Ann Thorac Surg 2001;71:341-343
© 2001 The Society of Thoracic Surgeons
Case report
Vineberg graft: flow reserve of bilateral implantation after 27 years
Roger Marx, MDa,
Thomas W. Jax, MDa,
Malte Kelm, MDa,
Frank C. Schoebel, MDa,
Bodo E. Strauer, MDa
a Department of Cardiology, Pneumology, and Angiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
Accepted for publication April 20, 2000.
Address reprint requests to Dr Marx, Klinik für Kardiologie, Herzzentrum Wuppertal, Universität Witten-Herdecke, Arrenberger Strasse 20, 42117 Wuppertal, Germany
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Abstract
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We report a patient who underwent bilateral internal thoracic artery implantation into the myocardium known as a Vineberg procedure 27 years ago. Coronary angiography and Doppler echocardiography revealed patent grafts with total occlusion of all native coronary arteries. We measured flow velocities at rest and under stress conditions with noninvasive ultrasonic Doppler echocardiography. The flow patterns in both grafts were biphasic as in native coronary arteries. Under stress conditions no increase in flow was detectable as a marker of end-stage coronary artery disease with refractory angina pectoris.
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Introduction
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As an approach of direct myocardial revascularization, Arthur Vineberg in Montreal developed the implantation of the internal thoracic artery (ITA) into the myocardium. The first successful procedure in a patient was carried out in 1950 and this procedure became popular over the next 20 years [1] until the aortocoronary bypass operation became the treatment of choice for myocardial revascularization. Before that Vineberg had demonstrated the development of anastomoses between coronary arteries and the ITA in animals. Although improved myocardial circulation and a patent ITA graft were ascertained in many patients, there was a controversy concerning the operation’s effectiveness. On the one hand, in some patients there was little evidence of increased blood flow to the ischemic myocardium, and on the other hand, sometimes there was dramatic arborization of the implant with visualization of the coronary arteries [2]. The bilateral ITA implantation promises increasing flow to the myocardial perfusion deficit, but only a few of the patients were relieved of their intractable symptoms of angina pectoris for a longer period. We report a patient who underwent bilateral ITA implantation into the myocardium for the treatment of medically refractory angina 27 years ago.
A 49-year-old man underwent bilateral Vineberg ITA implantation modified after Sewell and Vineberg [1]. Before operation he had two anterior myocardial infarctions in 1968 and 1970 and one posterior myocardial infarction in 1969. At the time of operation he was admitted due to refractory angina pectoris. Cardiac catheterization presented a complete obstruction of the left anterior descending and right coronary arteries and a midsize stenosis of the left main trunk with additional sclerotic changes in all coronary artery segments.
After this operation performed in 1971 he had stable angina pectoris of class I according to the Canadian Cardiovascular Society (CCS) classification. His symptoms increased since 1995, ie, 3 years before the current admission. Twenty-seven years after the operation, he was admitted to our hospital because of increasing anginal symptoms at minimal exercise (CCS III–IV).
Coronary angiography showed total occlusion of the right coronary artery proximally, of the left descending coronary artery at the midportion, and of the proximal circumflex artery. Injection into both of the ITAs with contrast medium presented a good patency and increased adapted diameters. The right ITA presented itself implanted to the anterolateral wall, and the left ITA to the posterolateral segments, both with fair collateralization to the distal branches (Fig 1).
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Fig 1. The left (A, B) and the right (C, D) Vineberg internal thoracic arteries demonstrate good patency (arrowheads).
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Noninvasive ultrasonic duplex echocardiography of both ITAs for measuring the velocity was performed with the same technique as previously reported [3]. The examination was carried out under rest and stress conditions induced by a hand-grip maneuver. The flow patterns of both ITAs were biphasic, whereby the diastolic component represents a marker of the coronary perfusion [3]. This flow pattern is comparable to the directly anastomosed ITA graft to a coronary artery and the coronary circulation. The patterns were the same on both sides.
The calculated mean diastolic flow velocity, comparable to diastolic flow, increased from 29.3 cm/s at rest to 30.4 cm/s for the right ITA (Fig 2), and the blood pressure frequency product increased from 10,584 to 12,546 mm Hg/s. While measuring the left ITA the velocity increased from 38.8 to 39.4 cm/s and the blood pressure frequency product rose from 10,080 to 12,240 mm Hg/s. Because of the anatomic situation no type of interventional therapy seemed to be reasonable. As a result the medical treatment was intensified.
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Fig 2. Flow pattern at rest (A) and under stress conditions (C) of the left Vineberg internal thoracic artery implantation. Comparable results on the right side at rest (B) and during exercise (D).
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Comment
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In the literature there are only a few reports regarding long-term follow-up after the Vineberg operation [4] in patients suffering from occlusion of all three coronary artery main branches and having no other interventional procedure. Only a few patients have survived total occlusion of both the right and left coronary arteries with successful bilateral Vineberg ITA implantation, probably because the original number of double implantations was not huge. We report a 27-year follow-up in a patient with bilateral Vineberg procedure.
The measured mean diastolic flow of the vessels is comparable to previous reports [3] using the transcutaneous assessment of Doppler measurements. The estimated flow velocity reserve under stress conditions in this case was nearly 1.0. The previous reported flow reserve of a directly anastomosed left ITA graft averaged 2.6 times the basal flow rate after operation [5]; the rate of a Vineberg ITA graft was described to be 1.6 times the basal flow previously [6]. The lack of velocity increase in both ITAs in our case could be explained by maximal flow in the graft under rest and no increase in capacity under stress conditions. This may explain the increase in symptoms with only very little exercise tolerance in this end stage of coronary artery disease.
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Acknowledgments
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We thank Wolfgang Bircks, MD, and Gunnar Plehn, MD, for critically revising the manuscript and Mrs Marion Ewers for preparing the manuscript.
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References
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Shrager J.B. The Vineberg procedure: the immediate forerunner of coronary artery bypass grafting. Ann Thorac Surg 1994;57:1354-1364.[Abstract]
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Dobell A.R.C. Arthur Vineberg and the internal mammary artery implantation procedure. Ann Thorac Surg 1992;53:167-169.[Abstract]
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Marx R, Jax T, Schoebel FC, et al. Arteria thoracica interna-Bypass—Grundlagen der Dopplersonographie für die prä—und postoperative Diagnostik Z Kardiol 1998;87(Suppl 2):80–6.
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Hayward R.H., Korompai F.L., Knight W.L. Long-term follow-up of the Vineberg internal mammary artery implant procedure. Ann Thorac Surg 1991;51:1002-1003.[Abstract]
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Akasaka T., Yoshikawa J., Yoshida K., et al. Flow capacity of internal mammary artery grafts: early restriction and later improvement assessed by Doppler guide wire. J Am Coll Cardiol 1995;25:640-647.[Abstract]
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Nasu M., Akasaka T., Chikusa H., Shoumura T. Flow reserve capacity of left internal thoracic artery 23 years after Vineberg procedure. Ann Thorac Surg 1996;61:1242-1244.[Abstract/Free Full Text]
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Abstract
Introduction
