Ann Thorac Surg 2008;86:1713-1716. doi:10.1016/j.athoracsur.2008.05.072
© 2008 The Society of Thoracic Surgeons
Our Surgical Heritage
Vineberg Operation: A Review of the Birth and Impact of This Surgical Technique
Prashanth Katrapati, MD,
Jon C. George, MD*
Division of Cardiovascular Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
* Address correspondence to Dr George, 11100 Euclid Ave, M.L. 5038, Cleveland, OH 44106-5038 (Email: jon.george{at}uhhospitals.org).
 |
Abstract
|
|---|
The Vineberg operation was introduced by Arthur Vineberg in the early 1940s as an experimental model for revascularization of ischemic cardiac tissue in animal models with direct implantation of left internal mammary artery into ventricular myocardium. The first attempt in a human was performed in 1950, followed by 10,000 to 15,000 Vineberg operations completed in the 1950s and 1960s until the birth of coronary artery bypass grafting. We report a historical perspective, birth and impact of this surgical technique, and possible implications for the future of cardiology and cardiac surgery.
|
Introduction
|
|---|
The Vineberg operation (VO) pioneered by Dr Arthur Vineberg in the early 1940s was an experimental model for revascularization of ischemic cardiac tissue with direct implantation of the left internal mammary artery into ventricular myocardium. Initial success with animal models led to the first human operation in April 1950. The VO is thought by many to be the first successful attempt at revascularization of ischemic myocardium, leading to the birth of coronary artery bypass grafting (CABG). Although approximately 10,000 to 15,000 VOs were performed in the 1950s and 1960s, the interest in this revolutionary technique was extinguished with the rise of CABG.
|
Biographic Sketch
|
|---|
Dr Arthur Vineberg (Fig 1) was born in Montreal, Quebec, Canada in 1903. He studied biochemistry and medicine and graduated from McGill University (BSc, 1924; MSc, 1925; MD, 1928) [1, 2]. He completed his surgical internship at Bellevue Hospital, New York (1928 to 1929), and residency at the Royal Victoria Hospital, Montreal (1929 to 1933), and concurrently procured a doctorate in experimental physiology at McGill University (PhD, 1933) [3].
View larger version (159K):
[in this window]
[in a new window]
|
Fig 1. Dr Arthur Vineberg (1903–1988). (Arthur Vineberg Fonds P126.E5,15, 1969–1971. Osler Library of the History of Medicine, McGill University, Montreal, Quebec, Canada.)
|
|
In 1942 Vineberg married Ann Porter Buckley and shortly thereafter was sent on active military service with the Royal Canadian Army Medical Corps. Upon return, he became a cardiac surgeon at the Royal Victoria Hospital and a lecturer in the Faculty of Medicine of McGill University [1], where he started his experimental studies developing and refining the concept of the VO.
Vineberg published more than 130 articles and 2 books and lectured both nationally and internationally [3]. He ultimately became a Companion of "The Order of Canada," Canada's highest civilian honor in 1986 at the age of 83, before he died 2 years later in 1988 [1].
|
Historical Perspective
|
|---|
Although the VO has been relegated as a curiosity of medical historians, it is a worthwhile endeavor to explore its inception and contributions to the treatment of cardiovascular disease. In 1927, after a strenuous wrestling workout at the McGill University gymnasium, Arthur Vineberg and colleague Eric MacNaughton sat discussing an earlier lecture by Professor Horst Oertel about the pathology of coronary artery disease involving primarily the surface coronary arteries and their epicardial branches [2, 3]. Vineberg then suggested the possibility of using another artery to graft into the heart muscle, where its branches could join the nondiseased intramyocardial arterioles. He further commented on the use of the left internal mammary artery as the best possible graft due to its proximity to the left ventricle and likely inconsequential removal with minimal damage to surrounding tissue [2, 3]. The idea rested until 1930, when Vineberg's father was crippled by a large myocardial infarction with recurrent angina until he died 5 years later [2]. The death of his father renewed Vineberg's interest in revascularization of ischemic myocardium, which prompted his experimental studies at the completion of his training.
