Ipsilateral Internal Mammary Artery Research Articles

Validity of Ipsilateral Internal Mammary Coronary Artery Bypass Graft of Arteriovenous Fistula

In coronary artery bypass grafting (CABG) for haemodialysis patients, arteriovenous fistula can reduce blood flow from the internal mammary artery (IMA) graft. The purpose of this study was to delineate the rationale of ipsilateral IMA grafting to the arteriovenous fistula by assessing graft flow and patency. The clinical records of 139 haemodialysis patients who underwent off-pump CABG, including IMA grafting to the left anterior descending artery (LAD) between April 2007 and December 2018, were retrospectively reviewed. Clinical outcomes and transit-time flowmetry results of IMA to LAD bypass grafts during off-pump CABG and postoperative angiography were examined. An ipsilateral IMA to the arteriovenous fistula (Ipsi-IMA) was used in 89 patients, and a contralateral IMA to the arteriovenous fistula (Contra-IMA) was used in 50 patients and no hospital deaths occurred. The mean graft flow and angiographic patency rate did not differ between the Ipsi-IMA and Contra-IMA groups. In patients with 51 to 90% stenosis of LAD, there was no significant difference in the mean graft flow. In comparison, in the patients with 91 to 100% stenosis of LAD, the mean graft flow in the Ipsi-IMA group was significantly lower than that in the Contra-IMA group (p=0.03). Kaplan-Meier analyses showed a 5-year survival rate of 57.6% for Ipsi-IMA and 64.8% for Contra-IMA (p=0.47). In the revascularisation of the LAD, the graft patency rate of the Ipsi-IMA was not inferior to that of the Contra-IMA. However, when the LAD has 91 to 100% stenosis, a Contra-IMA to arteriovenous fistula may be beneficial in terms of sufficient flow capacity.

Endovascular management of hemoptysis in a known case of tetralogy of fallot and tuberculosis complicated with aspergilloma: a case report

BackgroundHemoptysis is a life-threatening complication due to bleeding either from hypertrophied bronchial arteries or enlarged non-bronchial systemic collaterals, having multiple etiologies. Bronchial artery embolization (BAE) is a minimally invasive modality of management that can effectively manage moderate-to-severe hemoptysis.Case presentationWe report the case of a 25-year-old female with moderate-to-severe hemoptysis. There was prior history of tuberculosis and treatment with anti-tubercular therapy 6 months back. There was also a background of tetralogy of Fallot(TOF) with symptoms of chronic breathlessness and palpitations. Imaging evaluation with X-ray and HRCT thorax revealed a cavity in the left upper lobe with dependent soft tissue, implying a diagnosis of aspergilloma in an old tubercular cavity. TOF and right-sided aortic arch were noted. CT bronchial angiography showed dilated and tortuous left bronchial artery, as well as non-bronchial systemic collaterals from the ipsilateral internal mammary artery. Endovascular management was achieved by super-selective catheterization and embolization of the involved branch of the left bronchial artery and selective embolization of non-bronchial systemic collaterals from the ipsilateral internal mammary artery.ConclusionsBAE has a high clinical success rate and is recommended as first-line therapy in the management of massive hemoptysis. The CT pulmonary angiography, as well as the pre-embolization angiogram, is very important to detect the source of hemoptysis from the non-bronchial systemic circulation, increasing the success rate and decreasing the incidence of recurrence. BAE is effective even in presence of underlying vascular anomalies such as Fallot of Tetralogy.

