JTCS KCI
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Miralem Pasic
Roland Hetzer
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pasic, M.
Right arrow Articles by Hetzer, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pasic, M.
Right arrow Articles by Hetzer, R.
Related Collections
Right arrow Coronary disease

J Thorac Cardiovasc Surg 2005;129:1180-1182
© 2005 The American Association for Thoracic Surgery

Brief Communications

Reimplantation of a left internal thoracic artery during repeat coronary artery revascularization: Early and midterm results

Miralem Pasic, MD, PhD*, Peter Müller, MD, Peter Bergs, MD, Ilirijana Karabdic, MD, Wolfgang Ruisz, MD, Michael Hofmann, MD, Roland Hetzer, MD, PhD

Deutsches Herzzentrum Berlin, Berlin, Germany.

Received for publication September 20, 2004; accepted for publication September 27, 2004.

* Address for reprints: Professor Miralem Pasic, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany (E-mail: pasic{at}dhzb.de).

When used as an aorta-coronary bypass graft, the left internal thoracic artery (LITA) might remain open, despite significant restriction of flow through the graft. Potentially, a patent but nonfunctioning LITA might be reharvested and reused for repeat coronary artery bypass surgery (so-called LITA recycling). We report on our experience with successful reimplantation of the LITA during redo bypass surgery in 12 patients.

Patients and methods

Between 1997 and 2003, the LITA was reharvested and reinserted in 12 patients undergoing repeat coronary artery bypass grafting. There were 3 women and 9 men. The mean ± SD age of the patients was 64 ± 7 years (range, 53–74 years). Written informed consent was obtained from all patients. The patients’ mean left ventricular ejection fraction was 38% ± 16% (range, 25%-60%). The patent but nonfunctioning LITA was reused only if preoperative coronary angiography showed that the diameter of the LITA lumen was normal or almost normal. This was assessed by the respective surgeon according to his experience, and he considered it to be feasible.

The causes of LITA dysfunction were anastomotic problems in 7 patients and progression of atherosclerotic disease of the native vessel distal to the previous anastomosis in 5 patients. Stenosis of the anastomosis between the LITA and the left anterior descending coronary artery (LAD; Figure 1) was found in 5 patients and between the LITA and another vessel in 2 patients. Two patients had minimally invasive bypass grafting (off pump) in another institution and were referred to our hospital for redo operations. Reimplantation of the LITA was performed 6 months to 11 years (mean, 4.3 ± 3 years) after the first operation. In 7 patients with anastomotic problems, the interval between the first LITA implantation and LITA reimplantation ranged between 6 months and 6.6 years (mean, 2.6 ± 2.3 years). In 5 patients with distal progression of the atherosclerotic process in the native coronary artery, the interval was between 2.1 and 11 years (mean, 6.5 ± 2.8 years).


Figure 1
View larger version (145K):
[in this window]
[in a new window]
  		Figure 1. Preoperative coronary angiography showing stenosis of the anastomosis between the LITA and the LAD. The LITA is patent but nonfunctional.

 
During the operation, the LITA graft was identified and carefully dissected, retaining its original pedicle. To gain more length of the LITA pedicle, the LITA was always additionally dissected proximally toward its origin. In 8 patients the LITA was then directly reinserted into the distal LAD (Figure 2). In 4 patients the LITA graft was assessed as still too short, and additionally, it was either skeletonized (in 1 patient) or prolonged with a short (2–4 cm) segment of the greater saphenous vein (in 3 patients) before reimplantation into the distal LAD. The LITA graft was reimplanted during redo coronary artery bypass surgery as a single bypass in 3 patients, in combination with mitral valve reconstruction in 1 patient, and in combinations with mitral valve replacement in 1 patient. The procedures were performed either conventionally by using cardiopulmonary bypass with mild hypothermia (32°C) or as a minimally invasive procedure on the beating heart without cardiopulmonary bypass (off pump). There were no technical problems during the operations, and the postoperative course was uneventful in all patients. The mean follow-up after surgical intervention was 4.4 ± 2.4 years (range, 4 months to 7 years). Coronary artery angiographic examination was performed in 10 patients postoperatively. Two patients refused angiography because they had no symptoms. The examinations demonstrated patent LITA grafts with excellent flow in all patients. No stenosis was found in any reused LITA graft.


Figure 2
View larger version (161K):
[in this window]
[in a new window]
  		Figure 2. The LITA is reharvested and directly reinserted distally to the site of subtotal occlusion of the LAD.

 
Discussion

The reimplantation of a patent but nonfunctioning LITA graft is an infrequent clinical situation for which no evidence-based therapeutic strategy is established. Our experience shows that the reuse of a patent but nonfunctioning LITA graft is a feasible, safe, and effective option in selected situations. There was no early mortality, and the midterm postoperative results were excellent.

The incidence of the patent but nonfunctional LITA is very low because the LITA has the best patency among all bypass grafts for coronary artery revascularization. There are only exceptional reports on the reimplantation of a LITA graft during repeat coronary artery bypass revascularization and only in few patients.1–6 Although our experience includes only 12 patients, it represents the worldwide largest experience in dealing with reuse of the LITA. The results are favorable and encourage further use of such patent but nonfunctional arterial grafts. Therefore, we suggest that the reimplantation of the LITA graft should be used in ideal circumstances.

References

  1. Noyez L, Lacquet LK. Recycling of the internal mammary artery in coronary reoperation. Ann Thorac Surg 1993;55:597-599.[Abstract/Free Full Text]
  2. Antona C, Parolari A, Zanobini M, Arena V, Biglioli P. Midterm angiographic study of five recycled mammary arteries during four coronary redos. Ann Thorac Surg 1966;61:702-705.
  3. Velebit V, Maurice JP. Recycling of mammary arteries [Letter]. Ann Thorac Surg 1996;62:947-949.[Free Full Text]
  4. Noirhomme PH, Underwood MJ, El Khoury GA, et al. Recycling of arterial grafts during reoperative coronary artery operations. Ann Thorac Surg 1999;67:641-644.[Abstract/Free Full Text]
  5. Scioti G, Cabib M, Balbarini A, et al. Late patency of recycled internal mammary artery. verification by Doppler echocardiography and coronary angiography. Tex Heart Inst J 1999;26:303-305.[Medline]
  6. Uwabe K, Endo M, Kurihara H, Yoshida. Re-use of left internal thoracic artery for redo operation after MIDCAB. J Cardiovasc Surg 2000;41:399-400.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
B. El Oumeiri, D. Glineur, J. Price, M. Boodhwani, P. Yves Etienne, A. Poncelet, L. De Kerchove, S. Papadatos, P. Noirhomme, and G. El Khoury
Recycling of Internal Thoracic Arteries in Reoperative Coronary Surgery: In-Hospital and Midterm Results
Ann. Thorac. Surg., April 1, 2011; 91(4): 1165 - 1168.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Miralem Pasic
Roland Hetzer
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pasic, M.
Right arrow Articles by Hetzer, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pasic, M.
Right arrow Articles by Hetzer, R.
Related Collections
Right arrow Coronary disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS