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Ann Thorac Surg 1996;61:702-705
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Midterm Angiographic Study of Five Recycled Mammary Arteries During Four Coronary Redos

Department of Cardiac Surgery, University of Milan, Milano, Italy

Accepted for publication October 21, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Recently the technical feasibility of reusing the left internal mammary artery (IMA) in coronary artery reoperation has been documented, but the patency of ``recycled'' IMAs has not yet been established.

Methods. In 4 patients undergoing coronary reoperation, five internal mammary arteries (3 left IMAs and 2 right IMAs) that were patent but severely stenotic at the anastomotic site were taken down and reused. In 2 cases the IMAs were reanastomosed to the same target coronary artery, in 2 cases the IMAs were rerouted to another coronary artery, and in 1 case an interposition of a short segment of the greater saphenous vein was needed to reach the target coronary artery.

Results. Angiographic midterm evaluation, performed between 7 and 35 months postoperatively, showed patency of all the reused grafts without stenoses.

Conclusions. When feasible, recycling of the IMAs may be considered if one or both IMAs have been previously used and are stenotic in the perianastomotic area, or when there is a stenosis in the native coronary artery distal to the anastomosis itself.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 705.

Redo coronary artery bypass procedures represent an increasing proportion of coronary revascularizations relative to primary operations [1]. The increasing number of patients in whom one or both internal mammary arteries (IMAs) were used at their first operation raises the problem of lack of availability of the bypass conduits with the highest long-term performance at redo operation. Barner and Barnett [2] have shown excellent patency of the IMA grafts in a small group of patients who had catheterization in the 15- to 21-year interval after operation, but long-term patency of alternative arterial bypass conduits has not yet been determined [3].

A recently published experience has documented the technical feasibility of reusing the left IMA (LIMA) in coronary artery reoperation [4], but the patency of ``recycled'' IMAs has not yet been established. In this article we describe a midterm angiographic evaluation of five IMAs that were reused during four coronary artery reoperations.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patient Population
Between January 1990 and December 1993 we performed 78 coronary reoperations. In 10/78 cases (12.8%) at least one IMA had been used in a previous revascularization procedure: in 8 patients (10.3%) the LIMA was used at first intervention, in 1 patient (1.3%) the right IMA (RIMA) had been previously used, and in 1 patient (1.3%) both IMAs had already been used. In 4 of these patients coronary angiography before the repeat procedure disclosed five patent but severely stenotic IMAs (3 LIMAs and 2 RIMAs) at the anastomotic site. Two of the three stenotic LIMA grafts had been anastomosed to the left anterior descending artery, and the remaining one to the obtuse marginal artery. One of the two RIMAs was anastomosed to the right coronary artery, and the other to the posterior descending artery at the crux cordis. All five grafts had been used as ``in situ'' or pedicled grafts, and there were no proximal stenoses. Recycling of these arteries at reintervention therefore seemed feasible.

In 2 patients the decision to reoperate was based on the angiographic demonstration of graft failure, probably due to technical errors (Table 1, patients 1 and 2), whereas in the remaining 2 patients there was both progression of the native coronary artery disease and graft failure. Using the Canadian Cardiovascular Society angina classification, 2 patients were in functional class III and 2 in class IV. Three patients were at their first reintervention, whereas 1 patient had had two previous cardiac operations. Their mean age at reoperation was 50 ± 13 years, and the interval between the operations was 14 ± 15 months. Two patients had previously had an acute myocardial infarction (in 1 it was perioperative), and the average angiographic ejection fraction was 0.47 ± 0.07.

Whenever possible we prefer to dissect the anterior and lateral surfaces of the heart without the use of cardiopulmonary bypass and without cardioplegia administration, for two reasons: (1) to minimize aortic cross-clamp and cardiopulmonary bypass times and (2) to facilitate the position of the pedicle of the IMAs by identifying the site of the distal anastomosis and by palpating the pulsation of the artery during careful dissection toward their proximal origin from the subclavian arteries. Nevertheless, we were ready to start if hemodynamic deterioration of the patient occurred, or in cases of tearing of the heart. Cardiopulmonary bypass was then started, the ascending aorta and the dissected IMAs were clamped, and cold (4°C) crystalloid antegrade and retrograde cardioplegia (1,000 mL) was administered and reinfused retrogradely (500 mL) every 20 minutes. After aortic cross-clamping and cardioplegia administration the dissection of the inferior surface of the heart was completed. Even when some of the dissection of the anterolateral surface of the heart and of the IMAs requires aortic cross-clamping and cardioplegia administration, great effort is made to obtain sufficient length of the IMA for clamping before cardioplegia administration.

Coronary arteries were exposed and the length of the IMA was carefully evaluated to assess the technical feasibility of the anastomosis. If the length of the IMA was inadequate, it was rerouted to another coronary artery (patient 2) or a short segment of the greater saphenous vein (GSV) was interposed (patient 2).

Distal arterial anastomoses were performed with a running 8-0 polypropylene stitch with the ``parachute'' technique, whereas for distal vein anastomoses a running 7-0 polypropylene was employed. Proximal anastomoses were performed with a partial or total occluding clamp.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
As shown in Table 1, of the three recycled LIMAs, one (patient 2) was reanastomosed to the left anterior descending artery with the interposition of a GSV segment, another one (patient 3) was transposed from an obtuse marginal branch to a left anterior descending artery in which a significant stenosis had subsequently developed (and the right gastroepiploic artery was used for the anastomosis with the obtuse marginal branch), and the third LIMA (patient 4) was used to reconstruct the stenotic anastomosis to the left anterior descending artery. Of the recycled RIMAs, one (patient 1) was used to revascularize the right coronary artery at the same level, whereas the other one (patient 2), which had been previously anastomosed to the posterior descending artery, was anastomosed on native right coronary artery to avoid excessive tension on the anastomosis, and the posterior descending artery was revascularized with a GSV graft.