Abstract No. 405 Safety and efficacy of N-butyl cyanoacrylate in the treatment of life threatening hemoptysis in the presence of non-bronchial systemic to pulmonary and broncho-pulmonary shunts

The purpose of this study is to evaluate the safety and efficacy of N-butyl cyanoacrylate (NBCA) in treatment of patients with life threatening hemoptysis in the presence of non-bronchial systemic to pulmonary shunts (NBSPS) and broncho-pulmonary shunts (BPS). We performed a retrospective analysis of 91 patients (77 males and 14 females, age range, 42-92 years) who underwent embolization for massive hemoptysis between January 2014 and March 2019. The study was approved by the institutional review board. Angiographically demonstrable large volume NBPS and BPS was seen in 19 patients. The underlying etiology was tuberculosis and its sequelae in all 19 patients. Two patients had aspergillomas. Five patients had undergone at least two sessions of ipsilateral Bronchial artery embolization (BAE) for hemoptysis during the same admission. Three patients had embolization of the ipsilateral internal mammary artery (IMA) in addition to BAE. Target vessels were embolized based on CTA findings (when available) and selective catheter angiography. Coaxial technique using microcatheter was used to cannulate the target vessel. In our practice, 1 part NBCA was mixed with 3-4 parts of lipiodol depending on the blood flow dynamics. Devascularization of the abnormal target vessels and exclusion of the shunts were achieved in 18 patients using NBCA (95% technical success). No recurrence was noted in 11 patents for up to 2 years of follow-up (58%). Recurrence of hemoptysis occurred in 2 patients at 2 and 3 months from different vascular territory to previous embolization. Serious non target embolization to central nervous system (CNS) was seen in 2 patients. Five patients died during the follow-up. The presence of large volume non-bronchial systemic and bronchopulmonary shunts precludes the use of particulate embolic agents in order to prevent non-target embolization. NBCA may be the most suitable and effective embolic agent in these patients and is known to reduce recurrence. The operator and patients should however be aware of rare but unforgiving consequences of non-target embolization to the central nervous system.

Screening for subclinical subclavian artery stenosis before coronary artery bypass grafting: Should we do it?

Atherosclerotic subclavian artery disease is detected in about 5% of patients referred for coronary artery bypass (CABG) surgery. The internal mammary artery, a branch of the subclavian artery, is the most frequently utilized graft to restore coronary circulation because of its longevity. Stenosis or occlusion of the subclavian artery can cause retrograde blood flow in the ipsilateral internal mammary artery, known as "steal," compromising coronary circulation supplied by the graft. Steal may be asymptomatic or may result in symptoms of myocardial ischemia. Symptomatic subclavian artery stenosis post bypass is referred to as coronary subclavian steal syndrome post-CABG. The incidence is not well defined, and the benefits of screening patients referred for CABG are not known. Despite the various modalities available to detect subclavian artery stenosis, current guidelines fail to provide guidance about screening high-risk patients for this entity. Detection of subclavian artery disease prior to CABG can reduce complications posed by post-mammary artery graft cardiac ischemia. This review discusses the utility of preoperative subclavian artery screening prior to CABG.

Should dialysis-dependent patients with upper limb arterio-venous fistulae undergoing coronary artery bypass grafting avoid having ipsilateralin situmammary artery grafts?: Table 1:

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether dialysis-dependent patients with upper limb arterio-venous fistulae (AVFs) undergoing coronary artery bypass grafting should avoid having ipsilateral in situ internal mammary artery (IMA) grafts. A literature search performed yielded 28 peer reviewed articles, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The papers identified included 478 patients, of whom 219 had in situ IMA grafts with ipsilateral upper limb arterio-venous fistulae. There was a substantial variation between the papers, from single case reports to small retrospective cohort studies, but no randomized, controlled trials. The largest retrospective study included 155 patients and followed up for up to 5 years. Methods used to determine coronary steal included clinical assessment, electrocardiogram or echocardiographic changes, Doppler ultrasound of mammary arteries and angiography. The aggregate evidence suggested that 61 of the 219 patients with ipsilateral IMA grafts developed some clinical or physiological evidence of malperfusion during the use of the AVFs for dialysis. Comparisons with the contralateral IMA suggested that 27 of the 61 patients suffered similar problems when dialysis was applied. A number of studies used controls, including in situ right internal mammary artery (RIMA) flow and patients not on dialysis. In total, 32 patients had their in situ RIMA flow measurements studied, of which none showed any statistically significant flow alteration. While further strong evidence to demonstrate long-term outcomes is required, we recommend the avoidance, where possible, of ipsilateral in situ IMA grafts in patients with an upper limb AVF. There is sufficient experimental and anecdotal evidence to suggest that steal occurs and that in some patients, this has clinical implications on both morbidity and mortality. In this scenario, the use of the contralateral mammary is strongly advocated to maximize the patency of grafts in an already high-risk population.

