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Ann Thorac Surg 2001;71:142-147
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Growth potential of left internal thoracic artery grafts: analysis of angiographic findings

Yoshihiro Nakayama, MDa, Ryuzo Sakata, MDa, Masashi Ura, MDa

a Department of Cardiovascular Surgery, Kumamoto Central Hospital, Kumamoto, Japan

Accepted for publication June 26, 2000.

Address reprint requests to Dr Sakata, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima-shi, Japan 890-8520
e-mail: sakata{at}med1.kufm.kagoshima-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. The growth potential of the internal thoracic artery (ITA) is still undetermined, and little is known about the long-term effects of anastomosing it to the coronary artery.

Methods. Fifty-three patients whose left ITA (LITA) had been anastomosed to the left anterior descending (LAD) coronary artery underwent coronary angiography within 1 month of operation and in late follow-up (mean interval: 4.5 ± 1.5 years). The diameter ratios of LITA to LAD were designated as the matching ratio.

Results. In follow-up, the diameter of the LITA increased from 1.83 ± 0.40 to 2.46 ± 0.53 mm in the 29 patients with progressive proximal native coronary stenosis. However, late results indicate that the matching ratio did not vary according to the location of the LITA anastomosis on the LAD (proximal portion: 1.13 ± 0.16, distal portion 1.19 ± 0.13), and reached an upper limit of about 1.4.

Conclusions. Growth potential of the LITA is limited by the diameter of the coronary artery onto which it is anastomosed. The most effective procedure for enhancing the growth potential of the LITA is to anastomose as proximally as possible onto the LAD.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The internal thoracic artery (ITA) is considered to provide an excellent long-term patency rate, and its bypass procedure to the left anterior descending (LAD) coronary artery improves long-term survival after coronary artery bypass grafting (CABG) [1, 2]. However, a number of problems continue to be associated with ITA grafts, including inadequate perfusion during or after CABG [3–6] and distal narrowing because of competitive flow from the native coronary arteries [7–9], with these problems still a focus of controversy.

We evaluated the growth potential of the left ITA (LITA) by analyzing the subsequent changes in its size. The diameter of the LITA graft, LAD coronary artery, and matching ratio (MR) were compared in the early and late phases under various conditions of proximal competitive flow, and estimated in terms of severity of stenosis of the proximal native coronary artery. We additionally investigated whether the potential adaptability of LITA varied or not in relation to the diameter of the LAD coronary artery to which it was anastomosed.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
From September 1989 to December 1994 at Kumamoto Central Hospital, 115 patients consecutively underwent isolated CABG using bilateral ITA (BITA). The LITA was anastomosed to the LAD coronary artery and the right ITA (RITA) was anastomosed to the circumflex coronary artery via the transverse sinus. Early postoperative angiography was performed 2 to 3 weeks after surgery in 113 patients (2 patients declined). Seventy-three patients (67.0%) consented to the late angiographic restudy to evaluate the growth potential of LITA and the long-term patency of in situ RITA bypass via the transverse sinus of 109 long-term survivors [10]. From these 73 patients, we excluded any patients in whom the following conditions were evident in either early or late angiography: (1) the stenotic legion was not limited to segment 6 of the LAD coronary artery; (2) old myocardial infarction of anterior or septal wall present; (3) flow of other graft on diagonal branch diverted to LAD coronary artery; (4) selective angiography of LITA not possible; 5) major side branch of LITA present; 6) obvious stenotic region in LITA because of surgical injury; and 7) obstruction of LITA. After these exclusions, 53 patients were selected for this study. They comprised 43 (81%) male patients with a mean age of 62 ± 8.4 years (range 38 to 75 years), and the mean graft number was 3.3 ± 0.9.

To avoid any remaining undivided side branches, the LITA was dissected as close to its origin as possible. The ostium of the anastomosis was made sufficiently wide by cutting the LITA longitudinally and splitting the native coronary.

All 53 patients received coronary angiography (CAG) within 1 month of CABG (early study) and in the late phase (late study). The mean interval between the CAGs was 4.7 ± 1.5 years (range 2.3 to 8 years). None had shown any history of cardiac events in the LAD coronary system. Only 1 patient contracted unstable angina because of occlusion of the graft to the circumflex coronary artery. Before scheduling CAG in the late phase, we informed the patients of the purpose of this study and obtained their consent.

Coronary catheters with hand injection of low-osmolar radiographic contrast media were routinely used. Size 6F catheters were used in all the studies. In the early and late phases, all patients were placed on antiplatelet agent. No vasodilating agents were used. Angiograms were obtained at a basal sinus rhythm of 72 ± 8 beats/minute in all patients, except for 2 individuals with atrial fibrillation, without injection of vasodilators including isosorbide dinitrate. Flow patterns of distal perfusion of the LAD coronary artery were classified into three categories in relation to the native coronary artery and the LITA injections: 1) flow balanced between the native coronary artery and the LITA grafts (balanced type); 2) flow dependent on the LITA grafts (ITA-dependent type); and 3) flow dependent on the native coronary artery (native-dependent type). No patients showed native-dependent flow type in either early or late CAGs.

