HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mary J. Boylan Bruce W. Lytle Floyd D. Loop Paul C. Taylor Delos M. Cosgrove Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boylan, M. J. Articles by Cosgrove, D. M. Search for Related Content PubMed PubMed Citation Articles by Boylan, M. J. Articles by Cosgrove, D. M.

J Thorac Cardiovasc Surg 1994;107:657-662
© 1994 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

Surgical treatment of isolated left anterior descending coronary stenosis: Comparison of left internal mammary artery and venous autograft at 18 to 20 years of follow-up

Cleveland, Ohio

From The Cleveland Clinic Foundation, Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio.

Address for reprints: Bruce W. Lytle, MD, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195.

Abstract

To assess the long-term results of the surgical treatment of isolated left anterior descending coronary artery stenosis and compare surgical strategies for graft selection, we reviewed 100 consecutive patients receiving left internal mammary artery–to–left anterior descending artery grafts and 100 consecutive patients who received a saphenous vein autograft to the left anterior descending artery. All patients underwent operation from 1971 through 1973. The internal mammary artery and saphenous vein graft groups were equivalent with regard to preoperative clinical and angiographic variables, except that patients receiving left internal mammary artery grafts had a higher prevalence of noncritical disease (less than 50% stenosis) in the circumflex and right coronary arteries than did the saphenous vein graft group. Mean follow-up for the internal mammary artery and saphenous vein graft groups was 18.7 years and 20.7 years, respectively. The 18-year outcome was superior for the internal mammary artery group. Cox regression analysis confirmed that patients with left internal mammary artery grafts had superior survival, intervention-free survival, and event-free survival (all p < 0.01). The presence of noncritical disease in other vessels adversely affected intervention-free survival and event-free survival for both groups (all p < 0.03) and decreased survival for the saphenous vein graft group (p = 0.01) but not for the internal mammary artery group (p = 0.24). We conclude that in long-term follow-up of surgically treated isolated left anterior descending artery stenosis (1) the left internal mammary artery consistently yields better overall and intervention-free survival than does the saphenous vein graft, (2) outcome is influenced by the presence of noncritical disease in other vessels at the initial operation, and (3) deployment of the left internal mammary artery in the treatment of isolated left anterior descending artery stenosis yielded 18 years of intervention-free survival of 60.5% and provides a standard for comparison with other forms of therapeutic intervention. (J THORAC CARDIOVASC SURG1994;107:657-62)

Many studies have demonstrated the superiority of the left internal mammary (IMA) as a bypass graft to the left anterior descending coronary artery (LAD). ^1-10 One of these studies examined the 5-year results for 200 of our patients with isolated LAD stenoses who were treated surgically. ¹ One hundred consecutive patients received IMA grafts and 100 consecutive patients received SVGs. This current study reviews again the long-term outcome of those patients, now with a postoperative interval of two decades. This 20-year follow-up is useful not only to compare surgical strategies but also for the overall analysis of the long-term results of surgical treatment for isolated LAD coronary artery disease. These results establish a benchmark for the evaluation of other forms of treatment for isolated LAD disease—medical management and percutaneous interventions.

PATIENTS AND METHODS

Patient characteristics
Two consecutive series of 100 patients were reviewed, one group of 100 consecutive patients receiving IMA grafts and one group of 100 consecutive patients receiving SVGs to the LAD. All patients had an isolated LAD stenosis narrowing the cross-sectional lumen by at least 70% and underwent operation between January 1971 and December 1973. This study was not randomized, and the choice of bypass conduit was based on surgeon preference. Relative contraindications to IMA use during this time period included poor flow through the IMA, a severe graft-coronary size mismatch, and severe brachiocephalic atherosclerosis. Comparisons of the two groups with regard to clinical and angiographic characteristics are listed in Table I. Although the LAD was the sole site of a critical stenosis in all patients, noncritical stenoses (<50%) in the circumflex (Cx) or right coronary (RCA) system or both were present in 59 patients with IMA grafts and in only 35 patients with SVGs, (p < 0.001).

All patients had received interval follow-up as part of the previous study at a mean of 67 months after operation. ¹ The current follow-up was done by direct phone contact with the patients. In cases where there was an intervening event, the patient's physician was contacted and supporting documentation was obtained. Seven patients were lost to current follow-up but had at least 5 years of previous postoperative follow-up. The mean postoperative follow-up interval was 18.7 years for the IMA group and 20.7 years for the SVG group. Events coded into the database included death, reoperation, percutaneous transluminal coronary angioplasty (PTCA), and the diagnosis of a myocardial infarction. Survival analyses included all causes of death. Intervention-free survival was considered to be survival free from reoperation or PTCA. Event-free survival was considered to be survival free from reoperation, PTCA, or the diagnosis of myocardial infarction. Univariate comparisons were made by the Wilcoxon test and the Cox proportional hazard model was used for multivariate testing. ^11,12 Variables examined for their influence on outcome were age, conduit (IMA versus SVG), preoperative New York Heart Association Functional Class (I/II versus III/IV), gender, site of LAD stenosis (proximal or distal to the first major septal perforator), presence or absence of non-critical Cx/RCA disease, and left ventricular function (normal or mild impairment versus moderate or severe impairment).

