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Ann Thorac Surg 1996;62:947-949
© 1996 The Society of Thoracic Surgeons
Cardiovascular Surgery Unit, Hôpital de la Tour, 1 Bis Ave Jacob-D Maillard 1217 Meyrin-Genève Switzerland
To the Editor:
We read with great interest the article by Antona and associates [1] on the angiographic follow-up of recycled mammary grafts. The necessity of reusing mammary grafts because of lack of graft material has already been stressed by Noyez and Lacquet [2], and this recent report brings angiographic proof of the plausibility of recycling. Our own experience and favorable results with patent functioning mammary grafts [3] in redo coronary operations has encouraged us to also recycle these grafts when they are malfunctioning or repair the vessels dependent on them to improve distal perfusion.
We have had three particular circumstances in which we have done so with left internal mammary artery (LIMA) grafts. The particularities of each case illustrate the variety of possibilities that may be encountered.
The first patient was a 48-year-old man who had bilateral mammary grafts implanted-the LIMA to the left anterior descending artery (LAD) and the right internal mammary artery to the circumflex through the transverse sinus-3 years previously. Angiographic evaluation after recurrence of angina showed occlusion of the right internal mammary artery with a tight stenosis of the circumflex artery and occlusion of the distal LAD with a widely patent mammary graft. At operation, a venous graft to the circumflex artery was placed and an open endarterectomy of the LAD performed from the anastomosis of the mammary artery to the apex of the heart and closed with a venous patch. The postoperative course was uneventful. The 3-year postoperative follow-up continues to demonstrate absence of ischemia.
The second patient was a a 74-year-old man in whom unstable angina developed 9 years after bilateral mammary artery grafts to the LAD and right coronary artery. Coronary angiography showed progression of coronary disease on the circumflex and right coronary arteries, occlusion of the right internal mammary artery to the right coronary artery, and a subtotal anastomotic stenosis of the LIMA graft to the proximal LAD. This patient had poor-quality venous material at redo operation, and after both greater saphenous veins were harvested, an insufficient length of suitable vein grafts was available for complete revascularization. Three venous grafts were performed to the circumflex and posterior descending arteries. The LIMA was dissected extensively and ligated just proximal to the anastomosis to the LAD; it was reimplanted 15 mm distally after flow was checked. The patient had an uneventful recovery and is asymptomatic 11 months after the redo operation.
The third patient was a 78-year-old man with severe exertional angina 10 years after triple venous bypass grafting. At the initial operation, the LIMA was taken down but not used by the surgeon, being judged as too small. It was found intact inside the pericardium at the redo operation. Flow was evaluated after transection and found to be adequate, and this LIMA was then implanted on the LAD 12 years after it had been harvested. Two venous bypass grafts were performed as well to the obtuse marginal and posterior descending arteries. The patient had a difficult initial postoperative course but had no demonstrable perioperative infarct. Follow-up by thallium stress testing showed no anterior ischemia 7 months after the redo operation.
We have no postoperative angiographic studies of these 3 patients, because in all 3 the clinical and noninvasive follow-up is satisfactory.
We believe these three particular situations should be recognized among the numerous and sometimes odd situations facing a surgeon at redo operations. The successful use of recycled mammary artery grafts in these examples encourages us to pursue this policy whenever possible.
References
Department of Cardiac Surgery, University of Milan, Centro Cardiologico, Fondazione I Monzino, Via Parea, 4 20138 Milano Italy
To the Editor:
We thank Dr Velebit and Dr Maurice for their comments about our article. Their experience is additional proof that recycling of the mammary artery graft is at least a feasible and safe technique that can be considered whenever there is a previously implanted and distally stenotic internal mammary artery graft at a redo coronary procedure. In this way more patients may be able to benefit from the advantages of the use of more arterial than venous grafts during redo myocardial revascularization procedures, even when the mammary arteries have been previously implanted. Until now, we have successfully recycled 11 mammary arteries; in only 1 case we had to perform an additional saphenous vein graft to the same coronary target left anterior descending artery because we were not sure of the adequacy of the flow of the recycled mammary artery. All the postoperative angiograms have shown good patency of the recycled arteries.
Our experience, like the experience of Dr Velebit and Dr Maurice and like the previous report of Dr Noyez and Dr Lacquet [1], shows that this procedure can be performed with low risks. In addition, the good clinical results obtained, together with the well-known patency rates of the mammary artery grafts, support the continuation of the procedure when it is feasible, even if more clinical experiences and more postoperative angiographic studies are needed to establish the long-term results of this procedure.
Reference
Department of Thoracic and Cardiac Surgery University Hospital Nijmegen, St. Radboud Postbus 9101,Geert Grooteplein Zuid 10, 6500 Hb Nijmegen, the Netherlands
To the Editor:
In the article by Antona and associates [1] the angiographic patency of recycled internal mammary artery (IMA) grafts is documented. Also, the 3 patients described in the letter by Velebit and Maurice show the possibility of reusing IMA grafts. Of course, recycling of IMA grafts requires surgical "creativity" and can be helpful in a selected number of reoperations. In a previous report [2], we described our first 5 patients, and until now we have 15 patients in whom we reused the IMA graft. Mostly the patent left IMA-to-left anterior descending artery graft was taken down and this graft anastomosed to a branch of the circumflex coronary artery, and the right IMA was anastomosed to the left anterior descending artery.
In my opinion, the challenge is not the dissection of the IMA pedicle itself, but the identification of this pedicle and myocardial protection of the IMA-dependent myocardium during the reoperation. In our practice we begin cardiopulmonary bypass as soon as possible, and perform the dissection of the heart with an empty beating heart. The IMA pedicle is identified by the entrance in the pericardium. Then we clamp the IMA graft and the aorta, and begin retrograde delivery of blood cardioplegia. The further dissection of the heart and the IMA pedicle is performed on an asystolic heart [3]. Most lesions of the IMA pedicle are the result of incorrect identification of the IMA [3, 4]. The proposed pericardial Gore-Tex membrane (W.L. Gore & Associates, Flagstaff, AZ) can be useful for identification; however, the use of an IMA graft at a primary operation does not increase the surgical risk of reoperation [4], and one of the most difficult recyclings of an IMA graft I have seen was in a patient in whom a Gore-Tex soft tissue patch (W.L. Gore & Associates) was used to close the pericardium and wrapped around the IMA pedicle. At reoperation, the identification of the pedicle was not the problem, but the patch was, because it was shrunken and the dissection of the IMA out of this patch was technically difficult.
With the increasing use of IMA grafts in primary operations, and the increasing number of coronary reoperations, surgeons will become familiar with the challenge of the patent IMA graft and also with the possibility of recycling IMA grafts. It must, however, be clear that the placement of the IMA pedicle at the primary operation is essential for the reoperation [3, 4].
References
This article has been cited by other articles:
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  M. Pasic, P. Muller, P. Bergs, I. Karabdic, W. Ruisz, M. Hofmann, and R. Hetzer Reimplantation of a left internal thoracic artery during repeat coronary artery revascularization: Early and midterm results J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 1180 - 1182. [Full Text] [PDF]
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 P. H. Noirhomme, M. J. Underwood, G. A. El Khoury, D. Glineur, B. Elias, Y. d'Udekem, and R. A. Dion Recycling of arterial grafts during reoperative coronary artery operations Ann. Thorac. Surg., March 1, 1999; 67(3): 641 - 644. [Abstract] [Full Text] [PDF]
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