Patent LIMA Research Articles

Abstract 15772: From Agony to Relief: Overcoming Angina Through Endovascular Coiling of the Left Internal Mammary Artery (LIMA) to Pulmonary Artery (PA) Fistulae- A Case Report

Introduction: LIMA to PA fistulae are a rare complication after coronary artery bypass graft (CABG) surgery. We present a patient with angina secondary to a steal syndrome from LIMA-PA fistulae, treated with endovascular coiling. Case: The patient is a 49-year-old active male with coronary artery disease, status post CABG at age 46 with a LIMA graft to the left anterior descending artery, radial artery graft to the first obtuse marginal artery, and saphenous venous graft (SVG) to the posterior descending artery. At age 48, he developed angina and underwent stent placement to the distal right coronary artery after the SVG was found to be occluded. Several months later, he reported dyspnea and chest pain on exertion. An exercise nuclear stress test showed abnormal myocardial perfusion in the anteroseptal region, and he was referred for left heart catheterization (LHC). LHC revealed unchanged native coronary disease, patent LIMA, and a network of collateral vessels from the LIMA feeding into the pulmonary vasculature (Figure 1). The collaterals were not seen on LHC 9 months prior. CT coronary angiography confirmed multiple fistulae originating from the superior aspect of the LIMA graft communicating with the PA (Figure 1). After a multidisciplinary, patient-centered, heart team discussion, he underwent successful endovascular coiling of the collateral branches (Figure 2). Discussion: LIMA-PA fistulae is a rare cause of angina and there is a paucity of literature on management. To our knowledge, coil embolization has been described in roughly 10 cases. Here, we present a successful case of endovascular coiling of collateral vessels leading to symptomatic improvement.

Long-Term Outcome of Carotid-Subclavian Bypass in the Management of Coronary-Subclavian Steal Syndrome.

The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome. This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records. Nine patients (all males, mean age of 69.1years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft. Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

Abstract 9840: A Rare Etiology of Diffuse Coronary Aneurysms

Case: A 50-year-old woman with a prior right carotid aneurysm repair presented for chest pain. An evaluation 13 years ago showed a normal echo and cardiac catheterization. Four years prior, an echo showed an enlarged left ventricle with ejection fraction 57% and mid-anterolateral and inferolateral wall hypokinesis. Coronary angiography showed diffuse aneurysms of all coronary arteries with a proximal stenosis of the LAD, followed by a giant coronary aneurysm (Figure 1). CT angiography revealed bilateral intercostal artery aneurysms and a mildly ectatic aorta. She underwent bypass of the LAD with the LIMA. Aortic biopsy revealed no aortitis and prior carotid aneurysm pathology showed plasmalymphocytic inflammation; labs showed hypereosinophilia and elevated inflammatory markers with other negative immunologic work-up. She was diagnosed with hypereosinophilic vasculitis without evidence of granulomatosis and started on immunosuppressants.Due to symptoms, she underwent coronary angiography. Her LAD was occluded ostially with distal flow via a patent LIMA (Figure 2). There was progression of her aneurysmal disease at her proximal right coronary artery. No intervention was recommended. Instead, to improve control of her vasculitis, a Janus kinase inhibitor will be started. Discussion: Hypereosinophilic vasculitis, a variant of eosinophilic granulomatosis with polyangiitis, affects small- and medium-sized arteries and is challenging to diagnose. This case highlights a rare cardiac complication that can occur with this condition. Cardiac involvement often manifests as heart failure, pericarditis, valvular insufficiency, or rarely, coronary aneurysms.

Salvage CRT-D Implantation In A Patient With Advanced Biventricular Congestive Heart Failure Complicated With Cardiogenic Shock - Pace It Out

<h3>Background</h3> CRT-D therapy, when indicated, improves quality of life and reduces mortality and CHF readmission rates. It is unknown if CRT-D can be beneficial in certain advanced CHF patients presenting repeatedly with cardiogenic shock (CS). <h3>Case</h3> A 64 year old female with a history of CAD post CABG, CHF (EF 5-10% with severe RV dysfunction <b>Figure 1</b>, EF was 40-45% 1.5 years ago), presented with shortness of breath. BP 108/91 mmHg. Exam: Cool extremities. Lactic acid 3.85. EKG: Old LBBB with QRS of 158 msec. She was diagnosed with CS. She had recurrent readmissions for CHF and CS before: First at a local hospital in June 2020, second at our hospital in July 2020 with medical therapy optimization (MTO), and third at our hospital in July 2020 (this time). <h3>Decision-making</h3> The patient was admitted to CCU for milrinone and Lasix. LHC: Patent LIMA to LAD, occluded SVG to RI, and 70-80% RI disease <b>Figure 1</b>. After 2 days, she improved and was transferred to the floor. The big EF drop was out of proportion to CAD burden. She had recurrent readmissions with MTO failure. Due to lack of insurance, she was not able to get home inotropes or work up for LVAD or transplant. Thus, the decision was to proceed with salvage CRT-D implantation <b>Figure 1</b>. She was discharged after 11 days. Since discharge 3.5 months ago, she continued to do well without any admission. <h3>Conclusion</h3> Salvage CRT-D can be considered in patients with advanced CHF with recurrent inotrope reversible CS on a case-by-case basis. Further studies are needed to validate this consideration.