Hemodynamic Effects of Left Upper Extremity Arteriovenous Fistula on Ipsilateral Internal Mammary Coronary Artery Bypass Graft

Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Bilateral Simultaneous Laterally Placed Superior Gluteal Artery Flap for Unilateral Breast Reconstruction

Sir: The superior gluteal artery perforator (SGAP) flap has become an important alternative donor site for breast reconstruction, especially if abdominal tissue is inadequate or unavailable.1 Although a few centers have reported the performance of bilateral simultaneous SGAP flaps for bilateral breast reconstruction,2,3 and bilateral simultaneous deep inferior epigastric artery perforator flaps have been used for unilateral breast reconstruction,4 to our knowledge, the use of bilateral simultaneous SGAP flaps has not been reported for reconstruction of a single breast. The patient (body mass index, 18.6 kg m2) was first diagnosed with left-sided breast cancer in 2004. She underwent bilateral mastectomies with immediate implant reconstruction (the right mastectomy was prophylactic because of a strong family history of breast cancer). She then developed two local recurrences (in 2005 and 2007) and underwent left axillary lymph node dissection, and irradiation and further chemotherapy of the left side of the chest wall. Given her history of chest irradiation and obvious abdominal tissue inadequacy, we felt that the best option for her left breast reconstruction was bilateral simultaneous SGAP flaps. To ensure blood flow and adequate length to the recipient vessels (internal mammary), we created an arteriovenous fistula to the internal mammary artery and internal mammary vein using a saphenous vein (arteriovenous) graft (Fig. 1, above). In the second stage, the bilateral lateral SGAP flaps were transferred for single-breast reconstruction 4 days after the creation of the arteriovenous fistula.Fig. 1.: (Above) Saphenous vein graft anastomosed to the ipsilateral internal mammary vessels to create a temporary arteriovenous fistula. (Center) The “superior” SGAP flap pedicle is anastomosed to a side branch off the main pedicle of the “inferior” SGAP flap. In turn, the main pedicle of the “inferior” SGAP flap is then anastomosed to the two ends of the divided saphenous vein graft. (Below) Two new saphenous vein grafts are then anastomosed to the contralateral internal mammary vein and one of its intercostal perforators during the emergent flap take-back on postoperative day 1. The arterial anastomosis to the ipsilateral internal mammary artery is not shown because it remained patent and was not revised.The procedure began in the supine position by first ensuring patency of the arteriovenous fistula. The lateral septal SGAP dissection was performed in the septum between the gluteus maximus and medius toward the medusa head, as described previously.5 On the back table, the pedicle of one flap was sutured to large side branches of the other flap, leaving only one superior gluteal artery and vein pedicle for the internal mammary artery and internal mammary vein anastomoses (by means of the saphenous vein graft arteriovenous fistula). The flaps were then transferred to the chest and their pedicles were anastomosed to the existing saphenous vein graft loop (Fig. 1, center). Because of signs of venous congestion, the patient returned to the operating room on postoperative day 1. The initial vein graft appeared thrombosed and thus new vein grafts were used to the contralateral internal mammary vein and a contralateral, medial, intercostal perforator vein branch (Fig. 1, below). The patient was discharged on postoperative day 5 and had a nice result at 6-month follow-up (Fig. 2).Fig. 2.: The patient at 6-month postoperative follow-up after bilateral SGAP flap surgery for unilateral breast reconstruction. Note the incision on the medial aspect of the right breast that was used to access the contralateral internal mammary vein during the take-back.Given this patient's abdominal tissue inadequacy and her irradiated chest wall, the best potential donor site was her lateral gluteal tissue from both sides to accomplish projection and adequate skin coverage over her irradiated skin. To further support this approach, one must also consider that using bilateral SGAP flaps, as opposed to unilateral flaps, in a low-weight patient provides better donor-site symmetry. This case report exemplifies a safe, viable expansion of the previously reported surgical technique using the SGAP flap for breast reconstruction. With the successful use of bilateral simultaneous SGAP flaps for the reconstruction of a single breast, the authors of this article report an approach that proved to be a useful alternative for breast reconstruction in this patient with insufficient abdominal, back, inner thigh, and gluteal tissue. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Michael Magarakis, M.D. Jaime I. Flores, M.D. Sachin M. Shridharani, M.D. Philip S. Brazio, M.D. Raghunandan Venkat, M.D. Gedge D. Rosson, M.D. Division of Plastic, Reconstructive, and Maxillofacial Surgery Department of Surgery The Johns Hopkins University Baltimore, Md.