RESULTS

Survival
Sixty-eight late deaths occurred, 20 in the IMA group and 48 in the SVG group. In the IMA group, 11 of the 20 deaths (55%) were known to be due to noncardiac causes versus 15 of the 48 deaths (31%) in the SVG group (p = 0.066). Univariate comparison of survival according to the type of bypass conduit (Fig. 1) indicated that survival of the patients receiving left IMA grafts was superior to that of patients receiving SVGs (p = 0.006). A Cox proportional hazard model identified the type of bypass graft and age as factors influencing long-term survival (Table II). The risk of death for patients receiving a SVG was 2.6 times that for patients receiving an IMA graft.

View larger version (19K): [in this window] [in a new window]   Fig. 1. Comparison of the survival of the IMA versus SVG group showed equivalent survival at 5 years, almost equivalent survival at 10 years (95% versus 91%), but widening differences at 15 years (88% versus 77%) and 18 years (80% versus 65%) after operation (p = 0.0006).

View larger version (27K): [in this window] [in a new window]   Fig. 2. Although there was a trend toward decreased survival for patients in the IMA group who had noncritical Cx/RCA disease (87% versus 75% at 18 postoperative years) (p = 0.24), this difference was not significant, whereas, for patients in the SVG group,the presence of noncritical disease had a significant impact on survival (75% versus 47% at 18 postoperative years)(p = 0.01).

Reintervention
A total of 45 patients underwent 51 reoperations. Seventeen patients in the IMA group had repeat operations (three underwent reoperation twice) compared with 28 in the SVG group (p = 0.063). The causes of reoperation also differed between the two groups. Three patients in the IMA group received a new LAD graft at reoperation versus 20 patients in the SVG group. Furthermore, 13 of 17 (76%) patients requiring reoperation in the IMA group had noncritical Cx/RCA disease at the time of their primary surgery versus 12 (43%) of the 28 patients in the SVG group (p = 0.028). Seven patients in the IMA group and nine patients in the SVG group underwent PTCA.

Intervention-free survival was significantly better for the patients receiving IMA grafts than for the patients receiving SVGs (p = 0.009) (Fig. 3). A Cox proportional hazard model confirmed the influence of bypass conduit on intervention-free survival (Table II).

View larger version (19K): [in this window] [in a new window]   Fig. 3. Intervention-free survival was significantly superior for patients receiving IMA grafts, 97%, 89%, 73% and 60% versus 98%, 80%, 60% and 45% at 5, 10, 15 and 18 postoperative years, respectively.

View larger version (27K): [in this window] [in a new window]   Fig. 4. The presence of nonsignificant Cx/RCA disease decreased intervention-free survival for patients in both the IMA and the SVG groups. For patients with IMA without Cx/RCA stenoses, 18-year intervention-free survival was 77% versus 49% for those with Cx/RCA stenoses (p = 0.004). Corresponding data for the patients in the SVG group were 54% without Cx/RCA stenoses and 27% with Cx/RCA disease (p = 0.025).

Table III

The 10-year superiority of the IMA to LAD graft in either the setting of single LAD disease or multivessel disease is a matter of record, ^1-10 and the results of this study indicate that for patients with single LAD disease, the clinical benefits of the IMA-to-LAD graft increased during the second decade after operation. Our initial review of these patients at a mean postoperative interval of 67 months showed superior graft patency and a trend toward fewer cardiac events for the IMA group, but survival for both groups was excellent at the 5-year time period. At the end of the second decade of follow-up a substantial difference in survival is apparently in favor of the IMA group, as well as significant differences in the number of reinterventions.

This study was not randomized, and one of the dangers of retrospective analyses of this type is that differences in preoperative patient-related variables might confound the comparison of different surgical strategies. However, the only difference between the IMA and SVG groups that we noted was a higher prevalence of noncritical disease in the Cx/RCA systems in the IMA group. Because that variable adversely influenced long-term outcome, the superiority of the IMA group is even more impressive.

