Ann Thorac Surg 2009;87:e57-e58. doi:10.1016/j.athoracsur.2009.03.100
© 2009 The Society of Thoracic Surgeons
Case Reports
Combined Internal Mammary Artery Graft in Coronary Bypass: 18-Year Follow-Up
Askin Ali Korkmaz, MDa,*,
Burak Onan, MDb,
Selen Onan, MDb,
Ahmet Ozkara, MDb,
Mustafa Guden, MDa,
Cihat Bakay, MDb
a Department of Cardiovascular Surgery, Sema Hospital, Istanbul, Turkey
b Department of Cardiovascular Surgery, Florence Nightingale Hospital, Istanbul, Turkey
Accepted for publication March 19, 2009.
* Address correspondence to Dr Korkmaz, Sema Hospital Kalp Damar Cerrahisi Sahil yolu sk. No. 16 Dragos, Maltepe, 
stanbul, 34844, Turkey (Email: aakorkmaz{at}gmail.com).
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Abstract
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Graft preference is a key point for long-term patency in coronary artery bypass grafting. We present a patient with multivessel coronary artery disease who underwent coronary artery bypass grafting 18 years ago. Revascularization of the left coronary system was performed by using a combined internal mammary artery (IMA) graft, which consisted of an end-to-end anastomosis of left IMA (in situ) and right IMA (free), with the interposition of a small piece of vein. A coronary angiography at the 18-year follow-up revealed patency of all sequential anastomoses with an enlarged combined IMA graft.
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Introduction
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In coronary artery bypass grafting (CABG), selection of the type of graft is crucial for better long-term results. Long-term follow-up results for patency rates of different grafts with angiography play a key role for the graft preference.
A 77-year-old man with multivessel coronary artery disease who underwent an uneventful CABG 18 years ago was examined in our clinic. The patient was currently asymptomatic and free of angina, without an ischemic episode after the procedure.
The revascularization of the left coronary system was performed by using a combined internal mammary artery (IMA) graft, which consisted of an end-to-end anastomosis of the left IMA (in situ) and right IMA (free), with the interposition of a small piece of vein to get extra length (Fig 1) [1]. With this long graft, left anterior descending, diagonal, obtuse marginal, and posterolateral circumflex arteries were sequentially revascularized.
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Fig 1. Illustration shows the technique of combining the right (RIMA) and left internal mammary artery (LIMA).
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The patient's postoperative course was uneventful. Coronary angiography 2 days before discharge showed that all of the sequential anastomoses with the combined IMA graft were patent [1]. The patient was discharged on postoperative day 10.
The 18-year follow-up coronary angiography revealed that all sequential anastomoses were patent, and the combined left and right IMA grafts were enlarged (Figs 2, 3, and 4).
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Fig. 2. Recent angiography at the 18-year follow-up shows patency of all sequential anastomoses, with an enlarged combined internal mammary artery graft.
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Fig 3. Recent angiography at the 18-year follow-up shows patency of all sequential anastomoses, with an enlarged combined IMA graft.
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Comment
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It is reported that the sequential use of IMA grafts improves the long-term results of CABG because of excellent patency rates [2]. The extensive use of IMAs significantly decreases the recurrence of angina and reoperations, especially in patients with diabetes, low ejection fraction, and multivessel disease [3, 4]. Although the combined graft technique is not applied widely, we suggest that this case is a remarkable example of the effectiveness and long-term patency of sequential IMA grafting in CABG.
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References
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- Bakay C, Akçevin A, Süzer K, et al. Combined internal mammary artery graft for coronary artery revascularization Ann Thorac Surg 1990;50:553-556.[Abstract/Free Full Text]
- Dion R, Glineur D, Derouck D, et al. Long-term clinical and angiographic follow-up of sequential internal thoracic artery grafting Eur J Cardiothorac Surg 2000;17:407-414.[Abstract/Free Full Text]
- Bakay C, Erek E, Saliho
lu E, Kinolu B, Oztürk S. Sequential use of internal thoracic artery in myocardial revascularization: mid- and long-term results of 430 patients Cardiovasc Surg 2002;10:481-488.[Medline] - Schmidt SE, Jones JW, Thornby JI, Miller 3rd CC, Beall Jr AC. Improved survival with multiple left-sided bilateral internal thoracic artery grafts Ann Thorac Surg 1997;64:9-15.[Abstract/Free Full Text]
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Abstract
Introduction
