Multiple internal mammary artery bypass grafting for coronary revascularization
Oda, T.; Miyamoto, T.; Sakata, R.; Shiraishi, Y.; Hirata, K.; Takeuchi, T.; Higuchi, K.; Pak, C.; Shinkura, N.
Nihon Kyobu Geka Gakkai 36(10): 2276-2283
1988
ISSN/ISBN: 0369-4739 PMID: 3209883 Document Number: 310652
In the 18 month period of March 1985 to August 1986, 44 patients underwent coronary revascularization with bilateral internal mammary artery (IMA) and supplemental saphenous vein grafts. There were 37 men (84%) and 7 women (16%), ranging from 19 to 68 years in age; 20 patients (45%) had three vessel disease, and 21 patients (48%) left main coronary artery disease. Current contraindications for using IMA include occlusive disease of the proximal subclavian artery, aortic arch aneurysm, need for emergency revascularization, and low flow from the transected IMA. In choosing the coronary arteries to be grafted with IMAs, four factors are considered: i) the IMA must reach the coronary artery in question without tension: ii) give preference to a coronary artery (ies) difficult to be reached at reoperation, i.e., the circumflex artery; iii) use the IMA to revascularize the coronary branch with the largest territory of normally functioning myocardium, and iv) the IMA must at least match the size of the coronary artery to be grafted. The right IMA was grafted to the circumflex artery branches via the transverse sinus in most patients. An average of 2.1 IMA grafts and 1.5 saphenous vein grafts per patient were inserted. The left IMA was anastomosed to the LAD in 33 arteries, to the diagonal branch in 12, and to the circumflex artery (ies) in 7. The right IMA was anastomosed to the LAD in 5 arteries, to the diagonal branch in 3, and to the circumflex territory via the tranverse sinus in 39 artery(ies). Eleven IMA grafts were sequential. Postoperative arteriograms were available in 37 patients: 92% (24/26) of the IMA grafts to the LAD, 85% (28/33) to the circumflex, and 94% (17/18) of the sequential IMA grafts were patient. Three patients died within 30 days of surgery, one from gastrointestinal bleeding, one from brain infarction, and one from inadequate intraoperative myocardial protection. Postoperative complications included mediastinitis in 4, and reexploration for bleeding in 3. Most of the morbid and fatal complications were observed early in the experience. Routine bilateral IMA grafting for coronary bypass is safe, the early patency being better than with saphenous vein grafting.