The association of nonsignificant Cx/RCA disease with outcome is interesting. One argument against the surgical treatment of isolated LAD disease is that progression of atherosclerosis in other coronary vessels will compromise the long-term results. However, the results of this study seem to indicate that the most important principle is that the LAD revascularization be secure. For a patient receiving an IMA graft, the presence of Cx/RCA disease did not have a significant long-term impact on survival although there was a trend in that direction. Even for patients with noncritical Cx/RCA stenoses the survival was 76% at 18 years after operation. Because only 47% of SVG patients with Cx/RCA disease were alive at 18 years, it is apparent that treatment failure of the LAD revascularization is more important than progression of disease in other vessels, particularly with regard to survival. The presence of Cx/RCA disease did predict an increased risk of repeat revascularization even for patients who received IMA grafts. Still, even in this subgroup 18 years after operation, half of the patients were alive without having had further interventions.

Examination of the outcome for patients receiving IMA grafts who did not have Cx/RCA disease at the time of primary operation shows the striking figures of an 87% 18-year survival (including all causes of death, cardiac and noncardiac) and a 77% intervention-free survival.

The evaluation of the success of treatment strategies for isolated LAD disease requires a long-term perspective. The impact of the failure of treatment of the LAD on clinical outcome was not statistically obvious during the first 5 years of this study but began to become significant in the second decade of follow-up. The first explanation for this is that treatment failure (i.e. SVG occlusion) was not common within the first 5 years after operation. The second explanation is that treatment failure did occur but was not often clinically significant until it was combined with late progression of native vessel disease in the Cx/RCA systems.

The advent of PTCA has dramatically altered the choice of treatment for single vessel disease in the United States, and multiple publications have documented the relative safety of PTCA over the first 5 years after the procedure. However, even in the recent study by Frierson and associates ¹⁴—a review of isolated LAD angioplasty in the "modern era" of angioplasty—successful LAD angioplasty was followed by 5% risk of death, a 6% risk of bypass operation, and a 20% risk of repeat angioplasty over the next 5 years. ¹⁴ Despite the contention that angioplasty is relatively safe over the short term, careful clinical studies have now shown that the rate of restenosis after LAD angioplasty is extremely high, approximately 50% at 6 months after PTCA. ¹⁵ Until we reach 10 to 20 years of follow-up, the point where failure of the treatment of isolated LAD stenoses exhibits a large clinical impact, even serious consequences of that high rate of treatment failure for PTCA of the LAD may not become obvious.

Surgical procedures for coronary atherosclerosis is an anatomic palliation of a progressive metabolic disease, and treatment of LAD disease with IMA graft does not prevent progression of native coronary atherosclerosis. However, it does blunt the clinical impact of disease progression in other coronary vessels. For most patients, security of the revascularization of the LAD provides an excellent outcome for two decades after operation.

Appendix: DISCUSSION

Dr. James R. Pluth (Scottsdale, Ariz.).
I think there are two aspects from my point of view that deserve special attention. The first is the overall survival with the SVG. In 1983, Dr. Grondin reported that 36% of all saphenous veins at 10 to 12 years had atheromatous occlusions and 51% of the remaining grafts had significant atheromatous disease. In this current paper, approximately 32 of the patients with SVGs had late angiographic studies, and, of those, only 20 had occlusion of the SVG. I know it is improper to assume that all patients who had occlusion of the SVG would have had recurrence of symptoms and therefore late angiographic study, but it does seem that perhaps the overall survival of patients with SVGs is not as bad as we previously thought it to be. Could you comment on that?

Dr. Boylan.
There are two aspects to this answer. First, we looked at follow-up catheterizations on patients and categorized patients into those who underwent catheterization early, at less than 10 years, and those who had their catheterizations done after 10 years. We found that for most patients at less than 10 years, the indication for catheterization was frequently routine study to assess patency of the graft, IMA or SVG, whereas later on there was some clinical indication. In close analysis of our results and after obtaining the documentation from the hospital where the catheterization was done, we found that at greater than 10 years, the patency on SVG is 50% and is markedly less than data we had seen earlier. So, the patency of a SVG at greater than 10 years is 50%.

Dr. Pluth.
I believe that is still better than what we previously had thought them to be. It is noteworthy that at follow-up of 20 years and more for the patients with SVGs, even though some received reoperation, there is a 65% survival. That is a remarkable figure considering the way the SVG is often treated.

The second thing I would like to mention is the discrepancy between patients who had noncritical disease, whether they received an IMA or SVG. At first glance, one would say that because the IMA has improved patency and the LAD is so important to myocardial perfusion that this would explain the improved IMA result, but this does not correlate with your data. According to your data, when there is an absence of noncritical disease, there is no difference in survival between the IMA and the SVG. Is that correct?

Dr. Boylan.
It is correct that the overall survival in the absence of Cx/RCA disease is 87.3% for the IMA group and 75.0% for the SVG group with a p value of 0.10. However, on closer inspection, we see that the quality of survival is much better for the IMA group. Intervention-free (i.e., freedom from reoperation/PTCA) is 82.1% for the IMA group and 54.5% for the SVG group at 18 years with a p value of 0.008. Furthermore, multivariate testing identifies an IMA graft as a factor significantly increasing survival.

