Ann Thorac Surg 1996;61:1242-1244
© 1996 The Society of Thoracic Surgeons
Case Report
Flow Reserve Capacity of Left Internal Thoracic Artery 23 Years After Vineberg Procedure
Michihiro Nasu, MD,
Takashi Akasaka, MD,
Hiroaki Chikusa, MD,
Toyo Shoumura, MD
Department of Cardiovascular Surgery and Cardiology, Kobe City General Hospital, Kobe, and Department of Acute Medicine, Mie Medical College, Tsu, Mie, Japan
Accepted for publication September 20, 1995.
 |
Abstract
|
|---|
Graft flow volume and flow reserve were assessed by Doppler echocardiography 23 years after a Vineberg left internal thoracic artery implantation. Angiography showed good patency of the left internal thoracic artery, and the flow velocity profile was as biphasic as that of the coronary circulation. Drug-stressed test showed a physiologic reactivity of the Vineberg left internal thoracic artery but less response than that of a directly anastomosed left internal thoracic artery.
|
Introduction
|
|---|
In the previous review article in this journal, Shrager [1] reminded us of the Vineberg procedure as the forerunner of coronary artery bypass grafting. When most young cardiac surgeons learn this procedure, they raise doubts about the reproducibility and clinical effectiveness of this relatively crude operative technique. However, a certain group of patients were certainly relieved of intractable anginal symptoms [2]. This article describes graft flow volume and flow reserve in a patient who received a Vineberg left internal thoracic artery (LITA) graft 23 years ago.
A 38-year-old male patient underwent Vineberg LITA implantation on December 2, 1969, for complete obstruction of the left anterior descending artery. Although he had complained of effort angina for 1
years after operation, he has passed a normal life without angina since that time.
Twenty-three years after the operation, he was admitted to our hospital with silent ischemia, which was associated with ST depression at V4–6 during treadmill-stressed electrocardiogram. Coronary angiography showed complete occlusion at the just-proximal segment of the left anterior descending coronary artery and 50% stenosis at the midportion of the right coronary artery. Injection of the LITA with contrast medium showed its good patency and fair collateralization to the diagonal branch and the distal segment of the left anterior descending coronary artery (Fig 1
). The diameter of the LITA is 2.3 mm at the midportion. After angiography, velocimetry measurement of the LITA using Doppler echocardiography was carried out in the same manner as previously reported [3]. The flow pattern of the LITA is biphasic and the diastolic component is extremely predominant over the systolic one (see Fig 1). This flow pattern is completely the same as that of not only a directly anastomosed LITA [3] but also the coronary circulation. The calculated flow volume at the midportion of the graft is 24.3 mL/min. To evaluate the graft flow reserve, dipyridamole, 0.56 mg/kg body weight, was administered intravenously over 4 minutes. Five minutes after infusion, graft flow increased to 38.3 mL/min, which is 1.6 times as much as the basal flow (Fig 2). The patient continues to be maintained on a medical program because his coronary lesion is single-vessel disease with normal cardiac function and because of the rich collateralization from the Vineberg LITA.
View larger version (82K):
[in this window]
[in a new window]
|
Fig 1. . The Vineberg left internal thoracic artery is well patent and its diameter is 2.6 mm at the proximal portion, 2.3 mm in the middle, and 2.3 mm at the distal portion. At each position the flow velocity profile is biphasic and the diastolic component is predominant over the systolic one in the same manner as in the coronary system.
|
|
View larger version (56K):
[in this window]
[in a new window]
|
Fig 2. . (A) The calculated flow volume of the Vineberg left internal thoracic artery is 24.3 mL/min during the resting state. (B) Five minutes after intravenous administration of dipyridamole, 0.56 mg/kg body weight, the graft flow increases up to 38.3 mL/min, which is 1.6 times as much as the basal flow.
|
|
|
Comment
|
|---|
A few articles have shown late patency of an LITA that had been used in the Vineberg procedure [4]. There is little information, however, about the capability of a late Vineberg graft to transport blood into cardiac muscle. In our previous report, flow in the LITA graft, which was directly anastomosed to a left anterior descending coronary artery with more than 90% stenosis, averaged 34 mL/min [3]. Compared with this number, the Vineberg LITA graft in the present case can transport 0.7 times as much blood as a directly anastomosed LITA. Akasaka and associates [5] reported that the flow reserve of the directly anastomosed LITA averaged 2.6 times the basal flow late after operation, whereas that of the Vineberg LITA in our case was 1.6 times the basal flow. Therefore, the Vineberg LITA graft possesses the capability for transporting blood to the coronary system, but with slightly less response to drug stress than a directly anastomosed LITA. Shrager [1] commented that the pendulum swung from one extreme to the other in the history of coronary revascularization and Arthur Vineberg was caught in the middle, and our present data support his conclusion.
|
Footnotes
|
|---|
Address reprint requests to Dr Nasu, Department of Thoracic and Cardiovascular Surgery, Kobe City General Hospital, 4-6, Minatojima-Nakamachi, Chuo-ku, Kobe, Hyogo, 650, Japan.
|
References
|
|---|
- Shrager JB. The Vineberg procedure: the immediate forerunner of coronary artery bypass grafting. Ann Thorac Surg 1994;57:1354–64.[Abstract]
- Favaloro RG, Effler DB, Groves LK, Fergusson DJG, Lozada JS. Double internal mammary artery–myocardial implantation: clinical evaluation of results in 150 patients. Circulation 1968;37:549–55.[Abstract/Free Full Text]
- Nasu M, Akasaka T, Okazaki T, et al. Postoperative flow characteristics of left internal thoracic artery grafts. Ann Thorac Surg 1995;59:154–62.[Abstract/Free Full Text]
- Hayward RH, Korompani FL, Knight WL. Long-term follow-up of the Vineberg internal mammary artery implant procedure. Ann Thorac Surg 1991;51:1002–3.[Abstract]
- Akasaka T, Yoshikawa J, Yoshida K, et al. Flow capacity of internal mammary artery grafts: early restriction and late improvement assessed by Doppler guide wire: comparison with saphenous vein grafts. J Am Coll Cardiol 1995;25:640–7.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
P. Katrapati and J. C. George
Vineberg Operation: A Review of the Birth and Impact of This Surgical Technique
Ann. Thorac. Surg.,
November 1, 2008;
86(5):
1713 - 1716.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Marx, T. W. Jax, M. Kelm, F. C. Schoebel, and B. E. Strauer
Vineberg graft: flow reserve of bilateral implantation after 27 years
Ann. Thorac. Surg.,
January 1, 2001;
71(1):
341 - 343.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