Perhaps Vineberg would have never thought of the VO if it were not due to contributions from his predecessors. In 1933 Wearn and colleagues developed the concept of myocardial sinusoids, described as bridges between the terminal arterioles and the venous system that arose as the coronary vessels slowly lost their arterial characteristics and gave rise to channels that were continuous with the venous network of the heart [4]. Almost 20 years later, the notion of sinusoids was confirmed by Truex and Angulo in 1952 [5] and exploited again for the development of the VO.
Early experimentation for relief of angina pectoris involved attempts at denervation by cervical sympathectomy, irradiation, or chemical sclerosis. In 1910 Carrel [6] reported successful anastomosis of the innominate artery of one dog into the distal coronary of another, which prompted several studies evaluating direct manipulation of coronary flow. In 1935 Beck [7] developed a series of procedures to revascularize myocardium with extracardiac collateral development through pericardial talc poudrage, which then led to multiple variations of the procedure by O'Shaugnessy [8] and others, and eventually to the birth of the VO.
The sinusoidal concept of Wearn, along with the experimental techniques of Carrel and Beck, formed the foundation for Vinberg's experimentation with VO. In 1945 he attempted internal mammary artery (IMA) implantation in dogs by dissecting the IMA, ligating the distal end, creating artificial perforations in the ligated end, and inserting it into a tunnel created in the myocardium [9]. He based this operation on the concept of the sinusoids and hoped that these sinusoids would absorb the runoff from the perforated IMA. He further theorized that the sinusoids would fortify and develop collateral communications with the native coronary circulation [10].
After various modifications to his technique, Vineberg took a bold step and operated on the first human in 1950. Although his first patient only survived 62 hours after the operation, his procedure was viewed as a potential success after the postmortem examination revealed a patent IMA without evidence of infarction, hemorrhage, or hematoma.
|
Vineberg Experience
|
|---|
After several years of experimenting in human patients, Vineberg published a case series of 57 patients in 1958 in which he reported a 60% survival rate for up to 7 years [11]. During the same year, with the advent of coronary angiography by Sones and Shirley [12], Vineberg was finally able to prove his theory of revascularization with an angiographic demonstration of patent implants. Given the newly found evidence for the validity of the VO, its utility soared, and an estimated 10,000 to 15,000 procedures were performed from 1958 to 1975 [13].
Further substantiating the validity of the VO was a Cleveland Clinic study of 1100 IMA implants in 1968 that found 92% were patent, and moreover, 54% had communication with native coronary vessels [14]. In 1977 Oschner and associates [15] reported a case series of 55 patients who underwent 73 IMA implants. The follow-up angiographic assessment showed myocardial blushing in 21% and filling of a major coronary artery in 42% [15].
In an effort to show that the IMA implantation was the driving force behind patient survival, Vineberg reported a case-control study in 1977 that compared surgical revascularization with standard medical therapy: survival at 4 years was 86.5% in the surgical group compared with 53% and 60% in the two medically treated groups [16]. In addition to these large-scale studies that provided support for VO, several case reports of long-term success were also published; however, few reports extend greater than two decades of patency [17–23].
Despite the relative success of the VO, it had many critics. Colleagues of Vineberg who tried to reproduce his initial results were unsuccessful, with some conflicting results; later studies reported showing only 16% graft to native coronary vessel anastomosis [10] compared with 42% previously published by Oschner and associates [15]. Vineberg argued, however, that his colleagues did not mimic the atherosclerotic process and instead operated on animals with healthy coronary vessels. In fact, Oschner and associates [15] also showed that patency rates correlated with tissue ischemia; Vineberg implants were patent 95% of the time when the stenosis of the native vessels exceeded 75%.
The discrepancy between Vineberg's early results and those of his colleagues led to the randomized clinical trial undertaken by the Veterans Administration in 1966, which enrolled 146 patients and reported an operative mortality of 12% and implant patency of 67% at 1 year [24]. Given these mixed results compared with the Cleveland Clinic study [14] and the advent of CABG [25], the VO became outdated and a remnant of the past.
|
Vineberg's Legacy
|
|---|
Although the VO has become obsolete with the advent of CABG, important lessons were learned as a stepping-stone on the path toward the current gold standard of myocardial revascularization. The value of the IMA as an expendable artery and its resistance to thrombosis and atherosclerosis were both recognized by experimentation with the VO, making it the preferred conduit for CABG.