Dr. Pluth.
Therefore, some other factor is involved. I would assume that the other factor is a gradual development of atherosclerotic disease, not only in the SVG but also in the noncritical vessels, so that, at the time of follow-up SVG group disease is present in two or three vessels. This situation has a worse outlook than that for patients with an IMA graft in which one or two vessels might have disease.

Dr. Boylan.
The best way to assess patency of a graft is by angiogram. However, not all patients had postoperative cardiac catheterizations. We found that the most common indication for cardiac catheterization within the first 10 years after operation was to assess graft patency as part of a routine follow-up. In contrast, most patients studied after the 10-year mark had some symptom promoting the study. Half of the 32 patients with SVGs who underwent late catheterization (i.e., greater than 10 years after the operation) had occluded grafts and an additional four SVGs were stenosed by at least 50%. This results in a 38% (i.e., [16 + 4]/32]) late SVG patency.

Dr. Pluth.
From my experience, I would have a tendency to believe that the native vessel that has been grafted by the IMA is less likely to develop atheromatous disease than is the native vessel if it is grafted by the SVG.

Dr. Boylan.
We have no objective criteria to give a cause and effect analysis for an IMA versus SVG. The one thing we can say is that we see that the IMA remains patent and has recognized physiologic adaptability. By maintaining a secure patent conduit and a secure blood supply to the LAD, the IMA, according to our data, seems to nullify or certainly lessen the impact of disease in other vessels. In essence, by securing the LAD and that part of the heart supplied by the LAD, the IMA promotes better overall survival of the heart.

Dr. Pluth.
I think in your paper you stressed the importance of the IMA as part of the conduit or as part of an operative procedure when the LAD is involved, and I think that is an important message.

I do wish to ask, as a result of your findings on this particular paper, have you used more bilateral IMAs or all arterial revascularization, and do you believe it will reduce late prevalence of reoperation?

Dr. Boylan.
The concept of complete arterial revascularization has been investigated. A recent paper from The Clinic published in this JOURNAL included the results of single versus bilateral IMA grafts. In patients younger than 65 years of age, the long-term benefits of two IMA grafts are beginning to become evident. It encouraging to think that arterial grafts will be the best conduit for coronary revascularization. However, we do not yet have confirmation of consistent, reproducible long-term patency of other arterial grafts, such as the gastroepiploic artery, the inferior epigastric arteries, and the radial arteries.

Footnotes

Read at the Nineteenth Annual Meeting of The Western Thoracic Surgical Association, Carlsbad, Calif., June 23-26, 1993.

References

1. Lytle BW, Loop FD, Thurer RL, Groves LK, Taylor PC, Cosgrove DM. Isolated left anterior descending coronary atherosclerosis: long-term comparison of internal mammary artery and venous autografts. Circulation 1980;61:869-74.[Abstract/Free Full Text]
   
2. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft of 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
   
3. Lytle BW, Loop FD, Cosgrove DM, Ratliff NB, Easley K, Taylor PC. Long-term (5 to 12 years) serial studies of internal mammary and saphenous vein coronary bypass grafts. J THORAC CARDIOVASC SURG 1985;89:248-58.[Abstract]
   
4. Green GE, Stertzer SH, Gordon RB, Tice DA. Anastomosis of the internal mammary artery to the distal left anterior descending coronary artery. Circulation 1969;(Suppl):II79-85.
   
5. Tector AJ, Schmahl TM, Janson B, et al. The internal mammary artery graft: its longevity after coronary bypass. JAMA 1981;246:2181-3.[Abstract/Free Full Text]
   
6. Barner H, Swartz MT, Mudd JG, Tyras DH. Late patency of the internal mammary artery as a coronary bypass conduit. Ann Thorac Surg 1982;34:407-12.
   
7. Cosgrove DM, Loop FD, Lytle BW, et al. Determinants of 10-year survival after primary myocardial revascularization. Ann Surg 1985;202:480-90.[Medline]
   
8. Cameron A, Kemp HG, Green GE. Bypass surgery with the internal mammary artery graft: 15-year follow-up. Circulation 1876;74(Suppl)III30-6.
   
9. Okies JE, Page US, Bigelow JC, et al. The left internal mammary artery: the graft of choice. Circulation 1984;70(Suppl):I213-21.
   
