Internal Thoracic Research Articles

Histopathological Examination of Internal Thoracic Artery and Saphenous Vein in Patients with Diabetes Mellitus: Structural Changes in Grafts Used in Bypass Surgery

Introduction: Epidemiological studies show that cardiovascular mortality is two to three times higher in male gender and three to five times higher in women with diabetes than those without diabetes. In this study, LIMA, which we frequently use in coronary bypass surgery, and the comparison of structural differences, if any, that may affect the saphenous vein, were analyzed with samples taken from diabetic and non-diabetic patients. Materials and Methods: Twelve diabetic and 12 non-diabetic patients who underwent coronary by-pass between 2003-2004 use of this type were examined. We evaluated the intimal thickness, medial thickness, intima-media ratio, and medial calcification of the biopsies from these grafts used during the operation. Results: LIMA calcification were calculated as 10,84±0,98µ in diabetics and 12±2,15µ in the control (p=0.048). When the calcification in saphenous veins was evaluated as a percentage, it was calculated as 7.19±3,47µ in the diabetic and 7,95±1,16µ in the control (p=0.037). When the LIMA intima thickness was evaluated, it was calculated as 28,75±15,65µ and 26,36±24,05µ in the control (p=0.044). When the LIMA intima-media ratios were examined, it was calculated as 0.128±0.93µ in the diabetic group and 0.117±0.092µ in the control (p=0.041). Measurement of saphenous vein intimal thickness was found as 68,05±47,94µ in the diabetic group and 66,31±48,07µ in the control group (p=0.038). When measured as the medial thickness of the saphenous vein, it was found to be 422,18±131,7µ in the diabetic group and 465,6±146,28µ in the control (p=0.032). Conclusion: We could not find any statistically significant difference between the two groups. Since we could not find a significant difference in terms of grafts between the diabetic and control groups, we can only say that postoperative factors cause premature occlusion of grafts in diabetics.

Routine presternotomy extracorporeal circulation for redo surgery.

ABSTRACTTo reduce the risk of adverse events, presternotomy extracorporeal circulation (ECC) is routinely performed at our institution for patients who require resternotomy. We report our 10-year experience of performing presternotomy ECC for cardiac reoperation and the clinical results. Fifty-seven consecutive cardiac reoperations involving resternotomy were performed between January 2006 and December 2015. ECC was established prior to median sternotomy in all patients. Two patients sustained injury to the right ventricle during sternotomy. Eleven patients sustained injury to the mediastinal structures during dissection (right atrium in 3; superior vena cava in 2; inferior vena cava in 3; left internal thoracic artery in 1; and saphenous vein graft in 2 patients). Longer ECC time and greater transfusion volume were necessary. Two patients (3.5%) died within 30 days of operation. Perioperative morbidity included reexploration for bleeding in 4 (7.0%), stroke in 1 (1.8%), acute renal failure that required hemodialysis in 5 (8.8%), sepsis in 5 patients (8.8%), prolonged ventilation in 9 (15.8%) and tracheostomy in 5 (8.8%). Routine establishment of presternotomy ECC reduces the risk of injury to the mediastinal structures during reentry and facilitates easier repair in the event of structural injury during reentry or dissection. However, longer ECC time and significantly greater transfusion volume requires attention.

POST CABG SURGERY PAIN WITH THE USE OF SKELETONIZED VERSUS PEDICLED TECHNIQUE OF INTERNAL THORACIC ARTERY HARVESTING

Objective: To document post coronary artery bypass graft (CABG) surgery painwith the use of skeletonized technique versus pedicled technique of internalthoracic artery (ITA) harvesting in our population. Methodology: A cross sectional study was done from February 2014 toSeptember 2017. Patients who underwent elective on-pump coronary arterybypass graft surgery were included in the study. Patients ware subjected to twodifferent techniques for CABG surgery. Postoperatively CABG surgery painintensity was scored prior to discharge and at 01 month follow-up on a visualanalogue scale (VAS) ranging from 0 to 10. Chi square statistical test was utilized(p 0.05), whereas the Visual Analogue Score was significantlylower in the skeletonized left ITA group (p≤0.05) at one month follow up. Conclusion: There is decreased post CABG surgery pain with the use ofskeletonized technique of internal thoracic artery harvesting compared topedicled technique.

