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Ann Thorac Surg 2001;72:1443-1444
© 2001 The Society of Thoracic Surgeons

Correspondence

Vineberg procedure combined with therapeutic angiogenesis: old wine in a new bottle

W. Dudley Johnson, MDa, Valeri S. Chekanov, MD, PhDb, Victor V. Nikolaychik, MD, PhDb, Nicholas Kipshidze, MD, PhDc

a W. D. Johnson Heart Care Center, 350 Bishops Way, Suite 202, Brookfield, WI 53005, USA
b Milwaukee Heart Institute, Sinai Samaritan Medical Center, 960 N 12th St, Milwaukee, WI 53201-0342, USA
c Lenox Hill Heart and Vascular Institute, and Cardiovascular Research Foundation, Black Hall, 9th Floor, 130 E 77th St, New York, NY 10021, USA

e-mail: nkipshidze{at}lenoxhill.net

To the Editor

In a recent article in The Annals of Thoracic Surgery, Peter Pecher and Bernd A. Schumacher reported the results of 3 years of follow-up after applying growth factors to the myocardium during coronary artery bypass graft surgery (CABG) [1]. In our opinion, this elegant study is important because it shows that patients who are ineligible for current treatment options, such as percutaneous transluminal angioplasty (PTCA) and CABG, might be treated by therapeutic angiogenesis. Early clinical results of other studies have also been promising [2]. Despite these encouraging results, questions remain, especially in patients who have advanced coronary artery disease with many occluded arteries. Once administration of angiogenic factors has induced revascularization, there would be no source to supply blood to these new collateral vessels. We suggest that an answer might be to combine the Vineberg procedure (implantation of a nonanastomosed mammary artery) [3], which has been virtually neglected for decades, with therapeutic angiogenesis.

In a previous report [4], we showed that it is possible to revascularize severely ischemic skeletal muscle, the latissimus dorsi, by applying a fibrin sealant. Fortifying the sealant with aprotinin (a proteinase inhibitor) or deferoxamine (an iron chelator) greatly enhances capillary ingrowth from well-vascularized to severely ischemic tissue. The iron chelator inhibits the accumulation of free radicals in healing tissue [4]. In another study [5], using fibrin sealant plus deferoxamine in an animal model of chronic ischemic cardiomyopathy, we increased blood flow 2 months after application.

Encouraged by these results, we administered an angiogenic mixture plus sealant intramyocardially in combination with Vineberg procedure in 7 patients following CABG and endarterectomies, targeting vessels that were unsuitable for either bypass or endaterectomy. Documented informed consent was obtained from all patients. Long (up to 10 cm) intramyocardial tunnels were created in diffusely diseased regions, a mammary artery was implanted, then a fortified fibrin sealant containing cryoprecipitate (1 mL), thrombin 1 mL (1,000 U/mL), deferoxamine (100 mg), and human VEGF165 (100 µg) was injected into the myocardium surrounding the implant. There were no observed complications from this injection. Long-term follow-up showed extensive neovascularization in the treated areas (Fig 1).



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  		Fig 1. Angiography after procedure. (A) One-week follow-up. Patent Vineberg implant. No evidence of angiogenesis. (B) Three-month follow-up: extensive neovascularization with visualized distal segments of native coronary arteries.

 
Employing the Vineberg procedure provides an implanted mammary artery as a conduit for an abundant supply of blood to ischemic areas. In addition, the trauma from myocardial hemorrhage stimulates angiogenesis, a process that is greatly enhanced by introducing growth factors. We believe that further investigation is warranted to validate the Vineberg procedure in combination with growth factors and iron chelation therapy as an important option for the surgical revascularization of patients who have advanced coronary artery disease that cannot be treated by means of CABG or PTCA.

References

  1. Pecher P., Schumacher B.A. Angiogenesis in ischemic human myocardium: clinical results after 3 years. Ann Thorac Surg 2000;69:1414-1419.[Abstract/Free Full Text]
  2. Kipshidze N., Johnson D., Haudenschild C. Therapeutic angiogenesis in patients with advanced coronary artery disease; hype or hope?. J Invas Cardiol 1999;11:589-599.[Medline]
  3. Vineberg AM. Development of anastomosis between coronary vessels and transplanted internal mammary artery. Can Med Assoc J 1946;55:117.
  4. Chekanov V.S., Nikolaychik V.V., Reider M.A., et al. Autologous biological glue and aprotinin prevent latissimus dorsi muscle post mobilization ischemia. Basic Appl Myol 1998;8:211-220.
  5. Chekanov V.S., Maternowsky M., Nikolaychik V.V. Pharmacological support of angiogenesis using deferoxamine in biological glue for cardiomyoplasty. Basic Appl Myol 2000;10:61-62.

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Vineberg procedure combined with therapeutic angiogenesis: old wine in a new bottle: Reply
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Ann. Thorac. Surg. 72: 1444-1444. [Full Text]



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