Intercostal Artery–Based Rectus Abdominis Transposition Flap for Sternal Wound Reconstruction

The rectus abdominis transposition (RAT) flap is a well-accepted alternative to pectoralis muscle flaps for sternal reconstruction after debridement in poststernotomy mediastinitis. Use of this flap based on an intercostal artery pedicle, after division of the ipsilateral internal mammary artery (IMA), is a less-recognized option for reconstruction, given its less substantial vascular supply. The authors present 15 cases where intercostal artery-based RAT flaps were used for sternal reconstruction over a span of 15 years. They describe patient demographic data, management approaches, surgical techniques, and clinical outcomes. Perioperative flap survival and wound healing was optimal in all cases. One morbidity and 1 mortality were encountered in patients with multiple chronic medical problems. Follow-up demonstrated optimal surgical results and satisfied patients. Our observations suggest that the intercostal artery-based RAT flap is a safe treatment option for sternal reconstruction when pectoralis muscle flaps have failed or do not adequately provide coverage of sternal defects after debridement of the poststernotomy wound.

Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology

A rapidly increasing number of thoracic aortic lesions are now treated by endoluminal exclusion by using stent grafts. Many of these lesions abut the great vessels and limit the length of the proximal landing zone. Various methods have been used to address this issue. We report our experience with subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. Thirty (43%) of 70 patients undergoing thoracic endovascular stent-graft placement from January 2001 to August 2005 had lesions adjacent to or involving the origin of the subclavian artery. The mean age was 62 years (range, 22-85 years; 63% were men, and 37% were women). This subgroup of 30 patients had indications for repair that included thoracic aortic aneurysm (n = 15), traumatic transection (n = 6), chronic dissection with pseudoaneurysm (n = 5), and acute dissection with intramural hematoma (n = 4). All 30 patients had the subclavian origin covered by the stent graft. In eight cases (27%), no effort was made to revascularize the subclavian artery before or during the endograft placement procedure. Twenty-three (77%) of 30 patients underwent subclavian to carotid artery transposition (n = 21) or bypass (n = 2) before (n = 12; average of 14 days before stent-graft placement), concomitant with (n = 10), or after (n = 1) the endovascular procedure. Physical examination and computed tomography scans were performed after surgery at 1, 6, and 12 months and annually thereafter. The mean follow-up was 18 months (range, 1-51 months). Five acute complications occurred in the eight patients (63%) who had the subclavian artery covered without pre-endograft revascularization and included four patients who experienced stroke (accounting for the only death) and one patient who developed symptomatic subclavian-vertebral steal that necessitated transposition 7 months later. Two (9%) of the 23 patients who had subclavian revascularization experienced left-sided vocal cord palsies, and 1 patient (4%) developed lower extremity paraparesis secondary to spinal cord ischemia. No late endoleaks related to retrograde sac perfusion from the most distal great vessel have been identified in any patient. Subclavian revascularization procedures can be performed with relatively low risk. Complications are rare, and patient recovery is rapid. Although this is not necessary in all cases, we advocate subclavian to carotid transposition when the aortic lesion is within 15 mm of the left subclavian orifice to prevent type II endoleak or perfusion of a dissected false lumen when the ipsilateral vertebral artery is patent and dominant or when coronary revascularization using an ipsilateral internal mammary artery is anticipated and in cases that necessitate extensive coverage of intercostals that contribute to spinal cord perfusion. Carotid to subclavian artery bypass should be reserved for patients with a patent internal mammary artery conduit perfusing a coronary vessel and should be combined with proximal subclavian ligation.