10. Zeff RH, Kongtahworn C, Iannone LA, et al. Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10 year follow-up. Ann Thorac Surg 1988;45:533.[Abstract]
    
11. Cox DR. The analysis of binary data. London: Chapman & Hall, 1970.
    
12. Cox DR. Regression models and life tables. J R Stat Soc (B) 1972;34:187.
    
13. Kramer JR, Proudfit WL, Loop FD, et al. Late follow-up of 781 patients undergoing percutaneous transluminal coronary angioplasty or coronary artery bypass grafting for an isolated left anterior descending coronary artery. Am Heart J 1989;118:1144-53.[Medline]
    
14. Frierson JH, Dimas AP, Whitlow PL, et al. Angioplasty of the proximal left anterior descending coronary artery: initial success and long-term follow-up. JACC 1992;19:745-51.[Abstract]
    
15. Topol EJ, Leya F, Pinkerton CA, et al. A comparison of directional atherectomy with coronary angioplasty in patients with coronary artery disease. N Engl J Med 1993;329:221-7.[Abstract/Free Full Text]
    

This article has been cited by other articles:

				M. Kawamura, H. Nakajima, J. Kobayashi, T. Funatsu, Y. Otsuka, T. Yagihara, and S. Kitamura Patency rate of the internal thoracic artery to the left anterior descending artery bypass is reduced by competitive flow from the concomitant saphenous vein graft in the left coronary artery Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 833 - 838. [Abstract] [Full Text] [PDF]

				H. Kamiya, P. Akhyari, A. Martens, M. Karck, A. Haverich, and A. Lichtenberg Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: A randomized study J. Thorac. Cardiovasc. Surg., January 1, 2008; 135(1): 32 - 37. [Abstract] [Full Text] [PDF]

				H.-J. Sung, A. Yee, S. G. Eskin, and L. V. McIntire Cyclic strain and motion control produce opposite oxidative responses in two human endothelial cell types Am J Physiol Cell Physiol, July 1, 2007; 293(1): C87 - C94. [Abstract] [Full Text] [PDF]

				J. L. Ankeney and D. J. Goldstein Off-pump bypass of the left anterior descending coronary artery: 23- to 34-year follow-up J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1499 - 1503. [Abstract] [Full Text] [PDF]

				J. H. Shuhaiber I am afraid of using aprotinin because they say so? J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 732 - 733. [Full Text] [PDF]

				M. R. Katz, F. Van Praet, D. de Canniere, D. Murphy, L. Siwek, U. Seshadri-Kreaden, G. Friedrich, and J. Bonatti Integrated Coronary Revascularization: Percutaneous Coronary Intervention Plus Robotic Totally Endoscopic Coronary Artery Bypass Circulation, July 4, 2006; 114(1_suppl): I-473 - I-476. [Abstract] [Full Text] [PDF]

				S. Fraund, G. Herrmann, A. Witzke, J. Hedderich, G. Lutter, M. Brandt, A. Boning, and J. Cremer Midterm Follow-Up After Minimally Invasive Direct Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention Techniques Ann. Thorac. Surg., April 1, 2005; 79(4): 1225 - 1231. [Abstract] [Full Text] [PDF]

				S. Verma, P. E. Szmitko, R. D. Weisel, D. Bonneau, D. Latter, L. Errett, Y. LeClerc, and S. E. Fremes Should Radial Arteries Be Used Routinely for Coronary Artery Bypass Grafting? Circulation, August 3, 2004; 110(5): e40 - e46. [Full Text] [PDF]

				P. Massoudy, Y.-Y. Kim, M. Cetin, M. Thielmann, U. Herold, M. Kamler, and H. Jakob Internal thoracic artery malperfusion: fast decision for an additional vein graft has impact on patient outcome Ann. Thorac. Surg., June 1, 2004; 77(6): 2061 - 2065. [Abstract] [Full Text] [PDF]

				J. T. Reston, S. J. Tregear, and C. M. Turkelson Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting Ann. Thorac. Surg., November 1, 2003; 76(5): 1510 - 1515. [Abstract] [Full Text] [PDF]

				R. J. Dabal, J. R. Goss, C. Maynard, and G. S. Aldea The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization Ann. Thorac. Surg., August 1, 2003; 76(2): 464 - 470. [Abstract] [Full Text] [PDF]

				M. Qin, Z. Zeng, J. Zheng, P. K. Shah, S. M. Schwartz, L. D. Adams, and B. G. Sharifi Suppression Subtractive Hybridization Identifies Distinctive Expression Markers for Coronary and Internal Mammary Arteries Arterioscler Thromb Vasc Biol, March 1, 2003; 23(3): 425 - 433. [Abstract] [Full Text] [PDF]

				P J Bradshaw, K Jamrozik, M Le, I Gilfillan, and P L Thompson Mortality and recurrent cardiac events after coronary artery bypass graft: long term outcomes in a population study Heart, December 1, 2002; 88(5): 488 - 494. [Abstract] [Full Text] [PDF]

				K. D. Stahl, W.D. Boyd, T. A. Vassiliades, and H. L. Karamanoukian Hybrid robotic coronary artery surgery and angioplasty in multivessel coronaryartery disease Ann. Thorac. Surg., October 1, 2002; 74(4): S1358 - 1362. [Abstract] [Full Text] [PDF]

