Left Internal Mammary Graft Research Articles

Reverse Controlled Antegrade and Retrograde Tracking in Left Internal Mammary Artery Bypass Grafts

Reverse Controlled Antegrade and Retrograde Tracking in Left Internal Mammary Artery Bypass Grafts

C-2 | Comparing the Peri-procedural and Long-term Outcome between Minimally Invasive Hybrid Coronary Revascularization versus Percutaneous Coronary Intervention of Multivessel Coronary Artery Disease: A Meta Analysis

Hybrid Coronary Revascularization (HCR) involves harvesting Left Internal Mammary Artery (LIMA) and grafting it to Left Anterior Descending artery (LAD) with minimally invasive bypass surgery as well as percutaneous coronary intervention (PCI) of non- LAD arteries. The study aims to assess if there are any benefits of HCR when compared to PCI for both LAD and non-LAD lesions.

String sign recovery of the left internal mammary artery bypass graft.

String sign recovery of the left internal mammary artery bypass graft.

Very large aortic pseudoaneurysm repair using a septal occluder

A 63-year-old man, with previous coronary artery bypass surgery presented with infectious aortitis and a large ascending aorta pseudoaneurysm, causing compression of the left internal mammary graft. Percutaneous intervention with stenting of the graft followed by closure of the pseudoaneurysm using an atrial septal defect occluder was successfully carried out.

Multiple Bridging: Recovery, Decision, Transplantation, Recovery

Introduction This case describes multiple forms of short term mechanical circulatory support (sMCS) used sequentially in the same patient, and illustrates the role of different clinical goals of sMCS. Case Report A 59 year old man with previous coronary artery bypass surgery attended with troponin positive acute coronary syndrome. After workup, he went for PCI to a native coronary chronic total occlusion using anterograde/retrograde wires. Unfortunately, the left internal mammary graft was dissected, and he suffered cardiac arrest. Day 0: Impella CP as bridge to recover y : During resuscitation an Impella CP was placed via his right femoral artery and resolved circulatory arrest. Further PCI was performed to the LIMA ostium with restoration of flow. He was transferred to ITU. Day 3: Peripheral VA-ECMO as bridge to decision: His clinical status improved, but he remained in shock. His support was upgraded to peripheral veno-arterial (VA) extra-corporeal membrane oxygenation (ECMO), leaving the Impella in place as an LV vent. Day 14: BIVAD as bridge to transplantation: He remained MCS-dependent, and had no absolute contraindications to advanced therapies. He went to theatre for implantation of bilateral short term ventricular assist devices (BI-VAD) to optimise his organ support prior to transplantation. He was placed on the super-urgent waiting list. He had intermittent ventricular fibrillation but continued to mobilise on the ITU. Day 48: Transplantation and bridge to recovery with central ECMO: After 34 days on BIVAD, he underwent orthotopic cardiac transplantation. Due to vasoplegia and RV dysfunction, he was weaned from cardiopulmonary bypass onto central ECMO. Day 50: Weaning support - percutaneous RVAD as bridge to recover y : There was persistent RV dysfunction. Central ECMO was exchanged for a Protek RVAD. Day 56: Explant of RVAD: His status continued to improve. The RVAD was weaned and explanted after 6 days. Day 73: Discharge home: He required intense physiotherapy. After 73 days in hospital he was discharged home. At the time of submission he is alive at 291 days post transplant. Summary This man's successful outcome was facilitated by judicious use of sMCS, on each occasion with a clear strategy in mind. Surgically implanted and percutaneous modes were used. Collaboration between cardiologists, intensivists and cardiac surgeons was essential to facilitate optimal care.

Use of quantitative cardiovascular magnetic resonance myocardial perfusion mapping for characterization of ischemia in patients with left internal mammary coronary artery bypass grafts