Successful Recovery with Venovenous ECMO for ARDS After LVAD HeartMate 3 Implantation: A Case Report

<h3>Introduction</h3> ARDS following LVAD implantation is an unusual but devastating complication. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) can be used as a salvage treatment. We report the successful use of VV ECMO for ARDS Klebsiella pneumonia following urgent LVAD Heartmate 3 implantation. <h3>Case Report</h3> A 69-year-old male with past medical history significant for ischemic cardiomyopathy, status post CABG, and with known CHF presented to the emergency department after a witnessed cardiac arrest. He was found to have a wide-complex tachycardia and his internal cardiac defibrillator discharged. He was started on intravenous lidocaine which was transitioned to amiodarone and carvedilol. An echo demonstrated an EF of 10-15% and a dilated left ventricle. Left and right heart catheterization showed a patent LIMA to LAD bypass graft and a cardiac index of 1.64 L/min/m². The patient was optimized and underwent urgent LVAD Heartmate 3 implantation (HM3, Abbott, Chicago, IL). Post-operatively he was on 20 (ppm) inhaled nitric oxide (iNO) which was weaned and he was extubated on postoperative day 2 but subsequently re-intubated on the same day due to profound hypoxemia. On post-operative day 3 the hypoxemia was refractory despite maximal ventilator support with FiO2 100%, PIP 37, PEEP 13, 20 ppm iNO. The arterial blood gas (ABG) was a pH 7.4, pO2 54, pCO2 38, HCO3 24, BE -1,and the decision was made to cannulate for VV ECMO. The patient was cannulated with a dual-lumen cannula (Avalon Elite, Getinge, Gothenburg, Sweden) in the right internal jugular vein. Respiratory cultures were positive for Klebsiella aerogenes and the patient was treated with vancomycin and cefepime. He was supported with VV ECMO for 6 days then decannulated. Two days later, a percutaneous tracheostomy was performed and he was ambulating the halls. The tracheostomy was removed after 18 days. He was discharged to a rehab facility on post-operative day 18 where he stayed for 6 days. <h3>Summary</h3> When the ventilator is at maximal settings, with minimal changes in oxygenation, VV ECMO is the next step of care for otherwise appropriate candidates. Our case demonstrates that the use of VV ECMO is a successful treatment option for a patient with refractory hypoxemia, post-cardiotomy, s/p LVAD implantation. A multi-disciplinary approach along with early initiation of these interventions can result in successful weaning of VV ECMO.

P1481 Embolic infarct in a known coronary artery disease patient

Abstract A 60 y/o diabetic and hypertensive lady with previous anterior infarction treated by primary PCI with stenting of the proximal LAD (2011) and CABG for stent thrombosis, presented for chest pain. Admission ECG showed ST segment elevation in II, III aVF, ST segment depression in V1-V2 (A). Urgent coronary angiography was performed. It showed non-significant lesions on RCA and LCX, occlusion of the proximal LAD stent, patent LIMA to LAD and first diagonal with non-significant stenosis of the distal anastomosis (B). Transthoracic echocardiography (C) showed calcific mass involving the mitral annulus and posterior mitral leaflet, moderate mitral regurgitation, hipokinesia of the basal segment of the inferior wall with preserved LV ejection fraction. Transesophageal echocardiography (D) confirmed the calcified mass involving the mitral annulus and the posterior mitral leaflet. There was no significant mitral stenosis, and mitral regurgitation was moderate. Thoracic CT showed massive mitral calcification and a possible thrombus attached to it. (E) Myocardial infarction was confirmed by troponin rise and fall. The patient was discharged on dual antiplatelet therapy, ACE-I, betablocker and statin. At one month follow-up transthoracic echocardiography the central area of the mitral mass became hypoechogenic, and a bilobated hypermobile structure was seen attached to the ventricular side of the mass (F). Blood cultures were negative and there was no inflammatory syndrome. Cardiac magnetic resonance (H) confirmed myocardial infarction and showed massive calcification of the posterior mitral annulus. TEE performed after another month showed a very long hypermobile structure attached to the mitral annulus calcification, which was entering the left ventricular outflow tract reaching the plane of the aortic valve (G). The patient underwent surgical mitral valve replacement and redo CABG and the mass was excised. The pathologic aspect of the excised material was cazeous and friable (I). The initial presentation was presumably an embolic infarct with cazeous material. Abstract P1481 Figure.

