Pedicled Left Internal Thoracic Artery Research Articles

Left internal thoracic artery bypass graft.

A 77-year-old man presented with chest discomfort on exertion for several weeks. Thirty-one years prior, he had performed on-pump coronary artery bypass grafting (CABG) using the pedicled left internal thoracic artery (LITA) to left anterior descending artery (LAD) and saphenous vein grafts (SVGs). The SVGs to the left circumflex artery had already occluded and to the right coronary artery (RCA) had previously required percutaneous coronary intervention (PCI). Although an electrocardiogram showed no remarkable change and echocardiography showed findings of known old posterior myocardial infarction, single-photon emission computed tomography demonstrated new inferior myocardial ischemia. Coronary angiography showed occlusion of all native coronary artery and severe stenosis of the residual SVG to RCA. On the other hand, the 31-year-old LITA graft revealed excellent patency (Panel and Supplementary material online, Video). Since the 1980s, the LITA for LAD grafting has been a cornerstone of CABG surgery.1 The European Society of Cardiology guideline recommends grafting with internal thoracic artery to the LAD as Class I.2 Furthermore, LITA graft had better patency than SVG for 20 years post-operatively.3 This case showed the over 30 years patency of LITA graft, although the use of a pump or the harvesting method might affect patency. This case indicated that it is precisely in patients less than 50 years of age scheduled for CABG that LITA to the LAD should be utilized.

Coronary artery surgery in a patient with grossly emphysematous lung

The pedicled left internal thoracic artery graft is the mandatory conduit in coronary artery bypass surgery. A grossly emphysematous lung may sometimes present a significant problem for positioning of the pedicled left internal thoracic artery conduit. An inverted pedicled left internal thoracic artery graft (internal thoracic artery transected near its origin, thus supplied by retrograde flow from superior epigastric and musculophrenic arteries) might occasionally be the conduit of choice for those patients.

Can internal thoracic arteries be used for both coronary artery bypass and breast reconstruction?

Recently, the internal thoracic arteries have been preferentially used in autologous breast reconstruction at the levels of the third or fourth intercostal spaces. This may compromise future treatment of occult coronary disease. We hypothesized that internal thoracic artery length at the fourth intercostal space would allow both breast reconstruction and future coronary artery bypass grafting (CABG). Anatomic analysis of 20 female patients undergoing CABG was performed examining internal thoracic artery length from its origin to the third, fourth, fifth intercostal spaces and the left anterior descending (LAD) artery target. The left internal thoracic artery was anastamosed to the LAD target at a mean length of 11.4 ± 1.4 cm. The mean lengths of the pedicled left internal thoracic artery from its origin to the third, fourth and fifth intercostal space were 8.5 ± 1.0, 10.9 ± 1.2 and 13.0 ± 1.4 cm, respectively. Therefore, the left internal thoracic artery length was adequate at the fourth intercostal space in 6 of 20 (30%) patients. Dissection of the left internal thoracic artery to the fourth intercostal space would allow for concomitant use in CABG and breast reconstruction in one-third of cases. However, skeletonization of the internal thoracic artery at the level of the fourth intercostal space would be sufficient for CABG in all cases following autologous breast reconstruction.

Simultaneous multi-vessel coronary artery bypass grafting, ischemic mitral regurgitation repair and descending aortic aneurysm replacement: analysis of technical points☆

The combination of coronary artery disease and its complications (ischemic mitral regurgitation etc.) with the aneurysm of the descending thoracic aorta is not a rare case. The single-stage correction of coronary/intracardiac/aortic lesions may be considered as a way of managing the combined patients. Simultaneous multi-vessel coronary artery bypass grafting, suture mitral annuloplasty and descending aortic aneurysm replacement with synthetic prosthesis is described. The operation was performed through the left thoracotomy with cardiopulmonary bypass established by the cannulation of the ascending aorta and of the right atrial appendage. Ventricular fibrillation and no clamping of the ascending aorta were used. The circulatory arrest was induced for the construction of the proximal anastomosis between the descending aorta and the synthetic prosthesis. No complications related to the operation were diagnosed for the 14-month follow-up. Several technical points seem optimal for the combined procedure: (1) Minimization of manipulations on the ascending aorta (using of pedicled left internal thoracic artery; construction of the proximal anastomoses with synthetic aortic prosthesis; unclamped ascending aorta). (2) Revascularization of all coronary areas and correction of intracardiac lesions through the left thoracotomy. Individual planning of the procedural technical points for every patient may provide a safe feasibility of the combined procedure.