A recent study by Filho and associates [26] compared a modified VO with standard CABG. The modification involved grafting the left IMA to the anterior wall of the left ventricle with the aid of an endocardial pacemaker electrode introducer without using cardiopulmonary bypass, and standard technique using direct anastomosis of the left IMA to the left anterior descending artery under cardiopulmonary bypass. The study of eight modified VOs and 20 traditional grafts demonstrated angiographic patency in 100% of the modified VOs, with a lower mortality rate in the modified VO group (0%) compared with the traditional CABG group (5.4%). Despite lower total graft flow by Doppler imaging in the modified group, the authors demonstrated adequate augmentation of flow under myocardial stress in both groups, concluding that the modified VO can be used to revascularize ischemic myocardium with low rates of mortality and high rates of patency in those individuals not amenable to traditional CABG [26].
Furthermore, as we examine evolving revascularization technologies, there is an eerie similarity between the VO and transmyocardial laser revascularization (TMLR). Initially started in the mid-1990s as an adjunct to CABG, TMLR essentially created tunnels in ischemic myocardium similar to those Vineberg envisioned, except through the use of a laser. The theory of TMLR is based on the idea that oxygenated blood from the ventricles would traverse these tunnels and provide blood to the myocardial sinusoids. Others have also suggested that TMLR may stimulate angiogenesis [27].
A number of studies have compared the efficacy of TMLR plus CABG vs CABG alone in patients with diffusely diseased native coronary circulation. When the extent of anginal symptoms, functional class, and need for repeat procedures are examined, the overwhelming majority of studies seem to show that TMLR plus CABG is superior in these patients [28, 29].
Recent studies of TMLR and injection of angiogenic factors have also shown improvements in relief of angina of patients with severe ischemic heart disease [30, 31]. Although, the idea that TMLR alone improves functional status or perfusion has not been proven and is still disputed by various studies, the fundamental concept of revascularization through the direct manipulation of ischemic cardiac tissue is still at play today [31, 32].
|
References
|
|---|
- Osler Library Archives. Osler Library of the History of Medicine, McGill Universityhttp://www.health.library.mcgill.ca/OSLER/archivesAccessed: Mar 3, 2008.
- Westaby S, Bosher C. Surgery for coronary artery disease: Arthur Marie VinebergIn: Westaby S, Bosher C, editors. Landmarks in cardiac surgery. Oxford, UK: Oxford University Press; 1997. pp. 210-212.
- Berube B. Arthur Vineberg Can Med Assoc J 1981;125:1176.
- Wearn JT, Mettier SR, Klumpp TG, Zscthesche LJ. The nature of the vascular communications between the coronary arteries and the chambers of the heart Am Heart J 1933;9:143-164.
- Truex RC, Angulo AW. Comparative study of the arterial and venous systems of the ventricular myocardium with special reference to the coronary sinus Anat Rec 1952;113:467-491.[Medline]
- Carrel A. On the experimental surgery of the thoracic aorta and heart Ann Surg 1910;52:83-95.[Medline]
- Beck CS. The development of a new blood supply to the heart by operation Ann Surg 1935;102:801-813.[Medline]
- O'Shaughnessy L. Experimental method of providing collateral circulation to the heart Br J Surg 1936;23:6635-6670.
- Vineberg AM. Development of an anastamosis between the coronary vessels and a transplanted internal mammary artery Can Med Assoc J 1946;55:117-119.
- Thomas JL. The Vineberg legacy Tex Heart Inst J 1999;26:107-113.[Medline]
- Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation Can Med Assoc J 1958;78:871-879.[Medline]
- Sones FM, Shirley EK, Proudfit WL, Westcott RN. Cine-coronary arteriography Circulation 1959;20:773-774.
- Preston TA. Coronary artery surgery: a critical reviewNew York, NY: Raven Press; 1977. pp. 7-26.