How should I treat a patient with a mechanical aortic valve prosthesis and recurrent intracranial bleeding on anticoagulation with a patent LIMA to LAD?

How should I treat a patient with a mechanical aortic valve prosthesis and recurrent intracranial bleeding on anticoagulation with a patent LIMA to LAD?

TCTAP C-157 Percutaneous Coronary Intervention of Heavily Calcified In-stent Restenosis: Does Rota Mandatory?

### Patient initials or identifier number Mr. N, 55 yrs ### Relevant clinical history and physical exam Risk factors- HTN, DM, Smoking 2010- CABGx2 grafts done due to TVD: LIMA to LAD, RSVG to OM2, RCA was diffusely diseased. 2013- NSTEMI. CAG showed- Patent LIMA to LAD graft & RSVG to OM2, RCA

Coronary aneurysms and coronary arterial bypass graft disease as initial presentation of Takayasu's arteritis, induced by hepatitis B infection

A 51-year-old Indian gentleman, after CABG surgery, developed blood transfusion induced acute hepatitis B infection, which recovered completely with symptomatic treatment. Subsequently, he developed recurrent angina, dyspnoea along with musculoskeletal symptoms with elevated acute phase reactants. A CT angiography showed thickening of bilateral subclavian arteries and left renal artery stenosis. His RIMA graft was totally occluded at the origin and the LIMA graft showed an aneurysm at the anastomotic site with the left anterior descending artery (LAD). FDG-PET scan showed active inflammation of the ascending and descending thoracic aorta. He was diagnosed as Takayasu's arteritis. He responded to steroids and immunosuppressants. One month later he developed acute coronary syndrome and a coronary angiography showed severe left main stenosis with a left main aneurysm and a significant ostial LCx lesion. His LAD had an aneurysm at the anastomotic site with the patent LIMA graft. His RCA also had an aneurysm followed by a total occlusion. His LIMA graft also showed a significant lesion and his RIMA graft was occluded. He underwent angioplasty and stenting with DES to the LAD at the anastomotic site and to the left main-LCx. DiscussionThe case highlights the diverse modes of presentation of Takayasu's arteritis. Our case presented as acute coronary syndrome with multiple coronary aneurysms and bypass graft disease, which was successfully treated with angioplasty and stenting. The case also highlights the importance of viral infections and vaccinations in the pathogenesis of Takayasu's arteritis.

TCTAP C-153 Stride Micro-catheter for Tortuous Diagonal Angioplasty

### Patient initials or identifier number F4397/2013 ### Relevant clinical history and physical exam 79 yr old female pt undergone CABG in 2002 with LIMA to LAD and SVG to D1. In 2010 had USA, then CAG showed native mid LCX tight stenosis, patent LIMA to Lad and occluded SVG to D1. Then PCI to

Transcatheter aortic valve implantation by left subclavian access in the presence of a patent LIMA to LAD graft

We present a case of successful implantation of the Corevalve aortic bioprosthesis via the left subclavian artery in a patient with a patent internal mammary graft to the left anterior descending artery. This unusual choice of access, in the presence of adequate caliber femoral arteries, was justified by the presence of mobile thrombi in the abdominal aorta. The risk of thrombus dislodgement and subsequent major cholesterol embolization was deemed higher than the risk of coronary ischemia due to the large caliber sheath required for transcatheter aortic valve implantation. This case shows that presence of a LIMA to LAD graft is not an absolute contraindication for homolateral subclavian access and that the procedure is feasible and relatively safe provided that certain rules are followed.

Monitoring myocardial recovery during induced hypothermia with a disposable monoplane TEE probe

A 73 year old female with a history coronary artery bypass grafting and coronary stents had a witnessed cardiac arrest at home. She was transferred to an outside hospital and emergency heart catheterization revealed patent LIMA to LAD, stented grafts open, and no new culprit lesions. A temporary transvenous pacing wire was placed for bradycardia. She was transferred to the ICU where she was sedated and paralyzed for induction of hypothermia approximately five hours after the arrest. A miniaturized disposable TEE probe (Photo 1) was placed to allow ongoing monitoring of cardiac function and intravascular volume.

Transcatheter aortic valve implantation through the left subclavian artery with a patent LIMA graft

We report the case of an 80-year-old male with severe aortic valve stenosis previously submitted to surgical myocardial revascularization with patent mammary graft treated by TAVI through left-transaxillary approach because of unsuitable transfemoral and transapical approaches.

