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Ann Thorac Surg 1997;63:1759-1764
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Persistence of Mammary Artery Branches and Blood Supply to the Left Anterior Descending Artery

Division of Cardiology, Pescara, and Department of Cardiac Surgery, University "G. D'Annunzio," Chieti, Italy

Accepted for publication January 16, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
Background. Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery.

Methods. Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 µg) was injected and the average peak velocities before and after injection were calculated.

Results. The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 ± 7 and 26 ± 5 cm/sec, respectively, in group A versus 27 ± 5 and 25 ± 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 ± 0.3 in group A versus 0.69 ± 0.3 cm/s in group B; p = NS), but not distally (1.72 ± 0.1 in group A versus 0.97 ± 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 ± 0.6 and 2.5 ± 0.3 cm/s, respectively, in group A versus 2.6 ± 0.5 and 2.6 ± 0.3 cm/s, respectively, in group B; p = NS).

Conclusions. The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
See also page 1764.

The left internal mammary artery (LIMA) is the graft of choice for the left anterior descending artery (LAD) because its long-term patency rate is statistically higher than that of the saphenous vein [1, 2]. Moreover, the LIMA-to-LAD graft was found to be the major determinant of long-term survival after surgical myocardial revascularization [1].

Recently, the possibility of grafting the LIMA to the LAD through a left thoracotomy, to reduce surgical invasiveness and postoperative hospitalization and to increase the patient's comfort, was reported [3–6]. The LIMA can be harvested partially under direct vision or completely using a thoracoscope [4, 5], and the incision can be modified (anterior mediastinotomy) [3]. Our experience was reported recently [7] and involved a left anterior small thoracotomy. The LIMA was harvested only for the length necessary to reach the LAD, usually 4 to 6 cm, but sometimes up to 10 cm. Although it is simple, effective, and reproducible, this technique can be criticized because of the persistence of LIMA branches. Even though reports on inadequate flow to the LAD resulting from the persistence of undivided LIMA branches are anecdotal [8–10], many surgeons are afraid to leave patent LIMA branches. The term "steal syndrome" often is used to define this situation. To have a steal syndrome, however, reverse flow from the LAD to the LIMA must occur [11, 12], so the term may be a misnomer. In any case, the phenomenon is rare, its incidence being estimated at about 0.4% [13].

See also 1765.

To evaluate the influence of persisting LIMA branches on LAD blood supply, we studied blood flow patterns and flow reserve in two groups of patients, those in whom the LIMA had been completely harvested after a median sternotomy (group A), and those in whom it had been partially harvested after a left anterior small thoracotomy (group B).

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
Thirty patients who had received surgical revascularization of the LAD with the LIMA agreed to undergo a second angiographic study even if they were asymptomatic; each gave written informed consent. Two groups were identified based on complete (group A, n = 15) or partial (group B, n = 15) LIMA harvest. The interval from the operation to the study was similar in both groups (73 ± 13 versus 79 ± 20 days, respectively). Preoperative data are shown in Table 1.

In group B, the LIMA was harvested through a left anterior small thoracotomy only for the length necessary to reach the LAD, and was skeletonized in all patients. The anastomosis was performed on a beating heart using two 8/0 Prolene sutures. The LIMA was never fixed to the epicardium.

	Patient Selection

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
Criteria for inclusion in the study were the presence of a proximal LAD lesion and the absence of wall motion abnormalities in the LAD territory at preoperative angiography; the absence of symptoms and negative results on stress testing; the absence of an anterior wall motion abnormality; the presence of a perfect distal anastomosis; the absence of luminal narrowing in the LAD distal to the anastomosis; and the absence of a wall motion abnormality in any part of the LIMA. Only one patient in each group was excluded because of trivial anastomotic narrowing (less than 20%).

	Cardiac Catheterization and Intramammary Flow Velocity Measurement

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
All patients received diazepam (2 to 4 mg intravenously) as precatheterization medication and 3,000 to 5,000 IU of heparin before introduction of the Doppler guidewire and measurement of the flow velocity. There were no differences in risk factors and no patients had systemic diseases such as immunopathies, immune complex vasculitis, paraproteinemia, or polyglobulia. All patients gave informed consent for the invasive study and all medications were continued as clinically indicated.