The postoperative course was uneventful; no patient had enzymatic or electrocardiographic evidence of perioperative myocardial infarction. All patients had early (within 15 days) graft reinvestigation, which showed patency without stenoses of all five IMA grafts.

Follow-up ranged from 10 to 48 months; all patients are alive with no recurrent angina, and all underwent a maximal ergometric test with no evidence of residual ischemia. In addition, all patients were submitted to late graft reinvestigation at an interval ranging from 7 to 35 months postoperatively; the patency of the reused grafts and the absence of anastomotic stenoses were confirmed without angiographic demonstration of arteriosclerotic lesions (Figs 1, 2).

View larger version (83K): [in this window] [in a new window]   Fig 1. . (Patient 1.) (A) Preoperative angiogram showing a severe stenosis of a right internal mammary artery graft to right coronary artery in the perianastomotic area. The arrow indicates the right internal mammary artery perianastomotic stenosis. (B) Postoperative angiogram of the recycled right internal mammary artery.

View larger version (56K): [in this window] [in a new window]   Fig 2. . (Patient 4.) (A) Preoperative angiogram showing a severe anastomotic stenosis (arrow) of a left internal mammary artery graft to the left anterior descending coronary artery. (B) Postoperative angiogram of the recycled left internal mammary artery.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

When one or both IMAs have been used in a previous coronary bypass procedure, and there is a significant stenosis at the perianastomotic level or distal to the anastomosis itself, should we look at alternative arterial bypass conduits, or should we try to recycle these previously employed grafts? What is the fate of a reused IMA graft?

These problems will occur more frequently as the population of patients with IMA grafts previously employed and requesting a redo coronary procedure continues to increase, challenging the surgeon's technical skill and creativity. On the basis of our initial experience we make the following observations: (1) The recycling of one IMA that has been previously employed is technically feasible, although demanding, even if the LIMA, the RIMA, or both have formerly been used; in all cases in which it was planned, we were able to dissect the pedicle and to obtain a length sufficient to reach the heart again. (2) Even if we have been able to obtain an IMA pedicle long enough to reach the heart in each case, sometimes the anastomosis of the salvaged graft on the same coronary artery may cause excessive tension on the anastomosis itself (both the IMAs of patient number 2); in these cases the ``short'' IMA can be rerouted to a more accessible coronary artery that needs revascularization, or it can be elongated with an interposition of GSV or with other arterial conduits. We chose to elongate IMA with a short segment of the GSV to preserve the remaining arterial grafts for a subsequent reintervention because we were afraid of the eventual lack of arterial conduits in this cohort of relatively young patients, even if the use of the GSV may itself increase the risk of atherosclerosis of the graft. (3) Our initial experience suggests that preoperative patency of the IMA to be recycled has to be accurately demonstrated, as does the absence of stenoses along its course, except for the distal and perianastomotic area; in addition, preoperative angiography of the IMA may be helpful for location of the IMA pedicle at operation. (4) It is very encouraging that all the recycled grafts were patent without stenoses at follow-up.

Recycling of IMA grafts previously employed is a technical option that can be helpful in selected patients who need repeat coronary artery procedures, when one or both IMAs have been previously used and are stenotic in the perianastomotic area, or when there is a stenosis in the native coronary artery downstream to the anastomosis itself. The patency rate that we showed in this small cohort of patients supports the continuation of this procedure, even if more clinical experience is needed to draw definitive conclusions.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Parolari, Department of Cardiac Surgery, University of Milan, Centro Cardiologico, Fondazione I Monzino IRCCS, Via Parea, 4, 20138, Milano, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Salomon NW, Page US, Bigelow JC, Krause AH, Okies JE, Metzdorff MT. Reoperative coronary surgery. Comparative analysis of 6591 patients undergoing primary bypass and 508 patients undergoing reoperative coronary artery bypass. J Thorac Cardiovasc Surg 1990;100:250–60.[Abstract]
2. Barner HB, Barnett MG. Fifteen– to twenty-one–year angiographic assessment of internal thoracic artery as a bypass conduit. Ann Thorac Surg 1994;57:1526–8.[Abstract/Free Full Text]
3. ACC/AHA guidelines and indications for coronary artery bypass surgery. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Grafting). Circulation 1991;83:1125–73.[Free Full Text]
4. Noyez L, Lacquet LK. Recycling of the internal mammary artery in coronary reoperation. Ann Thorac Surg 1993;55:597–9.[Abstract/Free Full Text]
5. Cosgrove DM, Loop FD, Lytle BW, et al. Predictors of reoperation after myocardial revascularization. J Thorac Cardiovasc Surg 1986;92:811–21.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlo Antona Alessandro Parolari Marco Zanobini Vincenzo Arena Paolo Biglioli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Antona, C. Articles by Biglioli, P. Search for Related Content PubMed PubMed Citation Articles by Antona, C. Articles by Biglioli, P. Related Collections Related Article