A randomized trial of an external Dacron sheath for the prevention of vein graft disease: The Extent study

A randomized trial of an external Dacron sheath for the prevention of vein graft disease: The Extent study

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Intraoperative and Histochemical Comparison of the Skeletonized and Pedicled Internal Thoracic Artery

Skeletonization of the internal thoracic artery (ITA) has advantages, but the variation of ITA preparation may be traumatic for the arterial wall. We sought to compare intraoperative results and endothelial nitric oxide synthase (e-NOS) expression on the vessel wall after left ITA harvesting with skeletonization and the conventional technique. A prospective evaluation of 84 consecutive patients undergoing coronary artery bypass grafting was performed: 40 patients with skeletonized and 44 patients with pedicled left ITA. The lengths of ITA and free ITA blood flow were measured. Distal ITA segments were analyzed histopathologically and stained by antibodies against e-NOS. In the skeletonized group, the length of the ITA were significantly longer than in the pedicled group (15.7 +/- 0.4 cm versus 19.0 +/- 0.6 cm; P = .001). Also, the free-flow capacity of the ITA was significantly higher than in the pedicled group (62.4 +/- 4.8 mL/min versus 88.6 +/- 6.9 mL/min; P = .001). e-NOS expressions on endothelial cells were similar between the groups. Dense e-NOS immunostaining was observed in vaso vasorum of the adventitia in the pedicled group. However, there was not any e-NOS immunostaining in vaso vasorum of the adventitia in the skeletonized group. Although skeletonization of the ITA is a more technically demanding procedure, it provides some advantages such as increased available graft length and reduced sternal devascularization. This technique did not have any detrimental effects on the endothelial cell lining and e-NOS expressions on the endothelial layer. To reach a definitive judgment for using skeletonized ITA, we need information about the long-term angiographic patency rates.

Is there any change in free flow of pedicled left internal thoracic artery conduit at varying degrees of clockwise twist up to 360°?

Is there any change in free flow of pedicled left internal thoracic artery conduit at varying degrees of clockwise twist up to 360°?

Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention?

The choice of myocardial revascularization strategy for the right coronary artery (RCA) in patients with multivessel disease and chronic stable angina remains controversial. Our aim was to determine the better strategy-hybrid, combining bypass of the left coronary network and percutaneous coronary intervention of the RCA, or exclusively surgical-and if the latter, the best conduit. We used decision analysis, a modeling technique, to compare two RCA revascularization strategies: surgical grafting and percutaneous coronary intervention. A review of the English language literature determined the variables for each strategy. All possible outcomes of each strategy were analyzed to determine the baseline strategy yielding the highest expected effectiveness. Sensitivity analysis determined the most relevant elements in the model and indicated threshold values. Arterial grafting of the RCA led to the highest expected effectiveness, respectively 6% and 7% higher than that of percutaneous coronary intervention and the saphenous graft procedure. Of the arteries available-the radial, right gastroepiploic, and right internal thoracic artery-the most effective was the right internal thoracic artery, pedicled for the proximal part of the RCA and free connected as a Y or a T to the pedicled left internal thoracic artery for the distal part of the RCA. Sensitivity analysis showed surgery to be the appropriate strategy when the expected 1-year patency rate of the arterial graft exceeded 80%. This analysis shows arterial grafting of the RCA to have better outcomes than percutaneous coronary intervention, and the right internal thoracic artery to be the best conduit.

Twisting of pedicled left internal thoracic artery graft three hundred sixty degrees clockwise: Does it change the outcome?

Twisting of aorta-coronary venous conduits has been reported previously with fatal outcome and is an extremely uncommon occurrence.1 However, twisting of the pedicled left internal thoracic artery (LITA) graft was not found to be reported in a search of the English-language literature (MEDLINE and PUBMED), and its outcome is unknown. We report a case of an inadvertent clockwise 360° twisting of a LITA graft sequentially anastomosed to the diagonal and left anterior descending coronary arteries (LAD) with an angiographically documented patency with good distal runoff.