BackgroundQuantitative myocardial perfusion mapping using cardiovascular magnetic resonance (CMR) is validated for myocardial blood flow (MBF) estimation in native vessel coronary artery disease (CAD). Following coronary artery bypass graft (CABG) surgery, perfusion defects are often detected in territories supplied by the left internal mammary artery (LIMA) graft, but their interpretation and subsequent clinical management is variable.MethodsWe assessed myocardial perfusion using quantitative CMR perfusion mapping in 38 patients with prior CABG surgery, all with angiographically-proven patent LIMA grafts to the left anterior descending coronary artery (LAD) and no prior infarction in the LAD territory. Factors potentially determining MBF in the LIMA–LAD myocardial territory, including the impact of delayed contrast arrival through the LIMA graft were evaluated.ResultsPerfusion defects were reported on blinded visual analysis in the LIMA–LAD territory in 27 (71%) cases, despite LIMA graft patency and no LAD infarction. Native LAD chronic total occlusion (CTO) was a strong independent predictor of stress MBF (B = − 0.41, p = 0.014) and myocardial perfusion reserve (MPR) (B = − 0.56, p = 0.005), and was associated with reduced stress MBF in the basal (1.47 vs 2.07 ml/g/min; p = 0.002) but not the apical myocardial segments (1.52 vs 1.87 ml/g/min; p = 0.057). Extending the maximum arterial time delay incorporated in the quantitative perfusion algorithm, resulted only in a small increase (3.4%) of estimated stress MBF.ConclusionsPerfusion defects are frequently detected in LIMA–LAD subtended territories post CABG despite LIMA patency. Although delayed contrast arrival through LIMA grafts causes a small underestimation of MBF, perfusion defects are likely to reflect true reductions in myocardial blood flow, largely due to proximal native LAD disease.

Incidental Finding and Endovascular Repair of a Left Internal Mammary Artery Aneurysm following a Multivessel Coronary Artery Bypass Graft

True aneurysms discovered within the internal mammary artery are extremely rare and typically have an asymptomatic occurrence. Their presentation and management have also been variable due to their low incidence, decreased detection, or lack of documentation. They have a high risk for morbidity or mortality as they can possibly rupture with increasing size and thus become life-threatening. Coronary CT angiography is the most definitive test for confirming and finding complications related to the aneurysm. With an increase in the aging population and advancement in the techniques used in coronary artery bypass grafting, it is likely that the rate of recorded occurrence of aneurysms and pseudoaneurysms will increase. Endovascular repair is currently the most favored treatment modality. In this report, we describe a case of a 74-year-old male who was incidentally found to have a left internal mammary artery aneurysm following complaints of chest pain related to another nearly occluded grafted vessel. To the best of our knowledge, and following an extensive literature review, this is likely the first documented case of a true aneurysm found within a left internal mammary artery bypass graft. The patient recovered well following placement of a covered stent; however, upon follow-up one year later, he was found to have stenosis of the same vessel, which was subsequently treated without further complication.

Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery

ObjectiveThe risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG. MethodsUsing propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan–Meier survival curves. ResultsThe following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P < .01). The P value for the overall intergroup difference in long-term survival was .06. ConclusionsThis is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.

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

OC62 REDO MITRAL SURGERY AND HOSPITAL OUTCOME: IMPACT OF FAILED MITRAL VALVE REPAIR

Background and Aim: Mitral valve repair is the gold standard for mitral valve regurgitation, even if failed mitral repairs (FMR) have been reported. The aim of this study was to evaluate the impact of FMR on early outcome after redo mitral surgery. Methods: Operative mortality and major morbidity events from 920 redo mitral procedures at nine European centres were analysed. Statistical analysis was performed by the SPSS 13.0 program for Windows (SPSS, Inc., Chicago, IL, USA). To identify indipendent predictors of operative deaths, variables with a P &lt; 0.10 at univariable analysis were included in the regression models. All the outcome parameters were then adjusted by propensity matching, to compare similar cohorts of patients with FMR or diseased native mitral valves and similar cohorts of patients with FMR and malfunctioning prostheses. Results: FMR did not impact mortality at multivariable analysis (P = 0.64). Propensity-matched cohorts of FMR and native mitral valves showed no differences in mortality (P = 0.69). A preoperative Global Initiative for Chronic Obstructive Lung Disease score &gt;2 chronic lung disease (COPD) (OR 15.2, P &lt; 0.01), left ventricular ejection fraction &lt;30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P &lt; 0.01) or to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the FMR population. Conclusions: A failed mitral repair does not impact hospital outcome of redo surgery. Severe left ventricular dysfunction, COPD and injury at re-entry predict adverse early outcome.

Surgical left subclavian artery revascularization for thoracic aortic stent grafting: a single-centre experience in 101 patients.

