 73 +/- 7.5 years old), and off-pump bypass to the left anterior descending artery was achieved using the left internal thoracic artery or vein via a minithoracotomy (4.2 +/- 0.6 cm long). There was no instrument-related injury during each anastomosis. The mean sewing time per anastomosis was 12 minutes (range, 8-18 minutes). Angiography confirmed the patency of the graft in all cases. Although our experience is limited, we consider the present needle driver to be a viable device for facilitating off-pump, minientry coronary artery anastomosis with the suturing technique.

Vascular-pedicled costal cartilage graft for the treatment of subglottic and upper tracheal stenosis

Background/purpose Free costal cartilage graft for the treatment of subglottic and tracheal stenosis is widely used, but postoperative granulation formation is a problem. To reduce the risk of granulation formation after free costal graft, a new operation of costal cartilage graft with vascular pedicle was introduced. Methods A vascular pedicled fifth costal cartilage graft is prepared using internal thoracic artery and vein and intercostal artery and vein as a vascular pedicle. The prepared graft is brought to the upper trachea. The anterior wall of cricoid is split, and the costal cartilage graft is implanted to the split part and tracheostomy. Extubation on the next day is possible if the general condition of the patient permits. Results In 3 cases of subglottic or upper tracheal stenosis, this operation was performed. All the patients had tracheostomy made during early infancy. The postoperative course was uneventful, and all the patients were extubated soon after the operation. No granulation tissue was obserbed by postoperative bronchoscopic examinations. Conclusions Costal cartilage graft with vascular pedicle is a safe and useful new operation for the treatment of subglottic and upper tracheal stenosis. There also is a possibility of using this procedure for the treatment of long segment tracheal stenosis.

Flow in Coronary Bypass Conduits On-Pump and Off-Pump

The purpose of the study was to measure the blood flow in coronary artery bypass grafting conduits on-pump and off-pump and to estimate the total conduit flow. In a 3.5-year period, 120 patients having coronary artery bypass grafting on-pump and 97 patients having coronary artery bypass grafting off-pump with the left internal mammary artery anastomosed to the left anterior descending artery and saphenous vein grafts to the remaining diseased coronary arteries were included in the study. Flow in the bypass conduits was measured with the transit-time method. In men the left internal mammary artery flow (mean +/- standard error of the mean) was 33.7 +/- 2.0 mL/min on-pump and 34.4 +/- 2.9 off-pump (p > 0.05). In women the left internal mammary artery flow was 29.4 +/- 3.0 mL/min on-pump and 22.8 +/- 1.9 mL/min off-pump (p > 0.05). In men the vein graft flow per anastomosis was 30.4 +/- 1.3 mL/min on-pump and 37.8 +/- 5.4 mL/min off-pump (p > 0.05). In women the vein graft flow per anastomosis was 28.0 +/- 2.9 mL/min on-pump and 23.2 +/- 2.9 mL/min off-pump (p > 0.05). Consistently in women, the mean conduit flows were numerically lower than in men. In patients undergoing coronary artery bypass grafting on-pump the total conduit flows (left internal mammary artery plus vein grafts) were 131.4 +/- 2.5 mL/min in men and 108.4 +/- 3.2 mL/min in women. There were no major differences in conduit flow on-pump versus off-pump. Conventional coronary artery bypass grafting on-pump may restore up to approximately half of the normal resting coronary artery blood flow (250 mL/min).

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.

Single versus bilateral internal thoracic artery grafts with concomitant saphenous vein grafts for multivessel coronary artery bypass grafting: effects on mortality and event-free survival