				G. Polvani, M. R. Marino, M. Roberto, L. Dainese, A. Parolari, G. Pompilio, S. D. Matteo, A. Fumero, A. Cannata, F. Barili, et al. Acute effects of 17{beta}-estradiol on left internal mammary graft after coronary artery bypass grafting Ann. Thorac. Surg., September 1, 2002; 74(3): 695 - 699. [Abstract] [Full Text] [PDF]

				F.-C. Riess, R. Bader, P. Kremer, C. Kuhn, J. Kormann, D. Mathey, S. Moshar, T. Tuebler, N. Bleese, and J. Schofer Coronary hybrid revascularization from January 1997 to January 2001: a clinical follow-up Ann. Thorac. Surg., June 1, 2002; 73(6): 1849 - 1855. [Abstract] [Full Text] [PDF]

				S. A. Oliveira, L. A. F. Lisboa, L. A. O. Dallan, S. O. Rojas, and L. F. Poli de Figueiredo Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients Ann. Thorac. Surg., February 1, 2002; 73(2): 505 - 510. [Abstract] [Full Text] [PDF]

				R. Ascione, M. J. Underwood, C. T. Lloyd, J. Y. Jeremy, A. J. Bryan, and G. D. Angelini Clinical and angiographic outcome of different surgical strategies of bilateral internal mammary artery grafting Ann. Thorac. Surg., September 1, 2001; 72(3): 959 - 965. [Abstract] [Full Text] [PDF]

				A. Hammerer-Lercher, J. Mair, J. Bonatti, S. B.C. Watzka, B. Puschendorf, and S. Dirnhofer Hypoxia induces heat shock protein expression in human coronary artery bypass grafts Cardiovasc Res, April 1, 2001; 50(1): 115 - 124. [Abstract] [Full Text] [PDF]

				B. Dubey, A. Bhan, S. K. Choudhary, S. Sharma, R. Sharma, B. Airan, P. Venugopal, B. Dubey, A. Bhan, S. K. Choudhary, et al. Assessment of Internal Mammary Artery Graft Patency: Angiography or Doppler? Asian Cardiovasc Thorac Ann, December 1, 2000; 8(4): 325 - 329. [Abstract] [Full Text] [PDF]

				V. Gulielmos, M. Menschikowski, H.-M. Dill, M. Eller, S. Thiele, S. M. Tugtekin, W. Jaross, and S. Schueler Interleukin-1, interleukin-6 and myocardial enzyme response after coronary artery bypass grafting - a prospective randomized comparison of the conventional and three minimally invasive surgical techniques Eur. J. Cardiothorac. Surg., November 1, 2000; 18(5): 594 - 601. [Abstract] [Full Text] [PDF]

				Ömeroglu S. N., K. Kirali, M. Guler, M. Erdem Toker, and C. Yakut Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass Ann. Thorac. Surg., September 1, 2000; 70(3): 844 - 849. [Abstract] [Full Text] [PDF]

				G. Amoroso, R. A. Tio, M. A. Mariani, A. J. van Boven, G. A. J. Jessurun, S. H. J. Monnink, J. G. Grandjean, P. W. Boonstra, and H. J. G. M. Crijns Functional integrity and aging of the left internal thoracic artery after coronary artery bypass surgery J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 313 - 318. [Abstract] [Full Text] [PDF]

				L. Wiklund, M. Johansson, M. Bugge, L.O. G. Radberg, G. Brandup-Wognsen, and E. Berglin Early outcome and graft patency in mammary artery grafting of left anterior descending artery with sternotomy or anterior minithoracotomy Ann. Thorac. Surg., July 1, 2000; 70(1): 79 - 83. [Abstract] [Full Text] [PDF]

				R. Scott, E. H. Blackstone, P. M. McCarthy, B. W. Lytle, F. D. Loop, J. A. White, and D. M. Cosgrove Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary arteryLate consequences of incomplete revascularization J. Thorac. Cardiovasc. Surg., July 1, 2000; 120(1): 173 - 184. [Abstract] [Full Text] [PDF]

				T Wittwer, J Cremer, P Boonstra, J Grandjean, M Mariani, A Mugge, H Drexler, P den Heijer, E-R v Leitner, A Hepp, et al. Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study Heart, January 1, 2000; 83(1): 58 - 63. [Abstract] [Full Text] [PDF]

				P. B. Berger, E. L. Alderman, A. Nadel, and H. V. Schaff Frequency of Early Occlusion and Stenosis in a Left Internal Mammary Artery to Left Anterior Descending Artery Bypass Graft After Surgery Through a Median Sternotomy on Conventional Bypass : Benchmark for Minimally Invasive Direct Coronary Artery Bypass Circulation, December 7, 1999; 100(23): 2353 - 2358. [Abstract] [Full Text] [PDF]