To avoid too wide a range of perfusion areas from the LITA grafts, we arbitrarily selected patients according to the site of the stenotic lesions on the LAD coronary arteries. Using CAG findings, we restricted this study to patients with stenotic lesions on segment 6 of the LAD coronary arteries. Patients with stenosis (>=75%) of the LAD coronary arteries on the distal parts of the anastomosis were excluded. It was found in all patients that the LITA grafts were perfusing not only the distal LAD coronary artery area but also the proximal LAD areas (septal branch and diagonal branch areas) in both early and late phases. Any patients who demonstrated marked back flow to the LAD coronary arteries from the anastomosed grafts via a bypass to the diagonal branch were similarly excluded.

The patients were divided into three groups according to degree of stenosis of the proximal native coronary artery: (1) mild stenosis group < 90% stenosis; (2) severe stenosis group with 90% to 99% stenosis; and (3) complete obstruction group.

The diameter of the LITA and LAD coronary artery at the anastomotic site was measured on screen using calipers, and calculated from the diameter of the 6F catheters on the same screen. The MR of the LITA and the LAD coronary artery is shown in Figure 1. These values were calculated as an average of measurements taken from several different viewpoints. Coronary artery segments were categorized according to the American Heart Association classification. Abnormal Q wave revealed by electrocardiography was interpreted as presence of myocardial infarction.



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  		Fig 1. The diameter ratios of the LITA and LAD coronary artery at the anastomotic site on the coronary angiography were defined as the MR.

 
Statistical analysis
Data were analyzed by means of the StatView II statistical software package (Abacus Concepts, Inc, Berkeley, CA). Fisher’s exact test was used for the nonparametric variables. Continuous variables were analyzed by means of Student’s t test. Values were expressed as mean ± the standard deviation unless otherwise specified. A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Angiographical findings in the early study (Table 1)
The patients were divided according to the severity of stenosis of the native coronary artery into: the mild stenosis group, comprising 21 cases (40%); the severe stenosis group, comprising 20 cases (38%); and 12 cases (23%) comprising the complete obstruction group. The majority of the mild stenosis group belonged to the balanced flow type, whereas, in marked contrast, half of the severe stenosis group belonged to the ITA-dependent type. All cases in the complete obstruction group obviously belonged to the ITA-dependent type. The mean diameter of the LITA was 1.67 ± 0.39 mm in the mild stenosis group, 1.92 ± 0.33 mm in the severe stenosis group, and 2.27 ± 0.32 mm in the complete obstruction group, with a significant difference evident between all groups. However, the mean diameter of the LAD coronary artery did not show any significant differences. The MR was significantly higher in the complete obstruction group.


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  		Table 1. Angiographical Findings in the Early Study

 
Angiographical findings in the late study (Table 2)
In the late phase, all the LITA grafts were patent and showed no evidence of stenosis. Forty-eight (91%) of the patients presented severe stenosis or total occlusion of the proximal LAD coronary arteries. Four patients (80%) with mild stenosis of the LAD coronary artery presented balanced-type flow patterns. The degree of proximal stenosis and flow pattern was significantly correlated, as had also been seen in the early phase. The mean diameter of the LITA was 2.32 ± 0.38 mm in the complete obstruction group, significantly larger than that seen in the mild stenosis group (1.79 ± 0.45 mm). The mean diameter of the LAD coronary artery did not show any significant differences between each group. As a result, the MR was significantly highly in the complete obstruction group (1.13 ± 0.15) than in the mild stenosis group (0.87 ± 0.13).


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  		Table 2. Angiographical Findings in the Late Study

 
Comparisons between early and late studies
Figure 2 shows the changes in pathology of the proximal native coronary artery between the early and late study. Seventeen patients (81%) who initially had mild stenosis of the proximal native coronary artery in the early phase had developed severe stenosis or complete obstruction in the late phase. Only 1 patient showed a decrease in the degree of proximal native coronary stenosis (severe reduced to mild stenosis). In this patient, the diameter of the LITA decreased from 2.01 to 1.80 mm, and the diameter of the LAD coronary artery changed from 2.12 to 2.14 mm (MR, 0.95 to 0.84).



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  		Fig 2. The changes in pathology of the proximal native coronary artery between the early and late study.

 
In all 53 patients, the mean diameter of the LITA increased from 1.90 ± 0.41 to 2.33 ± 0.52 mm; the LAD coronary artery diameter remained relatively unchanged, at 2.19 ± 0.36 to 2.13 ± 0.39 mm; and MR increased from 0.87 ± 0.17 to 1.10 ± 0.18 between the early study and the late study. The diameter of the LITA and MR changed significantly.