Observational Treatment of Internal Thoracic Artery Graft Dissection.

Observational Treatment of Internal Thoracic Artery Graft Dissection.

P2709Wnt5a contributes to human atherosclerosis via novel USP17 redox signalling

Abstract Background Wnt5a is a non-canonical Wnt ligand with potential vascular effects, but its mechanistic role in atherosclerosis progression and the underlying downstream mechanisms are poorly explored. Purpose To address the hypothesis that Wnt5a induces vascular NADPH-oxidases activity, endothelial dysfunction and detrimental downstream redox signalling which could propagate atherosclerosis in humans. Methods Study 1 included 70 patients with coronary artery disease (CAD) versus age- and sex-matched non-CAD controls. Study 2 included 1,003 CAD patients undergoing cardiac surgery; internal mammary artery (IMA) and saphenous vein (SV) segments were harvested and used for ex vivo experiments. Study 3 included 68 individuals undergoing two cardiac computed tomography scans 3–5 years apart; calcified plaque burden was assessed by coronary calcium score (CCS). Superoxide (O2·−) generation was measured by lucigenin chemiluminescence with NADPH 100μM stimulation as indicator of NADPH-oxidases activity. Activation of Rac1, a key NADPH-oxidases subunit, was evaluated by a commercially available kit. Primary vascular smooth muscle cells (VSMCs) and HeLa cells were used for in vitro experiments. Circulating Wnt5a and Sfrp5 (a Wnt5a antagonist) were measured by ELISA in fasting plasma samples. Results In Study 1, the presence of CAD was independently linked with increased circulating Wnt5a bioavailability (A), which was, in turn, associated with increased IMA NADPH-oxidases activity in Study 2 (B). Recombinant Wnt5a directly stimulated NADPH-oxidases activity (C) via Rac1 activation (not shown) in human IMA, while inducing endothelial dysfunction evidenced by impaired SV endothelium-dependent acetylcholine (Ach) vasorelaxations (D). Transcriptomic analysis in Wnt5a-treated primary VSMCs versus controls identified USP17, a deubiquitinating enzyme implicated in Rac1 activation, as the top differentially regulated hit (not shown). Indeed, Wnt5a stimulated USP17 upregulation in VSMCs which was reversed by PEGylated superoxide dismutase (peg-SOD) 300U/mL (E), suggesting a redox sensitive effect. USP17 knockdown abolished the ability of Wnt5a to induce Rac1 activation in HeLa cells (F). At a clinical level, plasma Wnt5a was a predictor of plaque progression (defined as ΔCCS≥1, G) and new onset calcification (H) in Study 3. Conclusions We demonstrate for the first time that Wnt5a is elevated in CAD and causally associated with increased vascular oxidative stress and endothelial dysfunction in humans. We further reveal USP17 to be a novel, previously undescribed, link between Wnt5a, Rac1 activation and NADPH-oxidase activity induction in humans. We finally propose that circulating Wnt5a may have a clinically relevant role in predicting atherosclerosis progression. Our findings identify Wnt5a as rational therapeutic target in vascular disease. Acknowledgement/Funding British Heart Foundation; Alexandros S Onassis Public Benefit Foundation

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps.

The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein. Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively. Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps. The authors' results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. Therapeutic, IV.