To evaluate the indications, perioperative strategy and postoperative outcome of surgical left subclavian artery (LSA) revascularization combined with thoracic endovascular aortic repair (TEVAR) covering the LSA. Between 2000 and 2017, a total of 101 consecutive patients underwent surgical revascularization of the LSA prior to, concomitant or following TEVAR. Revascularization was performed through a small supraclavicular incision and consisted of a transposition or bypass graft, using intraoperative transcranial Doppler monitoring. Data regarding indication, procedural details and postoperative results were retrospectively analysed. In total, 63 subclavian-carotid bypass grafts and 38 subclavian-carotid transpositions were performed in the context of TEVAR. The majority was performed prior to stent grafting to reduce the risk of stroke (n = 50), spinal cord ischaemia (n = 20), left arm malperfusion (n = 10) or to preserve a patent left internal mammary artery coronary bypass graft (n = 2). Secondary revascularization was performed in 14 patients, 2 times immediately due to acute left arm malperfusion and 12 times to treat invalidating left arm claudication. No in-hospital mortality and permanent spinal cord ischaemia occurred. Two (2%) ischaemic strokes were observed in patients with concomitant procedures, and none when separate, staged procedures were performed. Additional complications observed were permanent peripheral nerve palsies (9%), chyle leakage requiring diet (6%) and 1 bypass occlusion requiring a redo procedure. In patients predominantly selected upon the anticipated risk of (posterior) stroke, spinal cord ischaemia and left arm malperfusion, surgical revascularization of the LSA proved to be a safe treatment option to preserve antegrade LSA flow in the context of TEVAR.

Late Survival of Left Internal Mammary Artery-Radial Artery-Y Graft Compared to Single Internal Mammary Artery and Saphenous Vein Grafts in Coronary Bypass Surgery

Late Survival of Left Internal Mammary Artery-Radial Artery-Y Graft Compared to Single Internal Mammary Artery and Saphenous Vein Grafts in Coronary Bypass Surgery

High-Output Cardiac Failure and Coronary Steal With an Arteriovenous Fistula

Creation of an arteriovenous access for hemodialysis can provoke a sequence of events that significantly affects cardiovascular hemodynamics. We present a 78-year-old man with end-stage renal disease and concomitant coronary artery disease previously requiring coronary artery bypass grafting including a left internal mammary graft to the left anterior descending artery, ischemic cardiomyopathy with left ventricular systolic dysfunction, and severe aortic stenosis who developed hypotension unresponsiveto medical therapy after recent angioplasty of his ipsilateral arteriovenous fistula for high-grade outflow stenosis. This case highlights the long-term effects of dialysis access on the cardiovascular system, with special emphasis on complications such as high-output cardiac failure and coronary artery steal syndrome. Banding of the arteriovenous fistula provided symptomatic relief with a decrease in cardiac output. Avoidance of arteriovenous access creation on the ipsilateral upper extremity in patients with a left internal mammary artery bypass graft may prevent coronary artery steal syndrome.

Long-term Outcomes of Carotid-Subclavian Bypass in the Setting of Thoracic Endovascular Aortic Repair

Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR) for a variety of indications ranging from prophylactic prevention of upper extremity and spinal cord ischemia to preservation of hemodialysis access or left internal mammary artery coronary artery bypass graft. Despite this, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass. We sought to define the outcomes associated with this procedure. Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. Categorical and continuous variables were compared using χ2 and Wilcoxon rank sum tests, respectively. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications. Of 579 patients undergoing TEVAR during this time interval, 114 patients (20%) underwent concomitant carotid-subclavian bypass. The cohort was 39% female (n = 44), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [92.2%]), with a minority being reversed saphenous vein grafts (n = 4 [3.5%]). The bypass procedure was done concomitantly at the time of TEVAR in 90.4% (n = 103) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 21% (n = 24). These complications included neck hematoma requiring re-exploration in 0.9% (n = 1), recurrent laryngeal nerve palsy in 5.3% (n = 6), axillary nerve palsy in 1.8% (n = 2), and phrenic nerve palsy in 13.2% (n = 15) of patients. The 30-day all-cause mortality rate was 5.3% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 108), follow-up imaging of the bypass graft was available in 84% (n = 96) of patients. Actuarial primary graft patency was 97% at 10 years (Fig). There were three patients (2.5%) with bypass graft occlusions, two of which were clinically silent and detected in follow-up imaging. The third was detected because of the symptoms of subclavian steal and required repeated revascularization. Two patients (1.8%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention. Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely to be higher than generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as “gold standard” comparison data for emerging branch graft devices.

Impact of failed mitral valve repair on hospital outcome of redo mitral valve procedures.

The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated. Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses. A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR. A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome.