Twenty cases who had already demonstrated complete obstruction in the early study did not show significant change in the mean diameter of the LITA (2.27 ± 0.32 to 2.32 ± 0.38 mm), the LAD coronary artery (2.19 ± 0.35 to 2.08 ± 0.37 mm), or MR (1.04 ± 0.10 to 1.13 ± 0.15) in the late study.

On the other hand, 29 cases who progressed to proximal native coronary stenosis (mild stenosis to severe stenosis, 6 cases; mild stenosis to complete obstruction, 11 cases; severe stenosis to complete obstruction, 12 cases) showed a statistically significant increase in the mean diameter of the LITA (1.83 ± 0.40 to 2.46 ± 0.53 mm) and MR (0.83 ± 0.14 to 1.13 ± 0.18) compared with the early phase. Also in these patients, the mean diameter of the LAD coronary artery did not show significant change (2.22 ± 0.38 to 2.18 ± 0.42 mm).

Effect of the anastomosis site on MR
The patients were divided into two groups, classified by position of the anastomosed site on the LAD coronary artery. In the late study, 35 patients demonstrated complete obstruction of the proximal native coronary artery. In 25 patients, the LITA had been anastomosed onto segment 7 or a more proximal site on the LAD coronary artery (proximal group), with 10 having undergone anastomosis onto segment 8 of the LAD coronary artery (distal group). We selected patients who showed stenosis of the proximal LAD coronary artery in this series to unify the perfusion area of the myocardium. However, the proximal site of the LAD (segment 6 or 7) of these 10 patients was buried in deep fatty tissue, and thus not suitable for anastomosis. To shorten aortic cross-clamp time, these patients required the anastomoses to be located on the distal part of the LAD coronary artery (segment 8). The mean diameter of the LITA and LAD coronary artery were statistically significantly larger in the proximal group than the distal group, and MR did not vary according to the location of the LITA anastomosis on the LAD coronary artery (Table 3). Figure 3 is a schema analyzing these results. The maximum MR was 1.44 in the proximal group and 1.42 in the distal group, which we assumed to be the upper limit of growth of LITA. We conclude that the growth potential of the LITA is limited not only by proximal competitive flow but by the diameter of the LAD coronary artery at the anastomosed LITA site.


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  		Table 3. Effects of Different Anastomosis Sites on Matching Ratio

 


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  		Fig 3. (A) The LITA anastomosed to the proximal site of the LAD coronary artery. (B) The LITA anastomosed to the distal site of the LAD coronary artery. The MR was not significantly different between A and B.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
There is some evidence that ITA behaves as a "living" conduit. In 1974, Barner introduced the term "disuse atrophy" to describe the phenomenon of shriveled and stenotic mammary graft on CAG. He later noted that mammary graft narrowing may be reversed [7, 11]. The terms "string sign" or "distal thread phenomenon" are used synonymously with this term, and are assumed to be a feature caused by competitive flow from the native coronary artery [7, 8, 11]. Kitamura and associates [12] also demonstrated the anatomical patency of the string-like LITA by temporary occlusion of the recipient LAD coronary artery with a percutaneous transluminal coronary angioplasty balloon.

However, the influence of competitive flow on the features of ITA remain controversial because these string-like phenomena do not always occur with patients who demonstrate strong competitive flow from the native coronary artery. Spence and associates [13] have reported that in the acute canine model, ITA graft flow is not limited by competitive flow from a fully patent native coronary artery. There is existing clinical evidence of the growing adaptability of the ITA after operation, but as yet insufficient data have been published.

We assessed the growth potential of the LITA from the relationship between LITA and LAD coronary artery diameter, MR, and the degree of proximal competitive flow (ie, the severity of proximal stenosis). We excluded from this study those patients with stenosis on the distal parts of the LAD coronary artery and with flow to the LAD coronary artery from any bypass graft to the diagonal branch, which creates the same effect as a large competitive flow. Therefore, in this study, the LITA have closely similar perfusion areas, and competitive native flow is completely dependent on the severity of proximal native coronary stenosis.

Patients with major side branches were also excluded from this study. The presence of undivided major side branches in the LITA graft is regarded as one of the most important influences on the postoperative LITA graft diameter and on string sign of the LITA graft. However, because of our approach of dissecting as far as possible towards the origin of the LITA during harvesting, no patients were excluded for this reason.

Background factors likely to influence the diameter of the LITA were unified as much as possible. Angiography was performed at basal rhythm, which was sinus in the majority, with a mean of 72 ± 8 beats/minute, and without the use of vasodilators including isosorbide dinitrate.