The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery

The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery

In situ pedicle graft and coronary-coronary bypass grafting using internal thoracic artery in management of multiple lesions of the left anterior descending coronary artery

Nowadays, coronary-coronary bypass grafting (CCBG) has been applied in patients with heavily calcified ascending aorta or due to lack of graft material. We describe a case in which the patient's large left anterior descending (LAD) coronary artery, running well over the cardiac apex, presented with proximal and distal stenosis. Although the pedicled left internal thoracic artery (ITA) graft is sometimes too short for sequential bypass in cases of distal stenosis of the LAD coronary artery, we used a free, short segment of the pedicled left ITA for coronary-coronary bypass grafting. The in situ remnant of the left pedicled ITA was used to bypass the proximal LAD stenosis. The patient's postoperative course was uneventful. Predischarge angiogram (on the 9th postoperative day) showed an in situ left ITA graft as well as afree coronarycoronary ITA graft. The patient had a regularfollow-up after 3 months, and was classified as New York Heart Association (NYHA) class I. Primarily used in aorto-coronary bypass surgery (termino-terminal interposition of the saphenous vein between two parts of a resected coronary artery), CCBG was revised latter on, and from hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed CCBG might be an attractive approach for bypassing distal lesions of large coronary arteries (combined with arterial or venous grafting of targeted arteries, if proximal stenoses are also present). The proximal remnant of ITA can be used as an in situ or free graft.

Decreased sternal vascularity after internal thoracic artery harvesting resolves with time: An assessment with single photon emission computed tomography

Objective: We sought to prospectively evaluate the long-term effect of left internal thoracic artery harvesting on sternal vascularity. Methods: Twelve consecutive patients undergoing primary coronary artery bypass grafting were studied. In all patients a pedicled left internal thoracic artery was harvested. Each patient underwent a preoperative technetium-99m methylene diphosphonate bone scan with single photon emission computed tomography. The ratio of the mean counts per pixel for each side of the sternum was obtained. All patients had early repeat bone scans 6 ± 2.4 days postoperatively and late repeat bone scans 18.6 ± 3.5 months after the operation. Ratios of unilateral sternal uptakes were compared between the different scans. One patient died during follow-up and was excluded from the study. Results: There was a significant decrease in flow to the left hemisternum in the early postoperative scan compared with that in the preoperative scan (P <.001). At late follow-up scans, flow to the left hemisternum had returned to normal (P =.119). Midterm clinical follow-up demonstrated 3 superficial wound infections. No musculoskeletal pain existed at the time of follow-up, but 3 patients had numbness or tingling at the skin area corresponding to the site from which the left internal thoracic artery was harvested. Conclusions: Acute postoperative sternal ischemia caused by harvesting of a pedicled left internal thoracic artery is temporary and resolves with time.J Thorac Cardiovasc Surg 2002;123:508-11

Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery

Objective: This study prospectively evaluates the effect on sternal vascularity of harvesting the left internal thoracic artery. Methods: Twenty-four consecutive patients undergoing primary coronary artery bypass grafting were studied. One patient’s procedure was altered during the operation, and he was eliminated from the study. The patients were prospectively randomized to receive a skeletonized internal thoracic artery (group I, n = 11) or a pedicled internal thoracic artery (group II, n = 12) graft. Each patient underwent a preoperative technetium 99 methylene diphosphonate bone scan using single photon emission computed tomography. The ratio of the mean counts per pixel on the left side of the sternum was compared with the mean counts per pixel on the right side. Postoperatively, all patients had a second scan, and sternal uptake was compared with the preoperative uptake. Results: No significant differences in preoperative and operative variables were observed between the groups. A statistically significant reduction in blood flow to the left side of the sternum was shown postoperatively in group II compared with group I (0.61 ± 0.11 vs 0.85 ± 0.09; P < .001). Multivariable logistic regression analysis of preoperative and operative variables revealed only a pedicled left internal thoracic artery to be associated with a 20% or more reduction in left-to-right sternal activity ratio (odds ratio, 100; 70% confidence limits, 22-465; P = .002). Conclusion: A pedicled left internal thoracic artery graft to the left anterior descending artery reduces blood flow to the left side of the sternum during the acute postoperative period. This does not occur when the left internal thoracic artery is skeletonized. (J Thorac Cardiovasc Surg 1999;118:496-502)

Revascularization of the circumflex artery with the pedicled right internal thoracic artery: Clinical functional and angiographic midterm results