Multiple Arterial Bypass Grafts Are Superior to Single Ones

Despite the established benefit of left internal thoracic artery (ITA) grafts to the left anterior descending coronary artery during coronary artery

Large-to-Small End-to-Side Venous Anastomosis in Free Flap Transfer

BackgroundVessel size discrepancy is one of the major risk factors for anastomotic failure in free flap transfer. The situation becomes challenging for reconstructive microsurgeons when the recipient vein is much smaller than the flap vein. We investigated the feasibility of large-to-small end-to-side venous anastomosis for such cases. Materials and methodsThe subjects were 16 consecutive patients who underwent a free flap transfer for oncologic defects with a large-to-small end-to-side venous anastomosis. The larger flap vein was anastomosed to the side slit of the smaller recipient vein under an operating microscope. Surgical details and postoperative outcome were investigated retrospectively. ResultsAn anterolateral thigh flap was used in five patients, a superficial inferior epigastric artery flap in four, a thoracodorsal artery perforator flap in three, and a latissimus dorsi musculocutaneous flap and a fibular osteocutaneous flap in two patients each. The internal mammary vein and the anterior tibial vein were most frequently used as a recipient vein (four patients each), followed by the deep inferior epigastric vein (three patients). The extent of vessel size discrepancy ranged from 1.3- to 3.3-fold, and the mean discrepancy was 1.9-fold. No anastomotic failure occurred postoperatively, and the flap survived in all patients. ConclusionsLarge-to-small end-to-side venous anastomosis can be a versatile option when only a small vein is available as a recipient vein. Internal mammary, deep inferior epigastric, and anterior tibial veins are good candidates for this technique.

Does Size Matter: Evaluating the Difference between Right and Left Internal Mammary Veins in Free Flap Breast Reconstruction.

Venous congestion in breast free flap reconstruction continues to be a major reason for flap compromise requiring reoperative exploration and possible flap failure. We aim to investigate whether size of the internal mammary vein (IMV) (1) varies between the left and right sides, (2) changes with certain patient demographics or preoperative factors, and (3) correlates with postoperative complications. We performed a retrospective cohort study examining all patients undergoing free flap breast reconstruction from September 2005 to March 2016 using internal mammary recipient veins. Venous coupler size was used as a surrogate measure of IMV diameter. Preoperative patient characteristics and factors were collected. Postoperative outcomes assessed included thrombosis, flap loss, fat necrosis, and mastectomy flap necrosis. Multivariate analyses were performed to evaluate if preoperative factors affected IMV diameter and to determine if coupler size and flap side were independent risk factors for postoperative complications. We examined 372 patients with a total of 561 flaps. One hundred eighty-nine patients received bilateral flaps with the IMV as a recipient. The right IMV (n = 286, average = 2.97 mm, standard deviation [SD] = 0.41) was significantly larger than the left (n = 275, average = 2.89, SD = 0.35, p = 0.008). Preoperative factors and postoperative complications were not statistically different between the left and right cohorts. The multivariable linear regression model with coupler size as the dependent variable found older age trended toward a larger coupler size but this was not significant (p = 0.05). In multilinear regression analysis, the postoperative outcomes did not have significant covariates. We found that IMV size significantly differs between the right and the left sides. However, incidence of postoperative complications was not significantly different between the left and right sides, and the multivariate analyses did not identify flap side as an independent risk factor for adverse outcomes. Prospective studies evaluating actual IMV diameter and associated complications may potentially elucidate clinical significance.

Persistent Left Superior Vena Cava Identified during Peripherally Inserted Central Catheter Line Placement