Endovascular treatment of a saccular aortic arch aneurysm in a patient with a patent LIMA graft

Eur J Vasc Endovasc Surg 25, 188–189 (2003)

Online and enhanced

MEDICAL JOURNALS, like all aspects of medical education, are making rapid changes to keep up with the revolution in biomedical technology. I am pleased that the new features of the Journal of Cardiothoracic and Vascular Anesthesia are being well received by our readership, contributors, and the Editorial Board. The new cover design celebrates our 15th year with more than 2,000 articles published in our subspecialty. There have been enormous changes during this time in anesthesia, surgery, and the related basic sciences and fields of medicine. This progress will be symbolized on the cover with a change from the original heart logo with a pulmonary artery catheter to a picture of new technology appearing in the issue, such as the color Doppler echocardiogram on this issue taken from the article by Schellenberg, Marshall, and Salgo entitled “Intraoperative Ultrasound for Localization of Patent LIMA Grafts in Repeat Cardiovascular Surgery.” The other technical advances in the Journal are meant to make it easier to be used by busy clinicians, residents and fellows, innovative educators, and international researchers. The Journal website (www.jcardioanesthesia.com) has had an increasing number of overall hits and averages more than 70,000 accesses per month from around the world. The home page allows complimentary access to tables of content, article abstracts, online discussion of the “Pro and Con” articles, and general Journal information. In addition, you can now view video clips online when provided by the authors. This availability of online video is an enhancement to the printed Journal content and figures. It is a unique benefit of the Internet that cannot be provided on paper, which should lead to wider and clearer dissemination of information from techniques such as echocardiography and other monitoring or diagnostic tools. These online videos should not replace the black and white or color figures in the Journal, but should be used in concert with them to further improve the Journal of Cardiothoracic and Vascular Anesthesia as the superior clinical resource in the field. This capability may be particularly useful when trying to demonstrate complex cardiovascular lesions or evolving clinical problems. Subscribers to the written Journal will also have access to the full text online with enhanced search capabilities via the electronic media. Although ultimately a subscriber-only benefit, W.B. Saunders will also make this available to nonsubscribers for a few months to demonstrate its unique features to both clinicians and researchers. Links to Medline, Pubmed, CrossRef, other databases, and all Harcourt Health Sciences (HHS) (Saunders, Churchill, Mosby, etc) publications make this a very useful reference source. The Catalyst referencing system allows for simple or advanced searches of the literature. The links to PubMed will allow the user to see the abstract, related articles, and other articles by the same author, as well as access to the Medline article. Other enriched linking features include cross-linking in the HHS system; moving directly to articles in participating non-HHS journals (bypassing Pubmed) by using CrossRef; using GenRx, a complete drug database; and obtaining genetic information on the condition being researched via the Online Mendelian Inheritance in Man (OMIM) database. Electronic publishing is exciting and is broadening our access to and use of medical data like nothing else has before. Initially, publishers were somewhat frightened by the possibility of e-publishing replacing standard texts and journals. Now, however, they are leading the way with new approaches, such as the Catalyst system, to help clinicians and scientists obtain rapid access to the expanding biomedical information. They are clearly doing the right thing. In this era of off-pump and minimally invasive cardiac surgery, I think the print journal is as unlikely to disappear as is the use of cardiopulmonary bypass. Besides, it is difficult to take a PC into the WC!

Beating heart operations including hybrid revascularization: initial experiences

Background. The outcome of patients (n = 45) with coronary one- to three-vessel disease undergoing beating heart operations using a recently developed stabilizing device was investigated. Methods. Left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) revascularization was carried out alone (n = 31) or as hybrid procedure in combination with a balloon angioplasty (n = 14). Results. All 45 patients underwent a successful LIMA-to-LAD procedure without intraoperative complication during a 21 ± 8-minute (range, 10 to 53 minutes) LAD occlusion time. In 14 hybrid procedures a total of 19 stenoses including 3 left main stenoses were treated successfully by percutaneous transluminal coronary angioplasty and stenting. The postoperative courses were uneventful with the exception of two surgical reexplorations necessitated by bleeding. No worsening of renal, neurologic, or respiratory functions occurred in any patient. In the group having a single LIMA-to-LAD procedure, early postoperative coronary angiograms (22 of 31) showed a patent LIMA graft and excellent anastomosis; this was also true in 4 patients 12 months after operation as shown in angiograms. All patients undergoing hybrid revascularization demonstrated a patent LIMA-to-LAD anastomosis; in 1 patient there was a dissection in the midlevel of the LIMA, which was stented successfully. The 6-month follow-up angiograms in 7 of 14 patients revealed open LIMA bypass grafts in all patients except 1, who was stented because of dissection. Conclusions. These data indicate that a beating heart operation including hybrid revascularization is safe and effective in selected patients with coronary one- to three-vessel disease including left main stenosis. This approach may be especially advantageous in comparison with conventional coronary artery bypass grafting in patients with severe concomitant disease.