Long-term results of internal mammary artery implantation for coronary artery disease: a controlled trial by the participants of the Veterans Administration Coronary Bypass Surgery Cooperative Study Group

Vineberg operation: a review of the birth and impact of this surgical technique

The Vineberg operation was introduced by Arthur Vineberg in the early 1940s as an experimental model for revascularization of ischemic cardiac tissue in animal models with direct implantation of left internal mammary artery into ventricular myocardium. The first attempt in a human was performed in 1950, followed by 10,000 to 15,000 Vineberg operations completed in the 1950s and 1960s until the birth of coronary artery bypass grafting. We report a historical perspective, birth and impact of this surgical technique, and possible implications for the future of cardiology and cardiac surgery.

The vineberg procedure revisited: Angiographic evaluation and coronary artery bypass surgery in a patient 21 years following bilateral internal mammary artery implantation

A patient receiving bilateral internal mammary implantation (Vineberg's operation) in 1969 was symptom free for a period of 21 years. In 1990 he developed acute myocardial infarction followed by post-infarction angina. Cardiac catheterization revealed severe left main and three vessel disease and patency of both mammary implants which filled the left anterior descending and circumflex coronary arteries via collaterals. Coronary artery bypass surgery was indicated due to the native coronary artery disease and inability of the internal mammary grafts' blood flow to alleviate symptoms. The patient underwent direct coronary artery bypass grafting utilizing femoral vessels for cannulation and saphenous veins for grafting, while preserving the mammary implants. This unique case attests to the longevity of the internal mammary artery grafts. These grafts, even if directly implanted, can serve as a crucial source of blood to an otherwise severely underperfused myocardium. Strategy and technical aspects of surgical redo in patients who underwent Vineberg's operation are discussed.

Long-term follow-up of the Vineberg internal mammary artery implant procedure

This report describes the 20-year follow-up of a patient who had undergone a double internal mammary implantation for coronary occlusive disease. A lack of similar reports in the literature suggests that such survival is rare, but this case indeed documents the fact that the internal mammary arteries can revascularize the myocardium, and this patient's continued survival appears to depend entirely on this collateral blood flow.

A potpourri of RCT topics

(1. Randomization of the first patient. At least six examples are known to the author, and there are undoubtedly others. (2. Factorially structured treatments. The advantages of conducting two trials in the same patients when there is no suggestion of interaction, and documenting interaction if it exists must be weighed against the potential loss of power and the inconvenience of missing values. (3. RCT control groups as a source of unnatural history. Such a small percentage of apparently suitable patients are actually randomized in most clinical trials that be control group can never the considered representative of that disease seen by practicing physicians. (4. Bias in random and nonrandom treatment assignments. Differences in risk factors documented before randomization can be as much responsible for differences in outcome as the treatments under study. (5. Time lags between innovation, RCTs, and practice. These have varied from a very few years (coronary bypass operations) to 154 years (treatment of scurvy).

Randomized versus historical controls for clinical trials

To compare the use of randomized controls (RCTs) and historical controls (HCTs) for clinical trials, we searched the literature for therapies studied by both methods. We found six therapies for which 50 RCTs and 56 HCTs were reported. Forty-four of 56 HCTs (79 percent) found the therapy better than the control regimen, but only 10 of 50 RCTs (20 percent) agreed. For each therapy, the treated patients in RCTs and HCTs of the same therapy was largely due to differences in outcome for the control groups, with HCT control patients generally doing worse than the RCT control groups. Adjustment of the outcomes of the HCTs for prognostic factors, when possible, did not appreciably change the results. The data suggest that biases in patient selection may irretrievably weight the outcome of HCts in favor of new therapies. RCTs may miss clinically important benefits because of inadequate attention to sample size. The predictive value of each might be improved by reconsidering the use of p less than 0.05 as the significance level for all types of clinical trials, and by the use of confidence intervals around estimates of treatment effects.