- Fergusson DJ, Shirey EK, Sheldon WC, Effler DB, Sones FM. Left internal mammary artery implant postoperative assessment Circulation 1968;38(4 suppl):II24-II26.
- Ochsner JL, Moseley PW, Mills NL, Bower PJ. Long-term follow-up of internal mammary artery myocardial implantation Ann Thorac Surg 1977;23:118-121.[Abstract]
- Vineberg AM. Evidence that revascularization by ventricular internal mammary artery implant increases longevity J Thorac Cardiovasc Surg 1975;70:381-393.[Abstract]
- Marx R, Jax TW, Kelm M, Schoebel FC, Strauer BE. Vineberg graft: flow reserve of bilateral implantation after 27 years Ann Thorac Surg 2001;71:341-343.[Abstract/Free Full Text]
- Krabatsch T, Onnen G, Hetzer R. Unilateral Vineberg arterial graft with a patency of 30 years Circulation 2000;102:1724-1725.[Free Full Text]
- Nasu M, Akasaka T, Chikasu 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]
- Hughes MM. Bilateral functioning Vineberg grafts Chest 1997;111:824-826.[Medline]
- Langenhove GV, Serrano P, Serruys PW. Vineberg revisited: Long-term survival more than two decades after direct surgical myocardial revascularization Int J Cardiol 2000;73:83-86.[Medline]
- Sabbagh AH, Schocket LI, Fritz JM, O'Hare JE, Anderson RM. Anomalous origin of the left coronary artery from the pulmonary artery treated by palliative Vineberg operation in an infant Cardiovasc Dis 1980;7:350-356.[Medline]
- Gupta R, Atar S, Schwarz ER, Utresky FB, Birnbaum Y. Vineberg procedure for inadvertent injury Tex Heart Inst J 2006;33:98-99.[Medline]
- Bhayana JN, Gage AA, Takaro T. Long-term results of internal mammary artery implantation for coronary artery disease: a controlled trial Ann Thorac Surg 1980;29:234-242.[Abstract]
- Captur G. Memento for René Favaloro Tex Heart Inst J 2004;31:47-60.[Medline]
- Filho JGL, Forte AJV, Leitao MCA, Filho HGL, Silva AA, Machado JJA. Vineberg's procedure modified technique: Flow analysis, immediate postoperative results and angiographic evaluation J Card Surg 2006;21:370-376.[Medline]
- Whittaker P, Rakusan K, Kloner RA. Transmural channels can protect ischemic tissue. Assessment of long-term myocardial response to laser-and needle-made channels. Circulation 1996;93:143-152.[Abstract/Free Full Text]
- Frazier OH, Tuzun E, Eichstadt H, et al. Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter study with 4-year follow-up Tex Heart Inst J 2004;31:231-239.[Medline]
- Zhao H, Wan F, Guo JX, et al. Chronic effects of transmyocardial laser revascularization combined with off-pump coronary artery by pass (OPCAB) compared with OPCAB alone in patients with ischemic heart disease: a prospective multicenter follow-up study Zhonghua Xin Xue Guan Bing Za Zhi 2006;34:710-713.[Medline]
- Gowdak LH, Schettert IT, Rochitte CE, et al. Transmyocardial laser revascularization plus cell therapy for refractory angina Int J Cardiol 2008;127:295-297.[Medline]
- van der Sloot JA, Huikeshoven M, Tukkie R, et al. Transmyocardial revascularization using an XeCl excimer laser: results of a randomized trial Ann Thorac Surg 2004;78:875-881.[Abstract/Free Full Text]
- Berishvili II, Sigaev IIu, Bokeriia LA. Transmyocardial laser revascularization of the myocardium Vestn Ross Akad Med Nauk 2005;4:58-65.[Medline]
Related Article
-
Vineberg Operation: A Successful Case 35 Years Later
- Prashanth Katrapati and Jon C. George
Ann. Thorac. Surg. 2008 86: 1676-1677.
[Abstract]
[Full Text]
[PDF]
Top
Abstract
Introduction