				V. Gulielmos, M. Eller, S. Thiele, H.-M. Dill, T. Jost, S. M. Tugtekin, and S. Schueler Influence of median sternotomy on the psychosomatic outcome in coronary artery single-vessel bypass grafting Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S34 - S38. [Abstract] [Full Text] [PDF]

				V. Gulielmos, M. Brandt, H.-M. Dill, M. Knaut, R. Cichon, K. Matschke, and S. Schueler Coronary artery bypass grafting via median sternotomy or lateral minithoracotomy Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S48 - S52. [Abstract] [Full Text] [PDF]

				V. Gulielmos, M. Knaut, R. Cichon, K. Matschke, U. Kappert, M. Brandt, J. Hoffmann, and S. Schueler Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients Eur. J. Cardiothorac. Surg., October 1, 1999; 14(4): 347 - 352. [Abstract] [Full Text] [PDF]

				V. Gulielmos, M. Brandt, M. Knaut, R. Cichon, F. M. Wagner, U. Kappert, and S. Schuler The Dresden approach for complete multivessel revascularization Ann. Thorac. Surg., October 1, 1999; 68(4): 1502 - 1505. [Abstract] [Full Text] [PDF]

				R. J. Damiano The minimally invasive direct coronary artery bypass procedure: What is its future role? J. Thorac. Cardiovasc. Surg., July 1, 1999; 118(1): 207 - 208. [Full Text]

				A. Diegeler, M. Matin, S. Kayser, Ch. Binner, R. Autschbach, R. Battellini, H. Krankenberg, and F.W. Mohr Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach Eur. J. Cardiothorac. Surg., May 1, 1999; 15(5): 680 - 684. [Abstract] [Full Text] [PDF]

				J. R. Doty, J. D. Fonger, J. D. Salazar, P. L. Walinsky, and N. W. Salomon EARLY EXPERIENCE WITH MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING WITH THE INTERNAL THORACIC ARTERY J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 873 - 880. [Abstract] [Full Text] [PDF]

				G. Wimmer-Greinecker, M. Yosseef-Hakimi, T. Rinne, R. Buhl, G. Matheis, S. Martens, K. Westphal, and A. Moritz Effect of internal thoracic artery preparation on blood loss, lung function, and pain Ann. Thorac. Surg., April 1, 1999; 67(4): 1078 - 1082. [Abstract] [Full Text] [PDF]

				M. Mack, R. Damiano, R. Matheny, H. Reichenspurner, and A. Carpentier Inertia of Success : A Response to Minimally Invasive Coronary Bypass: A Dissenting Opinion Circulation, March 23, 1999; 99(11): 1404 - 1406. [Full Text] [PDF]

				G. Tavilla, N. H.J. Pijls, E. Berreklouw, and K. H. Peels Noninvasive assessment of right gastroepiploic artery graft patency using transcutaneous color Doppler echocardiography Ann. Thorac. Surg., March 1, 1999; 67(3): 624 - 628. [Abstract] [Full Text] [PDF]

				J.-M. Farinas, M. Carrier, Y. Hebert, R. Cartier, M. Pellerin, L. P. Perrault, and L. C. Pelletier Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting Ann. Thorac. Surg., February 1, 1999; 67(2): 466 - 470. [Abstract] [Full Text] [PDF]

				F. D. Loop Coronary artery surgery: the end of the beginning Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 554 - 571. [Abstract] [Full Text] [PDF]

				M. J. Mack, J. A. Osborne, and H. Shennib Arterial graft patency in coronary artery bypass grafting: what do we really know? Ann. Thorac. Surg., September 1, 1998; 66(3): 1055 - 1059. [Abstract] [Full Text] [PDF]

				L. I. Bonchek and D. J. Ullyot Minimally Invasive Coronary Bypass : A Dissenting Opinion Circulation, August 11, 1998; 98(6): 495 - 497. [Full Text] [PDF]

				D Dougenis and A H Brown Long term results of reoperations for recurrent angina with internal mammary artery versus saphenous vein grafts Heart, July 1, 1998; 80(1): 9 - 13. [Abstract] [Full Text]

				H. Reichenspurner, V. Gulielmos, J. Wunderlich, M. Dangel, F. M. Wagner, M. F. Pompili, J. H. Stevens, J. Ludwig, W. G. Daniel, and S. Schuler Port-Access Coronary Artery Bypass Grafting With the Use of Cardiopulmonary Bypass and Cardioplegic Arrest Ann. Thorac. Surg., February 1, 1998; 65(2): 413 - 419. [Abstract] [Full Text] [PDF]

				Y. J. Gu, M. A. Mariani, W. van Oeveren, J. G. Grandjean, and P. W. Boonstra Reduction of the Inflammatory Response in Patients Undergoing Minimally Invasive Coronary Artery Bypass Grafting Ann. Thorac. Surg., February 1, 1998; 65(2): 420 - 424. [Abstract] [Full Text] [PDF]