Selective coronary angiography and selective LIMA angiography were performed by the femoral approach after local anesthesia with 0.5% lidocaine. The Judkins technique, using hand injection of low-osmolar radiographic contrast media, was used. Vessel diameter was quantified at sites of flow velocity measurement from the cineangiograms using an electronic digital caliber, with the 6F guiding catheter as a known reference diameter, using the on-line analysis system operating on digital images (ACA-DCI; Philips, Eindhoven, the Netherlands) [14].

The Doppler-tipped guidewire was a 0.018-inch (diameter 0.46 mm), 175-cm-long, flexible and steerable wire with a floppy distal end mounting a 12-MHz piezoelectric transducer at the tip (Flowwire, Cardiometrics, Mountain View, CA). The sample volume was positioned at a distance of 5.2 mm from the transducer. At this distance, the sample volume had a width of about 2 mm as a result of the divergent ultrasound beam, a 27-degree arc from the long axis, so that a large part of the flow velocity profile was included in the sample volume. The pulse repetition frequency (17 to 96 kHz) varied with the velocity range selected (50 to 600 cm/s), so that flow velocities up to 6 m/s could be recorded without frequency aliasing. A real-time fast Fourier transform algorithm was used for analysis of the Doppler signal, to increase the readability of the measurement [15]. The frequency response of the system calculated about 90 spectra per second. Simultaneous electrocardiographic and arterial pressure signals also were input to the video display. Digitized spectral velocities from three cardiac cycles were averaged to compute the average peak velocity and the diastolic-to-systolic peak velocity ratio. The Doppler guidewire has been validated for accurate measurement of phasic flow velocity patterns [16, 17]. The bypass conduits Doppler study was acquired at the proximal (proximal third) and distal (distal third or distal to the last intercostal artery for group B) vessels. The data were acquired only after stable selective vessel cannulation was accomplished in all patients and a stable, good flow velocity signal was obtained. Basal blood flow velocity was recorded in all patients about 3 to 5 minutes after the last injection of contrast media.

Maximal bypass flow reserve was calculated as the ratio of average peak velocity after adenosine intramammary bolus administration (12 to 14 µg) to average peak velocity at rest [18–21]. Adenosine was injected at the origin of the LIMA, and the registration site was in the distal third of the LIMA, before the distal anastomosis. Values greater than 2 were considered normal [21]. The pharmacologic effect lasted about 120 seconds. In 15 patients, the physiologic flow pattern in the ungrafted LIMA was studied during the preoperative catheterization and was used as a reference for any further comparison.

According to Doucette's formula [16], blood flow (milliliters per minute) is related directly to the internal size of the vessel and to the average peak velocity. In this study, all patients are compared to themselves. Therefore, LIMA internal size also is a constant. As a consequence, any modification in blood flow velocity (centimeters per second) means an identical modification in blood flow volume (milliliters per minute).

	Statistical Analysis

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
Results are expressed as mean values plus or minus standard deviations unless otherwise indicated. Statistical analysis comparing the two groups was performed with unpaired two-tailed t testing. One-way analysis of variance was used to compare the groups for catheterization, angiographic, and phasic flow data at the proximal and distal segments. A p value of less than 0.05 was considered significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
There was no difference between groups in preoperative data (see Table 1). However, postoperative angiographic findings were dissimilar because the LIMAs in group B had been only partially harvested (Fig 1).

View larger version (124K): [in this window] [in a new window]   Fig 1. . Left lateral projection. Partially harvested left internal mammary artery anastomosed to the left anterior descending coronary artery.

View larger version (88K): [in this window] [in a new window]   Fig 2. . Phasic blood flow velocity of the proximal left internal mammary artery anastomosed to the left anterior descending coronary artery. (A) Group A: a systolic-to-diastolic pattern is present; average peak velocity 28 cm/s, diastolic-to-systolic peak velocity ratio 0.9. (B) Group B: the flow pattern still shows a systolic prevalence; average peak velocity 28 cm/s, diastolic-to-systolic peak velocity ratio 0.7. (S = systolic; D = diastolic.)

View larger version (91K): [in this window] [in a new window]   Fig 3. . Phasic blood flow velocity of the distal left internal mammary artery anastomosed to the left anterior descending artery. (A) Group A: the diastolic flow velocity is prevalent; average peak velocity 27 cm/s; diastolic-to-systolic peak velocity ratio 1.6. (B) Group B: the probe is positioned after the last collateral and before the distal anastomosis. A diastolic-to-systolic pattern is still present; average peak velocity 27 cm/s, diastolic-to-systolic peak velocity ratio 1.0. (S = systolic; D = diastolic.)