Retroaortic crossing of the pedicled right internal thoracic artery for revascularization of the circumflex artery used in combination with a pedicled left internal thoracic artery anastomosed to the left anterior descending artery and its branches is an attractive technique to achieve an extensive arterial revascularization of the left ventricle. However, there is a suspicion that pulling the right internal thoracic artery through the transverse sinus could compromise its blood flow capacity and patency. Between January 1990 and July 1994 this technique was applied in 256 patients (202 men, 54 women; average age 62 years, range 31 to 80 years). Sixty-one patients had two-vessel disease and 195 had three-vessel disease. Seventeen patients were undergoing a reoperation. Twenty-two had a left ventricular ejection fraction of 40% or less. Thirty had diabetes. Twenty-eight had morbid obesity. The right internal thoracic artery was directed to the circumflex artery (259 anastomoses) through the transverse sinus and the left internal thoracic artery was anastomosed to the left anterior descending artery and its branches (375 anastomoses) in all patients. The 195 patients with three-vessel disease received additional coronary artery bypass grafts to the right coronary artery (93 saphenous vein grafts, 89 free inferior epigastric artery grafts, 12 pedicled right gastroepiploic artery grafts). In total, the 256 patients received 833 distal anastomoses (average 3.2, maximum 5 per patient) and 634 distal anastomoses were internal thoracic artery anastomoses (average 2.4, maximum 4 per patient). Three patients died early and eight had a nonfatal myocardial infarction. Seven patients needed postoperative intraaortic balloon pump support. Six patients underwent early reoperation because of excessive bleeding. Sternal dehiscence occurred in four patients. One of these four patients died of the complication 10 months after the operation. No patient was lost to follow-up (average 33 months). During follow-up, two sudden deaths and six noncardiac deaths occurred. Two patients had a nonfatal myocardial infarction and 12 had recurrence of angina. There were no late reoperations. One patient underwent a successful percutaneous balloon angioplasty of a native left anterior descending artery. Seventy-four patients, enrolled in prospective angiographic studies, underwent a postoperative recatheterization (average 13.2 months, range 6 to 58 months). Seventy-three of the 74 right internal thoracic artery grafts were patent. In comparison, 74 of 74 of the left internal thoracic artery grafts (106/107 anastomoses) were patent. Maximal stress thallium-201 scintigraphy results, obtained in 25 of those patients, did not reveal ischemia in the area of the circumflex artery. Extensive arterial revascularization of the left ventricle by means of both pedicled internal thoracic arteries can be done with acceptable mortality and morbidity. The midterm patency rate of the pedicled right internal thoracic artery when passed through the transverse sinus for bypassing the circumflex artery is excellent and does not differ from the patency rate of the left internal thoracic artery anastomosed to the left anterior descending artery. (J T HORAC C ARDIOVASC S URG 1995;110:1338-43)

Anomalous origin of the left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery To the Editor: In a recent article in this JOURNAL, Tashiro and colleagues I reported their use of a new technique to restore a dual coronary system for repair of anomalous origin of the left coronary artery from the pulmonary artery in two adult patients. The repair entails transection and reanastomosis of the pulmonary trunk, as well as creation of a new left main coronary artery with anastomosis to the aorta, and mandates aortic crossclamping and cardioplegic arrest. Although we agree that teleologic supposition would favor restoration of a two coronary system in this setting, we nonetheless submit that this technique, although innovative, may be unnecessarily complex. We believe comparable results can be effected by conventional revascularization techniques. A 66-year-old man was admitted to an outside hospital with the recent onset of exertional dyspnea. Workup at that institution revealed evidence of a sinus arrhythmia for which the patient underwent insertion of a permanent transvenous VVI pacemaker. Over the subsequent 2 years, the patient continued to have worsening dyspnea and was transferred to our institution after requiring hospitalization for an exacerbation of congestive heart failure. Cardiac catheterization demonstrated an anomalous origin of the left coronary artery from the pulmonary artery with collateral flow from a massively dilated right coronary artery. At operation, the proximal 3 em of the right coronary artery was severely calcified and the left anterior descending artery measured approximately 8 mm in its mid portion. Repair included two-layer closure of a 12 mm fistulous opening from within the pulmonary artery and bypass grafting of the mid portion of the left anterior descending artery with the pedicled left internal thoracic artery. This repair was easily accomplished in a moderately hypothermic fibrillating heart vented through the open pulmonary artery, with a brief period of local occlusion for the arterial anastomosis. The postoperative course was uneventful and the patient remains well 16 months later. The technique proposed by the authors may, indeed, be advantageous in infants and small children, in whom size constraints may preclude effective internal thoracic artery grafting. However, for the rare patient in whom this anomaly becomes manifest in adult life, closure of the fistula with arterial grafting of the left anterior descending artery would seem to be considerably less complicated. As described here, we purposely wanted the aorta unclamped while closing the fistula to ensure complete obliteration and to avoid maldistribution of antegrade infusion of cardioplegic solution into the aortic root. Alternatively, cardioplegic solution could have been given retrograde or after fistula closure. Regardless of the myocardial protective strategy, we maintained the advantage of a two coronary system without need for prosthetic material or concern over the longevity of saphenous vein bypass grafting.