				K. B. Allen, R. G. Matheny, R. J. Robison, D. A. Heimansohn, and C. J. Shaar Minimally Invasive Versus Conventional Reoperative Coronary Artery Bypass Ann. Thorac. Surg., September 1, 1997; 64(3): 616 - 622. [Abstract] [Full Text]

				M. A. Mariani, P. W. Boonstra, J. G. Grandjean, J. O. J. Peels, S. H. J. Monnink, P. den Heijer, and H. J. G. M. Crijns MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING VERSUS CORONARY ANGIOPLASTY FOR ISOLATED TYPE C STENOSIS OF THE LEFT ANTERIOR DESCENDING ARTERY J. Thorac. Cardiovasc. Surg., September 1, 1997; 114(3): 434 - 439. [Abstract] [Full Text]

				M. C. Robinson, D. R. Gross, K. A. Thielmeier, B. B. Hill, and W. F. Zeman Development of a Minimally Invasive Technique for Coronary Revascularization in a Porcine Model Ann. Thorac. Surg., July 1, 1997; 64(1): 64 - 69. [Abstract] [Full Text]

				D. S. Schwartz, G. H. Ribakove, E. A. Grossi, J. D. Schwartz, P. M. Buttenheim, F. G. Baumann, S. B. Colvin, and A. C. Galloway SINGLE AND MULTIVESSEL PORT-ACCESS CORONARY ARTERY BYPASS GRAFTING WITH CARDIOPLEGIC ARREST: TECHNIQUE AND REPRODUCIBILITY J. Thorac. Cardiovasc. Surg., July 1, 1997; 114(1): 46 - 52. [Abstract] [Full Text]

				E. Ovrum, G. Tangen, and E. A. Holen Facing the Era of Minimally Invasive Coronary Grafting: Current Results of Conventional Bypass Grafting for Single-Vessel Disease Ann. Thorac. Surg., July 1, 1997; 64(1): 159 - 162. [Abstract] [Full Text]

				P. W. Boonstra, J. G. Grandjean, and M. A. Mariani Improved Method for Direct Coronary Grafting Without CPB via Anterolateral Small Thoracotomy Ann. Thorac. Surg., February 1, 1997; 63(2): 567 - 569. [Abstract] [Full Text]

				T. Carrel, P. Horber, and M. I. Turina Operation for Two-Vessel Coronary Artery Disease: Midterm Results of Bilateral ITA Grafting Versus Unilateral ITA and Saphenous Vein Grafting Ann. Thorac. Surg., November 1, 1996; 62(5): 1289 - 1294. [Abstract] [Full Text]

				L. R. Gerola, L. B. Puig, L. F. P. Moreira, G. V. Cividanes, G. P. Gemha, R. C. M. Souto, E. C. Oppi, and A. H. S. Souza Right Internal Thoracic Artery Through the Transverse Sinus in Myocardial Revascularization Ann. Thorac. Surg., June 1, 1996; 61(6): 1708 - 1712. [Abstract] [Full Text]

				H. Takemura, M. Kawasuji, N. Sakakibara, T. Tedoriya, T. Ushijima, and Y. Watanabe Internal Thoracic Artery Graft Function During Exercise Assessed by Transthoracic Doppler Echography Ann. Thorac. Surg., March 1, 1996; 61(3): 914 - 919. [Abstract] [Full Text]

				J. H. Stevens, T. A. Burdon, W. S. Peters, L. C. Siegel, M. F. Pompili, M. A. Vierra, F. G. St. Goar, G. H. Ribakove, R. S. Mitchell, and B. A. Reitz PORT-ACCESS CORONARY ARTERY BYPASS GRAFTING: A PROPOSED SURGICAL METHOD J. Thorac. Cardiovasc. Surg., March 1, 1996; 111(3): 567 - 573. [Abstract] [Full Text]

				F. D. Loop Internal-Thoracic-Artery Grafts -- Biologically Better Coronary Arteries N. Engl. J. Med., January 25, 1996; 334(4): 263 - 265. [Full Text]

				M. Nasu, T. Akasaka, T. Okazaki, M. Shinkai, H. Fujiwara, J. Sono, Y. Okada, S. Miyamoto, S. Nishiuchi, J. Yoshikawa, et al. Postoperative Flow Characteristics of Left Internal Thoracic Artery Grafts Ann. Thorac. Surg., January 1, 1995; 59(1): 154 - 162. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mary J. Boylan Bruce W. Lytle Floyd D. Loop Paul C. Taylor Delos M. Cosgrove Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boylan, M. J. Articles by Cosgrove, D. M. Search for Related Content PubMed PubMed Citation Articles by Boylan, M. J. Articles by Cosgrove, D. M.