Duplex Waveform Analysis of the Subclavian Artery in a Case with Internal Mammary Steal Syndrome

In patients undergoing chronic hemodialysis through an arteriovenous fistula (AVF), coronary insufficiency may occur if the patient undergoes coronary artery bypass grafting (CABG) using the ipsilateral internal mammary artery (left internal mammary artery [LIMA] or right internal mammary artery [RIMA]). Creation of a new AVF after CABG should therefore avoid using the arm ipsilateral to the side where the internal mammary artery was used. In cases where coronary syndrome appears when this advice was not followed, treatment should be offered aiming to overcome the hemodynamic interference between the diminished coronary supply through the LIMA/RIMA and the excessive flow through the AVF. By using subclavian artery (SCA) waveform analysis on a duplex scan, a noninvasive evaluation of the flow through the SCA ipsilateral to the side of the mammary artery and the fistula can be performed both with the patent (functioning) and closed fistula. Waveform analysis can enlighten the phenomena of steal syndrome through the internal mammary artery and is highly recommended in this small and unusual group of patients.

Preserving the left arm vein in cases of hemodialysis access generating left internal mammary artery steal syndrome

In patients undergoing chronic hemodialysis (HD) through an arm arteriovenous fistula (AVF), coronary insufficiency can occur if the patient undergoes a coronary artery bypass graft (CABG) using the ipsilateral internal mammary artery (1-4). Therefore, the creation of a new AVF after CABG should avoid using the arm ipsilateral to the side where the internal thoracic artery was used. In cases where coronary syndrome appears when this advice is not followed, treatment should be offered aimed at overcoming the hemodynamic interference between the diminished coronary supply through the left or right internal mammary artery by closure of the existing fistula, with or without temporary central venous line insertion until the maturation of a new fistula. We suggest a different approach by moving only the arterial inflow site of the AVF to the controlateral subclavian artery, but in addition, leaving the well functioning venous outflow tract intact. In cases of left internal mammary steal it is achieved by creating a conduit running from the right subclavian artery to the left cephalic vein; therefore, creating a new arterial inflow source, connected to the existing functioning old venous outflow tract to maintain an immediately functioning new fistula without a coronary steal.

A previous mastectomy does not increase sternal complications after coronary artery bypass grafting regardless of whether an internal mammary artery is used.

A mastectomy for breast cancer may alter the selection of grafts or the postoperative outcomes after coronary artery bypass grafting (CABG). To clarify these points, a retrospective analysis of patients who underwent CABG after a mastectomy was undertaken. A total of 19 mastectomy patients (13 left, 6 right, and 1 bilateral mastectomy) were identified prior to CABG, and their perioperative data as well as late outcomes were examined. The studied group consisted of all females with a mean age of 68.8 +/- 6.2 years. The internal mammary artery (IMA) was used in 14 (73.7%) patients; however, there were no patients in whom bilateral IMAs were harvested. Among these 14 patients, an ipsilateral IMA was harvested in 6 and a contralateral IMA in 8. Alternative grafts were selected in 6 patients. A contralateral IMA or other graft conduits were utilized instead of an ipsilateral IMA. There were no in-hospital deaths or sternal wound complications. With a mean follow-up of 2.6 years, 3 patients died (1 cardiac death and 2 noncardiac deaths) and 1 patient developed angina due to de-novo coronary artery stenosis. In patients who have undergone a previous mastectomy, CABG using a single IMA is considered to be safe. If the IMA has good pulsation and if IMA harvesting is not difficult, even after a mastectomy, it can be used as a graft conduit without increasing the risk of sternal wound complications.