Abstract Introduction A persistent left superior vena cava (SVC) is found in 0.3 to 0.5% of the general population. It is seen in up to 10% of the patients with a congenital cardiac anomaly, being the most common thoracic venous anomaly, and is usually asymptomatic. Being familiar with such anomaly could help clinicians avoid complications during the placement of central lines, Swan-Ganz catheters, peripherally inserted central catheter (PICC) lines, dialysis catheters, defibrillators, and pacemakers. Case Presentation We describe a case of persistent left SVC which was noted after placement of a PICC line. A 5-year-old male child was hospitalized for evaluation and management of leukemia. He required PICC line placement for chemotherapy. He was noted to have a persistent left SVC during the procedure under fluoroscopic guidance and subsequently correct placement of PICC line in right SVC. Discussion This anatomical variant can pose iatrogenic risks if the clinician does not recognize it. A central catheter that tracks down the left mediastinal border may also be in the descending aorta, internal thoracic vein, superior intercostal vein, pericardiophrenic vein, pleura, pericardium, or mediastinum. Conclusion Our case is significant because the patient was diagnosed with double SVC on table only followed by the placement of PICC line into the right SVC. This case strongly demonstrates the importance of knowing the thoracic venous anomalies.

Superdrainage Using the Cephalic Vein Due to Unsuitable Internal Thoracic Vein for Microvascular Anastomosis in Esophageal Reconstruction Using Pedicled Jejunum.

The progress and popularization of microvascular surgical techniques may improve the outcomes of esophageal reconstruction using non-gastric tube (GT) grafts. A pedicled jejunum (PJ) with microvascular anastomoses is frequently selected as a reconstructed conduit for esophageal reconstruction when the GT is unavailable, and the internal thoracic (IT) vein is frequently selected as a recipient blood vessel for microvascular anastomosis. However, the IT vein may be inadequate for microvascular anastomosis because of its absence or underdevelopment. Since it is difficult to preoperatively predict such rare cases, it becomes necessary to urgently and rapidly prepare an alternative blood vessel. Herein, we present surgical procedures for superdrainage using the cephalic vein (CeV). Due the superficial nature of the CeV, it is both easy to identify and collect sufficient length. Thus, the CeV is very useful as an urgent substitute blood vessel when the IT vein is unavailable for microvascular anastomosis in esophageal reconstruction.

Internal Mammary Artery and Vein Perforator Vessels as Troubleshooter Recipient Vessels.

Summary:In autologous breast reconstruction, the internal mammary artery (IMA) and internal mammary vein (IMV) are the standard recipient vessels. Recently, the perforator vessels of the IMA and IMV were found to be a safe alternative as recipient vessels cause less morbidity and allow adequate flap. We describe 2 cases in which the IMA and IMV perforators were used as additional recipient vessels to overcome intraoperatively occurred complications. The IMA and IMV perforators have some advantages over the IMA/IMV: (1) the dissection is done superficially and directly from the mastectomy site. Flap positioning is facilitated. (2) There is no need to remove a rib, which reduces postoperative pain and possible contour deformities. (3) Possible injuries to the pleura are avoided. (4) The IMA is spared for possible cardiac revascularization. Disadvantages can be that (1) the IMA perforators are not always present with the required caliber, (2) the position of the perforators is not suitable to adequately position the flap, and (3) dissection of the IMA perforators and their anastomoses has a learning curve. In the presented cases, the IMA and IMV perforators have proven to offer a simple solution to avoid complications. The additional dissection is done from the same recipient site, and there is no further dissection or incision necessary at the axilla or to explore the cephalic vein. This keeps morbidity and operation time low. Therefore, we suggest keeping the IMA and IMV perforators in mind not only as primary recipient vessels but also as a possible solution for intraoperatively occurred complications.

Management of Paravalvular Leak After Rapid Deployment Edwards Intuity Elite Valve

A 74-year-old man with a past medical history of diabetes mellitus, hypertension, severe aortic stenosis, coronary artery disease status post-coronary artery bypass surgery with left internal mammary artery, vein graft, and aortic valve replacement with a Rapid Deployment Edwards 23-mm Intuity Elite

