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The Journal of Thoracic and Cardiovascular Surgery, Vol 98, 902-907, Copyright © 1989 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
EL Jones, OM Lattouf and WS Weintraub
Inappropriate use of the internal mammary artery for complex coronary
artery bypass operations may have disastrous yet avoidable consequences. In
712 consecutive coronary artery bypass operations performed between January
1985 and September 1986, five patients had an intraoperative course
suggesting internal mammary artery hypoperfusion. In three, coronary artery
bypass was performed as a reoperative procedure. The following similarities
were noted in all five patients: a technically satisfactory internal
mammary artery anastomosis, a left anterior descending coronary artery
having critical proximal stenosis (greater than or equal to 90%), a distal
artery at least 2.0 mm diameter free of disease, satisfactory left
ventricular function, a catastrophic clinical outcome (death in three,
cardiac transplantation in one, 3-month hospitalization in one), and all
patients could be weaned from cardiopulmonary bypass only after insertion
of a saphenous vein graft distal to the internal mammary artery graft.
Bilateral internal mammary grafts were used in four of five patients. In
both patients without prior coronary artery bypass, there was a discrepancy
in internal mammary artery flow and myocardial demand: cardiac hypertrophy,
large (2.5 mm) distal left anterior descending supplied by a small (less
than 2.0 mm) internal mammary artery, and sequentially grafted arteries.
All three patients having reoperative coronary artery bypass had normal
anterior wall motion, and in two of the three patients, the left anterior
descending-saphenous vein graft was arteriographically normal and the sole
source of blood to the anterior, septum, and inferior myocardium. In two
patients the normal left anterior descending-saphenous vein graft supply a
large left anterior descending (greater than 2.0 mm) was replaced with a
small left internal mammary artery. Internal mammary artery hypoperfusion
typically occurred 30 to 40 minutes after discontinuation of
cardiopulmonary bypass but was also seen in the intensive care unit. The
condition may be confused with internal mammary artery or coronary artery
spasm. It may be avoided by careful prebypass planning of the operation,
intraoperative assessment of internal mammary artery flow and size with
prudent use of sequential internal mammary artery grafting, avoiding use of
the terminal left anterior descending (unless large), retaining
nonobstructed saphenous vein grafts when the internal mammary artery has
marginal flow or size, and placement of a saphenous vein graft distal to
the left internal mammary artery when size or flow in the latter is small.
ARTICLES
Catastrophic consequences of internal mammary artery hypoperfusion
Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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A. J. Tector, D. C. Kress, S. M. Amundsen, F. X. Downey, and T. M. Schmahl Reoperation in Patients With Closed SVG and Patent LITA-LAD Graft: T-Graft Approach Ann. Thorac. Surg., June 1, 1995; 59(6): 1509 - 1512. [Abstract] [Full Text]
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J. A. Barra, E. Bezon, J. Mansourati, I. Rukbi, P. Mondine, and Y. Youssef Reimplantation of the right internal thoracic artery as a free graft into the left in situ internal thoracic artery (Y Procedure): One-year angiographic results J. Thorac. Cardiovasc. Surg., June 1, 1995; 109(6): 1042 - 1048. [Abstract] [Full Text]
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M. Otaki, R. M. Lust, Y. S. Sun, T. O. Norton, and W. R. Chitwood Jr Distal Flow Determinants in Canine Myocardium Perfused Through Internal Thoracic Artery Bypass Grafts Ann. Thorac. Surg., April 1, 1995; 59(4): 829 - 834. [Abstract] [Full Text]
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L. Sasson, A. J. Cohen, E. Hauptman, and A. Schachner Effect of Topical Vasodilators on Internal Mammary Arteries Ann. Thorac. Surg., February 1, 1995; 59(2): 494 - 496. [Abstract] [Full Text]
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H. Tatar, S. Cicek, H. Suer, A. T. Yilmaz, O. Y. Ozturk, and R. D. Narbay Use of topical sodium nitroprusside to relieve perioperative spasm of the internal mammary artery: A word of caution J. Thorac. Cardiovasc. Surg., August 1, 1994; 108(2): 387 - 387. [Full Text]
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M. B. Izzat, R. R. West, C. Ragoonanan, and G. D. Angelini Effect of systemic vasodilators on internal mammary artery flowImplications for postoperative treatment after myocardial revascularization J. Thorac. Cardiovasc. Surg., July 1, 1994; 108(1): 82 - 85. [Abstract] [Full Text]
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B. W. Lytle, D. McElroy, P. McCarthy, F. D. Loop, P. C. Taylor, M. Goormastic, R. W. Stewart, and D. M. Cosgrove Influence of arterial coronary bypass grafts on the mortality in coronary reoperations J. Thorac. Cardiovasc. Surg., March 1, 1994; 107(3): 675 - 683. [Abstract] [Full Text]
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