View larger version (107K): [in this window] [in a new window]   Fig 4. . Group B: the probe is positioned just before the distal anastomosis. The flow pattern is mainly diastolic; average peak velocity 25 cm/s, diastolic-to-systolic peak velocity ratio 1.9. (S = systolic; D = diastolic.)

View larger version (108K): [in this window] [in a new window]   Fig 5. . Phasic blood flow velocity after adenosine hyperemia induction. The probe is positioned as in Figure 3. (A) Group A (same patient as in Figure 3A): average peak velocity 84 cm/s, diastolic-to-systolic peak velocity ratio 1.8; average peak velocity ratio before and after adenosine injection 3.0. (B) Group B (same patient as in Figure 3B): average peak velocity 75 cm/s, diastolic-to-systolic peak velocity ratio 1.9; average peak velocity ratio before and after adenosine injection 2.8. (S = systolic; D = diastolic.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

The necessity of harvesting the whole length of the LIMA during a conventional operation performed through a median sternotomy is justified first by technical considerations. When the sternum is retracted, the lungs are displaced and the pericardium is opened. The heart drops and the LIMA must be long enough to reach the LAD or a marginal branch, or long enough to perform a sequential anastomosis (diagonal-LAD or other combinations).

To harvest a long LIMA, all the branches (sternal, muscular, and intercostal) must be divided; the persistence of some of the branches (usually the first intercostal or the thoracic lateral branches) is accidental and not part of a routine strategy, but is not a cause of LAD hypoperfusion by itself [23–25]. When the LAD is approached through a left anterior small thoracotomy, the heart remains in its usual position, near the sternum. As a consequence, a totally harvested LIMA is not needed, only a LIMA that is long enough to reach the LAD.

However, because of increased interest in minimally invasive coronary artery bypass grafting, the possibility of inadequate LAD perfusion resulting from the persistence of LIMA branches becomes an important issue. If it is possible to demonstrate any impairment in the blood flow of the LAD after partial harvest of the LIMA, we are justified in searching for any technique that could allow total harvest of the conduit using a surgical approach other than median sternotomy.

Physiologically, the flow to territories supplied by the LIMA is mainly systolic; in contrast, LAD flow after LIMA-to-LAD anastomosis is mainly diastolic. Therefore, the muscular and coronary territories do not share the same amount of flow because their hemodynamic phases are different. As a consequence, LAD flow is added to systolic flow. To produce an inadequate LAD perfusion syndrome as a result of persistent undivided branches, these branches must have a diastolic flow or the LAD must have a systolic flow that is an unphysiologic event.

In this study, the persistence of LIMA branches modified the blood flow velocity pattern between groups. In group A, the diastolic-to-systolic peak velocity ratio in the proximal third was influenced by high systolic blood flow velocity in the subclavian artery and that in the distal third was influenced by high diastolic blood flow velocity in the coronary artery. In group B, the diastolic-to-systolic peak velocity ratio showed the same pattern as in group A in the proximal third, but the influence of the diastolic coronary blood flow velocity was modulated by the systolic blood flow to the undivided branches in the distal third [26]. The result was that the ratio was higher than the proximal value, but still nearly 1. Only near the distal anastomosis did the blood flow velocity pattern become mainly diastolic (see Fig 4).

These different blood flow velocity patterns do not have practical implications, however, because the physiologic behavior in both groups was similar. The LIMA graft flow reserve, detected with intramammary injection of adenosine, showed a similar response in all LIMAs, independent of the different harvesting techniques.

In conclusion, when a left anterior small thoracotomy is used in LAD direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon. Because the persistence of LIMA branches does not influence the increase in blood flow velocity, even in extreme situations (ie, acute adenosine-induced myocardial hyperemia), we think that our policy (partial LIMA harvesting) is a reasonable solution that makes a left anterior small thoracotomy an easy and safe procedure.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 
Address reprint requests to Dr Calafiore, Division of Cardiac Surgery, "San Camillo de' Lellis" Hospital, via Forlanini 50, 66100 Chieti, Italy (e-mail: calafiore{at}unich.it).

	References

Top Footnotes Abstract Introduction Material and Methods Patient Selection Cardiac Catheterization and... Statistical Analysis Results Comment References

 

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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): Giovanni Teodori Gabriele Di Giammarco Antonio M. Calafiore Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luise, R. Articles by Calafiore, A. M. Search for Related Content PubMed PubMed Citation Articles by Luise, R. Articles by Calafiore, A. M. Related Collections Related Articles