Letter to Editor Regarding

Sir: It was with great interest that we read the article by Dr. Lee and colleagues on the location of the internal mammary vessels for microvascular autologous breast reconstruction.1 Knowledge of the anatomic variations of the internal mammary vessels is necessary for efficient operative dissection with minimal costal cartilage excision. For this reason, the senior author (A.T.) of this letter pursued a similar cadaveric study, albeit for another purpose, almost 30 years ago2: to delineate the internal mammary vessels, not as recipient vessels but as donor vessels, for the free vascularized anterior rib graft. Thoma et al.2 reported the pertinent anatomy of the internal mammary vessels, their diameters, and the distance from the sternal midline. Notably, the internal mammary vein was found to branch between the third and fifth ribs, most commonly in the fourth intercostal space.2 Lee et al.1 claimed that this finding had not been established prior to their study. The 1987 publication also delineated the costal blood supply from the inferior intercostal and supracostal vessels branching from the internal mammary vessels.2 The Lee et al.1 article bears fundamental similarities to the Thoma et al.2 article; however, we acknowledge, it entails a larger sample of cadavers, and a far more rigorous tabulation of findings. In the Lee et al.1 article, the costal level at which the internal mammary vein bifurcates is documented for the left and right of each cadaver. The authors also report the distance between the internal artery and vein, and the distance of the vessels from both the sternal border and the costochondral junction at each intercostal level.1 These precise findings allow a more detailed mapping of the vessels and represent an improvement in the standard of data reporting since the publication of the Thoma et al.2 article. Despite its similarities, we do not believe Lee et al.1 had knowledge of our publication, as the branching of the internal mammary vein in the fourth intercostal was reported as novel information. A well-constructed literature search should be done before any project is undertaken to avoid the duplication of labor in research, and all similar papers should be appropriately cited. Readers can refer to the guide by Waltho et al.3 for step-by-step instructions on searching and synthesizing evidence. Use of the keywords “internal mammary vessel*” and “plastic surgery” identified the Thoma et al.2 article in Medline. Given the significant improvement in reporting between the Lee et al.1 and Thoma et al.2 articles, we consider this article a new and valuable contribution to the literature. However, we would like to emphasize the importance of a thorough literature review before a study is begun. If the Thoma et al.2 findings had been reported more meticulously, it would be a redundant waste of research resources to conduct another cadaveric study of the internal mammary vessels. With an estimated $170 billion wasted on faulty and redundant research annually, overlooking simple steps of a literature search is a mistake we cannot afford.4 Nevertheless, we commend the thorough work done by Lee et al.,1 and we hope it will have a positive impact on dissection of the internal mammary vessels in the future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding was obtained for the production of this communication. Syena Moltaji, B.Sc., M.D.(c)Michael G. DeGroote School of MedicineMcMaster University Jessica Murphy, M.Sc.Division of Plastic SurgeryDepartment of SurgeryMcMaster University Achilleas Thoma, M.D., M.Sc.Division of Plastic SurgeryDepartment of SurgeryDepartment of Health Research Methods, Evidence, and ImpactMcMaster University.Hamilton, Ontario, Canada

Radial Artery Versus Right Internal Thoracic Artery Versus Saphenous Vein as the Second Conduit for Coronary Artery Bypass Surgery: A Network Meta-Analysis of Clinical Outcomes.

BackgroundThere remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery (RA), right internal thoracic artery (RITA), and saphenous vein (SV). No network meta‐analysis has compared these 3 strategies.Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA, SV, and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection (DSWI). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included (RA, 16 201, SV, 112 018, RITA, 21 683). At NMA, the use of SV was associated with higher long‐term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI, 1.12–1.34) and RITA (incidence rate ratio, 1.26; 95% CI, 1.17–1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI, 0.55–0.91). There were no differences for any outcome between RITA and RA, although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI, 0.92–2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used.ConclusionsThe use of the RA or the RITA is associated with a similar and statistically significant long‐term clinical benefit compared with the SV. There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