Seki and associates [14] reported that the internal thoracic artery diameter had a particularly strong correlation with the degree of LAD coronary stenosis. Their analysis was based on single postoperative angiographical findings that were performed from 16 days to 62 months after CABG in 147 patients, but the natural diameter of the LITA and anastomotic parts on the LAD coronary artery were not measured. To directly ascertain the growth potential of the LITA, we compared the early-phase and late-phase angiographical findings. The diameters of the LITA and MR of patients with severe proximal stenosis or complete obstruction were already higher than that seen in the mild stenosis group in the early phase, which agrees with the results of Seki and associates. Also, in the late phase, the diameter of the LITA and MR dramatically increased with the progression of native coronary lesions. Our data indicate that the adaptive potential of the LITA to myocardial blood demand is already present in the early postoperative phase and, furthermore, is sustained in the late phase.

There is a risk of narrowing of the anastomotic site of the native LAD coronary artery because of neointimal proliferation, so the anastomosis needs to have as wide a diameter as possible to allow for future growth of the ITA.

In the late phase study, in the 35 patients with total occlusion of the proximal LAD coronary artery, whom the growth potential of the LITA was maximally enhanced, the MR was not influenced by the anastomotic site of the LAD coronary artery. Figure 3 shows the results in schematic form. This would appear at first glance to be a natural consequence of the operation, because the proximal, large LITA is anastomosed to the proximal, large LAD coronary artery and vice versa, and our data did, in fact, statistically confirm this.

However, these results suggest a more important phenomenon. The growth of the ITA may be limited by the diameter of the anastomosed LAD coronary artery. Our data show that MR levels off in the late phase at 1.44 and 1.42, respectively, in cases anastomosed to the proximal LAD coronary artery and the distal coronary artery. In these patients, the LAD coronary arteries were completely occluded. In addition, the diameter of the LAD coronary artery at the anastomotic location did not change significantly between the early phase and late phase, irrespective of where the LITA was anastomosed onto the LAD coronary artery. These results may also explain the so-called hypoperfusion of the ITA. The adaptive potential of the LITA is maximally enhanced by the maneuver of anastomosing as proximally as possible to the LAD coronary artery.

According to the prizometer principle [15, 16], antegrade flow should prevent the drop in head of pressure caused by retrograde perfusion. This theory is one positive indicator for surgical patch angioplasty for patients with isolated left main coronary disease [15–18]. Anastomosing the LITA onto the proximal LAD coronary artery results in an increase in septal and diagonal branches that are perfused in antegrade fashion from the LITA. This feature has also borne out our approach of selecting a more proximal site for the LAD coronary artery.

Anatomical studies [19] have demonstrated that the ITA is a passive and elastic conduit at most portions along its length except at its proximal and its very distal sections. On the other hand, pharmacological studies on the human ITA have revealed that the artery is pharmacologically reactive [20, 21]. He reported in 1993 [22] that different sections of the ITA showed different contractility and concluded that the midsection of the ITA is a large "passive conduit," but that the distal section (3 to 4 cm proximal to the bifurcation) is a pharmacologically reactive conduit. Patients with the LITA anastomosed at segment 6 or 7 of the LAD coronary artery used the midsection of the LITA. Segment 8 used the distal section. However, the MR increased in the late phase, coping with the flow demand in patients using the elastic, passive conduits of the ITA as well as in those patients using the distal, pharmacologically reactive conduit.

Some authors [7–9] report that a relationship exists between significant native flow and string sign in the LITA. We also observed a similar phenomenon in patients with very mild stenosis (< 50%) of the LAD coronary artery. However, in this study, in spite of patients even in the mild stenosis group showing at least 75% stenosis on the LAD coronary artery, none revealed string sign of the LITA. This fact may indirectly demonstrate the possibility that the LITA suffers string sign because of significant native flow.

Study limitations
We assessed the adaptive potential of the LITA from measurement of diameter as growth potential. In our analysis, no data for flow or perfusion measurement were included. There is some evidence [7–9, 11, 12] to indicate that the LITA adapts to myocardial blood demand by changing its size. It may be true that the diameter of the LITA correlates with the flow it carries.

Because the main purpose of this study was to assess the growth potential of the LITA in response to proximal native stenosis, measurement data under stress conditions were not included. In addition, the LITA graft has already been shown by Hanet and associates [23] to alter its size, measured angiographically, in response to hemodynamics.

Conclusions
The main feature of the LITA is that it is clearly influenced by competitive native flow, and exhibits adaptation potential even in the early postoperative phase, followed by sustained growth potential in the late phase, coping with the blood demand of the left ventricle. Wherever the LITA is anastomosed, the MR between the LITA and the LAD coronary artery showed similar adaptive growth in both early and late phases, before leveling off at an upper limit. The most effective procedure for enhancing growth potential of LITA is, therefore, to anastomose as proximally as possible onto the LAD coronary artery.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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