Comparison of Right Radial Artery with Femoral Artery Access for Patients with LIMA Grafts

Background: Right Radial Angiography (RRA) is the preferred approach for invasive coronary angiography. Coronary artery bypass graft (CABG) patients with left internal mammary graft (LIMA) remain a technical challenge via this approach. Methods: A retrospective audit was carried out on all CABG patients with LIMA grafts who had diagnostic only angiography between December 2015 and December 2016 at North Shore Hospital. Right femoral artery (RFA) or RRA access (using a BartorelliCozzi catheter) was decided by the operator. Patient and procedural characteristics were compared with mean ± standard deviation and F-test statistical analysis (p < 0.05). Results: Thirty-one patients (72 ± 9 years, 90% male) underwent RFA approach and forty-four patients (70 ± 10 years, 75% male) underwent RRA approach. The procedure characteristics are presented in the table below:Tabled 1RFARRAp-valueProcedure duration (minutes)26 ± 935 ± 130.07Fluoroscopy time (minutes)11 ± 916 ± 80.43Dose Area Product (mGym2)4791 ± 25115926 ± 28620.46Contrast volume (mL)106 ± 51112 ± 420.29Procedural success (LIMA engaged)31/3142/44 Open table in a new tab The two conversions from RRA to RFA approach were due to not being able to pass a stented subclavian artery with glide wire and radial tortuosity prohibiting engagement of the ascending aortic grafts. One RFA patient had a large groin haematoma. Conclusion: LIMA angiography via the RRA appears feasible. There may be some resultant increase in procedural times that warrant further prospective study.

Hemodynamics of left internal mammary artery bypass graft: Effect of anastomotic geometry, coronary artery stenosis, and postoperative time

Although the left internal mammary artery (LIMA) bypass graft is the best choice for surgical revascularization, its hemodynamics are still complex and can result in long-term graft failure. Here, we performed a hemodynamic analysis of the LIMA-coronary artery with end-to-side/side-to-side anastomoses based on 15 patient-specific CTA images at various postoperative periods. We hypothesize that hemodynamic patterns are determined by the interplay of LIMA geometry, anastomotic configuration, and severity of native coronary artery stenosis, which are strongly affected by the postoperative time. A 3D finite volume method with the inlet pressure wave and outlet resistance boundary conditions was used to compute the distribution of pressure and flow, from which the time-averaged wall shear stress (TAWSS), oscillation shear index (OSI), time-averaged WSS gradient (TAWSSG), and transverse WSS (transWSS) were determined. To characterize the hemodynamic environment, we defined surface area ratios of low TAWSS (≤4dynes/cm2), high OSI (≥0.15), TAWSSG (≥500dynes/cm3), and transWSS (≥6dynes/cm2) in the LIMA graft and at the anastomosis between LIMA graft and coronary artery. These ratios were determined by the interplay of multiple morphometric parameters in the LIMA-coronary artery, but increased with postoperative time. These findings have significant implications for understanding LIMA graft patency.

Total occlusion at ostial Left internal mammary graft with successful angioplasty and longterm patency result

Total occlusion at ostial Left internal mammary graft with successful angioplasty and longterm patency result

High-risk acute coronary syndrome in a patient with coronary subclavian steal syndrome secondary to critical subclavian artery stenosis.

Patients with multivessel coronary artery disease are more likely to have extensive atherosclerosis that involves other major arteries. Critical subclavian artery (SCA) stenosis can result in coronary subclavian steal syndrome that may present as recurrent ischemia and even myocardial infarction in patients with coronary artery bypass graft (CABG). In patients with concomitant severe native coronary disease, occluded saphenous venous grafts (SVG) to other arteries, percutaneous intervention on critical subclavian artery (SCA) stenosis that will compromise the blood flow to left internal mammary graft (LIMA) and left anterior descending (LAD) artery will be a high-risk procedure and may be associated with cardiogenic shock, especially in patients with preexisting ischemic cardiomyopathy. The use of percutaneous left ventricular (LV) assist device like Impella will offer better hemodynamic support and coronary perfusion and therefore results in decreased myocardial damage, maximized residual cardiac function, and lower incidence of cardiogenic shock.

Urgent trans‐axillary valve‐in‐valve procedure using the Edwards 16‐F expandable introducer

Transcatheter aortic valve implantation could represent an alternative option to conventional surgery in high-risk patients with degeneration of aortic bioprosthesis. Herein, we report the performance of a valve-in-valve procedure in urgent conditions and via the left axillary artery in a patient with patent left internal mammary artery coronary graft. A 23-mm Edwards Sapien(®) transcatheter valve was deployed within a 23-mm Edwards Magna Ease bioprosthesis through the novel Edwards 16-F expandable introducer. In this non-elective case, the expandable introducer allowed a safe procedure, reduced the risk of subclavian injury, and preserved the left internal mammary artery graft flow.