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Ann Thorac Surg 1997;63:706-708
© 1997 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Low-Grade Intimal Hyperplasia in Internal Mammary and Right Gastroepiploic Arteries as Bypass Grafts

Jacques A. M. van Son, MDPhD, Volkmar Falk, MD, Thomas Walther, MD, Frank M. Smedts, MDPhD, Friedrich W. Mohr, MD

Herzzentrum, University of Leipzig, Leipzig, Germany

Accepted for publication October 10, 1996.


   Abstract
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 Abstract
Introduction
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Background. Knowledge is limited regarding the histology of the internal and right gastroepiploic arteries that have been functioning as coronary artery bypass conduits.

Methods. Four internal mammary arteries, 3 right gastroepiploic arteries, and 1 saphenous vein graft that had been functioning as coronary artery bypass grafts were harvested and examined histologically in 3 male patients who had died at 19, 38, and 47 months after coronary revascularization.

Results. All grafts were patent. The mean thicknesses of the intima in the proximal, middle, and distal segments were 41.0, 31.8, and 25.8 µm for the internal mammary artery and 58.0, 40.3, and 34.3 µm for the right gastroepiploic artery. The saphenous vein graft showed severe focal atherosclerosis.

Conclusions. This histologic study in a small number of patients corroborates the reported excellent patency rates at medium- to long-term follow-up of the internal mammary and right gastroepiploic arteries used as coronary artery bypass grafts.


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See also page 708a.

The internal mammary artery (IMA) has an excellent track record as a coronary artery bypass graft, with patency rates beyond 10 years in the 90% range [1]. A similar (although early) patency rate has been reported for the right gastroepiploic artery (GEA) [2]. Recent histologic studies of the IMA and GEA obtained at autopsy documented only mild intimal hyperplasia in both vessels, with the media in both vessels being structurally different, that is, alternating elastomuscular and elastic in the IMA versus muscular in the GEA [3–5]. Thus far, knowledge is limited regarding the histology of IMAs and GEAs that have been functioning as coronary artery bypass conduits.


   Material and Methods
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During the last 5 years, 4 IMAs (3 left and 1 right), 3 GEAs, and 1 venous conduit were harvested at autopsy in 3 male patients (Table 1Go). The conduits had been functioning as coronary artery bypass grafts for 19, 38, and 47 months. In 2 patients, the cause of death was end-stage malignancy: 1 patient died of colonic carcinoma 9 months after hemicolectomy, and the second patient died of malignant melanoma originating from the upper back 4 months after surgical excision of the lesion. Neither of the patients had been treated with chemotherapeutic agents. The third patient died secondary to an automobile accident. Associated conditions consisted of moderate pulmonary emphysema in the first 2 patients and mild diabetes mellitus in the last patient.


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  		Table 1. . Clinical and Histologic Data
 
At autopsy, the 2 patients who died of end-stage malignancy had marked pulmonary edema and secondary dilation of the right ventricle. Otherwise, besides three-vessel coronary atherosclerosis and varying degrees of myocardial scarring, the hearts were normal. The patient who was involved in an automobile accident had died of a rupture of the thoracic aorta at the level of the isthmus. In addition, the anterior surface of the heart showed a 4 x 6-cm hematoma.

The arterial and venous conduits were carefully dissected. In all grafts patency was demonstrated by injection of dye solution into the proximal segment of the various conduits and observation of efflux of solution through an incision in the target coronary artery distal to the anastomosis. Subsequently, after having been processed, the conduits were laminated in consecutive transverse sections at intervals of 1 cm, embedded in paraffin wax, prepared in 4-µm sections, and stained. The thickness of the intima was subsequently measured at four random locations per section and a mean value calculated.


   Results
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In all IMA and GEA conduits there was mild intimal hyperplasia (Figs 1A, 1BGoGo) with a mean thickness of the intima in the proximal, middle, and distal segments of 41.0, 31.8, and 25.8 µm for the IMA and 58.0, 40.3, and 34.3 µm for the GEA, respectively (see Table 1Go). In contrast, in the only venous conduit in this study, there was marked intimal hyperplasia (mean intimal width in the proximal, middle, and distal segments of 82, 65, and 58 µm, respectively) with focally severe atherosclerosis (Fig 1CGo).



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  		Fig 1. . (A) Distal left internal mammary artery after having served as a conduit to the left anterior descending coronary artery for 47 months. Note multiple elastic lamellae in elastomuscular media and low-grade intimal hyperplasia. (B) Distal right gastroepiploic artery anastomosed to the right coronary artery in same patient. Note muscular media and mild degree of intimal thickening. (C) Saphenous vein after having served as an aortocoronary bypass graft to the circumflex coronary artery for 38 months. Note severe focal atherosclerosis, resulting in near occlusion of graft. (Elastin-trichrome stain; A and B, x150 before 28% reduction; C, x50 before 7% reduction.)

 

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In previous histologic studies we have documented a low tendency toward intimal hyperplasia in the native IMA and GEA [3–5]. In this study, postmortem histologic examination of 4 IMAs and 3 GEAs that had functioned as coronary artery bypass grafts for 19, 38, and 47 months demonstrated only mild intimal hyperplasia in all IMA and GEA specimens. These data, albeit in a small number of patients and with limited follow-up, corroborate, on a histologic basis, the reported excellent patency rates, based on angiographic studies, for the IMA and the GEA as bypass grafts in myocardial revascularization [1, 2]. We anticipate that use of the IMA and GEA as in situ grafts (as opposed to free grafts), thus protected by retention in their usual physiologic environment, may delay the development of intimal thickening. The IMA may have additional protection against intimal thickening by means of the multiple elastic lamellae in its media [3, 4]. Future histologic studies of both in situ and free IMAs and GEAs after long-term function as coronary bypass grafts may reveal the potential influence of absence or presence of a proximal aortic anastomosis and architecture of the media (elastic versus muscular) on the development and rate of development of intimal hyperplasia.


   Footnotes
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Address reprint requests to Dr van Son, Herzzentrum, University of Leipzig, Russenstraße 19, 04289 Leipzig, Germany.


   References
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 References
 

  1. Cameron A, Davis KB, Green G, Schaff HV. Coronary bypass surgery with internal thoracic grafts: effect on survival over a 15 year period. N Engl J Med 1996;334:216–9.[Abstract/Free Full Text]
  2. Grandjean JG, Boonstra PW, den Heyer P, Ebels T. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309–16.[Abstract/Free Full Text]
  3. Van Son JAM, Smedts F, Vincent JG, van Lier HJJ, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:703–7.[Abstract]
  4. Van Son JAM, Smedts F, de Wilde PCM, et al. Histological study of the internal mammary artery with emphasis on its suitability as a coronary artery bypass graft. Ann Thorac Surg 1993;55:106–13.[Abstract]
  5. Van Son JAM, Smedts FM, Yang C-Q, et al. Morphometric study of the right gastroepiploic and inferior epigastric arteries. Ann Thorac Surg 1997;63:709–15.[Abstract/Free Full Text]



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This Article
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