Background The issue of superiority of single internal thoracic artery grafting versus bilateral internal thoracic artery grafting remains unresolved. The aim of this study was to compare the long-term outcome of single and bilateral internal thoracic artery grafting with concomitant saphenous vein grafting for multivessel coronary artery bypass grafting. Methods Between March 1985 and April 1995, 6650 patients underwent primary isolated coronary artery bypass grafting with internal thoracic artery grafts, including 4382 patients with multivessel bypass grafting requiring at least 3 grafts. Outcomes of patients undergoing single internal thoracic artery plus saphenous vein grafting (n = 2547) and bilateral internal thoracic artery plus saphenous vein grafting (n = 1835) were obtained at a mean follow-up of 11 ± 3 years. Results Patients with bilateral internal thoracic artery grafting were younger, were mostly male, and had less diabetes, hypertension, unstable angina, and recent myocardial infarction than patients undergoing single internal thoracic artery grafting. Thirty-day mortality was 2.3% for the group undergoing single internal thoracic artery grafting versus 1.2% for those undergoing bilateral internal thoracic artery grafting ( P = .007). Survival probability at 10 years was 88% for the single-graft group compared with 93% for the bilateral-graft group ( P < .001). Multivariate analysis with propensity scoring showed that bilateral internal thoracic artery grafting decreased the risk of death (hazard ratio, 0.74; 95% confidence interval, 0.60-0.90), myocardial infarction (hazard ratio, 0.79; 95% confidence interval, 0.67-0.93), and coronary reoperation (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80) throughout the follow-up period. Other significant predictors of death were diabetes, prior myocardial infarction, need for intra-aortic balloon pump, chronic heart failure, and peripheral vascular disease. Conclusion Patients undergoing bilateral internal thoracic plus saphenous vein grafting appear to have a significantly better long-term clinical outcome than patients undergoing single internal thoracic artery plus saphenous vein grafting for multivessel coronary artery bypass grafting.

A hemodynamic animal model of distal ends of internal mammary artery and vein

目的 为了明确胸廓内动脉远心端供血能力,以及胸廓内静脉远心端回流能力.方法选择2头小型猪,每头猪形成髂腰部皮瓣左右侧各1个,共4个,均为以旋髂深动静脉的直接皮动脉为蒂的岛状轴型皮瓣.测量蒂部的压力、流量,分别与胸廓内动脉远近心端的压力相比较,将皮瓣蒂部的动静脉与胸廓内动静脉远心端行端端吻合的游离移植,测量吻合口于吻合后即刻、30、60 min流量,测量皮瓣原位及吻合血管后皮瓣相应状态下包括术后7 d、14 d的灌注值(PU).术后观察皮瓣成活情况.结果胸廓内动脉远心端压力为近心端压力的61 %～65 %,单独胸廓内动、静脉远心端可使15 cm×30 cm×2cm游离皮瓣全部成活.结论虽然胸廓内动脉远心端的压力较低,但具有足够的供血能力,胸廓内静脉远心端具有足够的回流能力;以旋髂深动静脉的直接皮动脉为蒂的岛状皮瓣是理想的轴型皮瓣动物模型;建立了以旋髂深动静脉为蒂的游离皮瓣与胸廓内动静脉远心端直接吻合的动物模型,可进一步推广应用。

Off-Pump Coronary Artery Bypass Grafts Assessment by Multislice Computed Tomography.

Abstract Background: Selective coronary angiography is the standard but invasive procedure for postoperative assessment of coronary artery bypass graft patency. The aim of this prospective study is to evaluate the multislice computed tomography (CT) as a means of postoperative patency assessment and anastomotic site control of arterial and venous coronary bypass grafts performed with off-pump coronary artery bypass techniques. Methods: Over a 6-month period, 20 patients underwent isolated coronary artery bypass (beating heart technique) and benefited, 7 days later, from a patency and anastomotic site control by multidetector angio multislice CT with cardiac gating. Results: Whole internal thoracic artery bypasses and venous grafts were visualized perfectly on their entire length, including the anastomotic site, and 3-dimensional reconstruction was possible. The relationship between cardiac cavities and the bypasses were well visualized, allowing quantification of bypass stenosis ensured by software analysis. Conclusions: Postoperative control of coronary bypasses is possible by multislice CT with a very satisfactory resolution, thus making it possible to check the patency of coronary bypasses and the quality of anastomosis with a noninvasive method. Three-dimensional reconstructions are very useful in the event of redo surgery.

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft.

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.