Superior vena cava syndrome after cardiac surgery

Superior vena cava (SVC) syndrome is a group of symptoms caused by obstruction of the SVC at the junction of the right atrium. This obstruction was found to be caused by either external compression or internal occlusion. It leads then to impaired venous drainage into the heart, which will in turn reduce the preload and consequently the cardiac output that might be fatal at some stage. On the flip side, it causes blood engorgement of the upper half of the body resulting in swelling and increased pressures. SVC syndrome may happen acutely in relation to cardiac surgery as a less frequent complication. It might be then caused by mechanical obstruction by a retractor, improper placement of venous cannula, thrombus formation on top of indwelling catheters or pacemaker wires, or overflow following ‘Glenn’ surgery in pediatrics. Diagnosis of the SVC syndrome should involve a high index of suspicion in the context of cardiac surgery especially that the manifestations are not classic in all cases. So, once the manifestations of the syndrome start to appear, prompt actions should be taken to confirm the diagnosis and to start treatment to avoid hemodynamic instability resulting from the dramatic decrease in preload, taking into consideration the limited time available for the collateral drainage (e.g. from azygos, hemiazygos, or internal mammary veins) to develop and bypass the obstruction. Exploring different causes of developing SVC syndrome after cardiac surgery would help early diagnosis and management, which could be lifesaving in many scenarios.

Prediction of inadvertent internal mammary (thoracic) vein cannulation by CVP monitoring.

Prediction of inadvertent internal mammary (thoracic) vein cannulation by CVP monitoring.

Coronary Endarterectomy Improve Left Ventricle Ejection Fraction After Coronary Artery Bypass Grafting Surgery

The diffusely diseased coronary artery is a challenge for cardiac surgeons, although coronary endarterectomy is an option for surgical reconstruction of a diffusely diseased vessel. It may assures complete revascularization of myocardium in case of diffusely diseased vessels and prevent residual ischemia but it has not been widely used. recently cardiac surgeons are performing and increasing number of coronary artery endarterectomy and it has evolved as an important adjuvant procedure in coronary artery bypass grafting surgery. we reviewed the early clinical and hemodynamic out comes with echocardiography of 22 patients undergoing coronary artery endarterectomy of left anterior descending artery (LAD) diagonal branches (D1 or D2) and right coronary artery and posterior descending artery (RCA and PDA) with patch plasty method using left internal mammary artery (LIMA) and saphenous vein graft (SVG) between January 2017 and June 2018. mean follow up of all patients were 3-6 months postoperatively, Left internal mammary artery (LIMA) anastomosed to left anterior descending artery (LAD) with endarterectomy and artery patch plasty in 12 (54, 5%) patients, saphenous vein graft (SVG) anastomosed to left anterior descending artery (LAD) with endarterectomy and vein patch plasty in 2 (9%) patients, and saphenous vein graft (SVG) to Right coronary artery (RCA) Diagonal (D1) and posterior descending artery (PDA) with endarterectomy and vein patch plasty in 9 (40.9%) patients. Postoperative mortality was 0% and echocardiographic assessment done by modified Simpson method on outpatient department (OPD) basis, 7 patients had left ventricle ejection fraction of (50-55%) preoperatively with no changes on postoperative period and 7 patients had improvement of left ventricle ejection fraction from (30-35%) preoperatively to (40-45%) in postoperative period. principle goal in coronary artery bypass grafting surgery (CABG) is to achieve complete revascularization of diseased coronary arteries, in particular the left anterior descending artery (LAD) is very important vessel because incomplete revascularization of the LAD has been proven to be a predictor of worse mortality after coronary artery bypass grafting surgery (CABG). Recent publications have revealed that coronary endarterectomy is a safe procedure and demonstrated favorable long term out comes. In our experience coronary endarterectomy has been performed with good clinical and hemodynamic out comes with echocardiography.

Very rare malposition of a central venous catheter into the left internal mammary vein in patient with coronary artery disease

Very rare malposition of a central venous catheter into the left internal mammary vein in patient with coronary artery disease

Correction: Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011.

[This corrects the article DOI: 10.1371/journal.pone.0201227.].