Concomitant subclavian and coronary artery disease

Background. Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia. Methods. We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal. Results. All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years). Conclusions. Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

Use of Angioplasty in the Prevention and Treatment of Coronary–Subclavian Steal Syndrome

The coronary-subclavian artery steal (CSS) syndrome is caused by critical stenosis in the subclavian artery proximal to a bypass graft from the internal mammary artery (IMA) to the coronary artery. The stenosis results in retrograde flow in the IMA and steal from the coronary artery. Percutaneous transluminal angioplasty (PTA) was performed in eight patients (five men, three women). In four patients (group 1), coronary ischemia had developed 0.5-70 months (mean, 31 months) after IMA-to-coronary artery bypass surgery. These four patients (mean age, 58 years; range, 44-68 years) underwent PTA of a single area of focal subclavian stenosis to treat CSS. In four other patients (group 2), atherosclerotic subclavian stenosis had developed proximal to a donor IMA before planned bypass surgery. These patients (mean age, 53 years; range, 50-57 years) underwent PTA of a single focal subclavian stenosis to prevent CSS. Group 1 patients were free of myocardial ischemia at follow-up (mean follow-up, 39.0 months; range, 14-101 months). Three of four patients in group 2 underwent coronary artery bypass grafting with the ipsilateral IMA following PTA of the subclavian stenosis; they were free of angina at follow-up (mean follow-up, 14 months; range, 10-18 months). PTA is a safe and efficacious short-term method for prevention and treatment of CSS syndrome.

Angiography of the internal mammary artery via the contralateral brachial artery.

A new technique for angiography of the contralateral internal mammary artery via the brachial artery approach is described. A Simmons (sidewinder) catheter is maneuvered into the ascending aorta and is rotated as to assume its performed shape. The catheter is advanced into the contralateral subclavian artery beyond the internal mammary artery. With the aid of an exchange wire, the Simmons catheter is replaced with a preformed internal mammary angiographic catheter. The internal mammary artery is cannulated, and angiography is performed. Fifty patients were successfully studied by means of this technique without incident. In 20 cases, the ipsilateral internal mammary artery was subsequently visualized. Brachial angiographers may prefer to add this technique to their repertoire.

Double blood supply of bronchogenic carcinoma from multiple arteries.

Angiography was performed in connection with intra-arterial chemotherapy in 110 patients with bronchogenic carcinoma. All tumors were supplied from at least one ipsilateral bronchial artery. A double systemic arterial supply was found in 12 patients, the additional blood supply coming from a second ipsilateral bronchial artery in 3 patients, from the ipsilateral internal mammary artery in 4, from intercostal arteries in 4 and from the subclavian artery in one patient. All patients with tumor supply from a non-bronchial artery had direct tumor spread to the chest wall or to the mediastinum. A complete angiographic examination may therefore be of prognostic significance and necessary before intra-arterial chemotherapy, which mainly has a local effect.

New method of treating melanoma of the pectoral region

<h2>Summary</h2> Four patients with melanoma of the pectoral region have been treated by wide excision of the primary site including the axillary or neck nodes, and by insertion of a radioactive Ir¹⁹² or Co⁶⁰ wire into the ipsilateral internal mammary artery for heavy irradiation of the nodes in this area. Each patient is apparently free of disease; however, it will require several years to prove the efficacy of this simple technic.