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Kunihara T, Shingu Y, Wakasa S, Sugiki H, Kamikubo Y, Shiiya N, Matsui Y. Blood flow characteristics of the bilateral internal thoracic artery: implications of optimal graft configuration for coronary artery bypass grafting to maximize blood supply. Gen Thorac Cardiovasc Surg 2023; 71:552-560. [PMID: 36995639 DOI: 10.1007/s11748-023-01930-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/15/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE There is controversy regarding which internal thoracic artery (ITA) should be anastomosed to the left anterior descending artery (LAD). Here, we propose an optimal graft design based on measurement of blood flow in the ITA. METHODS Sixty-one patients (53 men, median age 68 [62-75] years) undergoing first elective coronary artery bypass grafting were enrolled. Fifty-seven left ITAs (LITAs) and 28 right ITAs (RITAs) were harvested in either a semi-skeletonized manner using a harmonic scalpel covered with papaverine-soaked gauze (group-A, n = 45) or a fully skeletonized manner using electrocautery with intraluminal papaverine injection (group-B, n = 41). Free flow of 33 ITAs was measured after pharmacological dilatation and in situ ITA-LAD flow was measured in 59 patients by transit-time flowmetry. RESULTS RITA and LITA free flow were 147.0 [87.8-213.0] mL/min and 108.0 [90.0-144.0] mL/min, respectively (P = 0.199). The group-B had significantly higher ITA free flow (135.0 [102.0-171.0] mL/min) than group-A (63.0 [36.0-96.0] mL/min, P = 0.009). In 13 patients with bilateral ITA harvesting, free flow of the RITA (138.0 [79.5-204.0] mL/min) was also significantly higher than the LITA (102.0 [81.0-138.0] mL/min, P = 0.046). There was no significant difference between RITA and LITA flow anastomosed to the LAD. The group-B had significantly higher ITA-LAD flow (56.5 [32.3-73.6] mL/min) than group-A (40.9 [20.1-53.7] mL/min, P = 0.023). CONCLUSION RITA provides significantly higher free flow than LITA but similar blood flow to the LAD. Full skeletonization with intraluminal papaverine injection maximizes both free flow and ITA-LAD flow.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Yasushige Shingu
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoru Wakasa
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Sugiki
- Department of Cardiovascular Surgery, NTT EAST Medical Center Sapporo, Sapporo, Japan
| | - Yasuhiro Kamikubo
- Department of Cardiovascular Surgery, Kushiro City General Hospital, Kushiro, Japan
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yoshiro Matsui
- Department of Cardiovascular Surgery, Hanaoka Seishu Memorial Cardiovascular Clinic, Sapporo, Japan
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Crielaard H, Hoogewerf M, van Putte BP, van de Vosse FN, Vlachojannis GJ, Stecher D, Stijnen M, Doevendans PA. Evaluating the Arteriotomy Size of a New Sutureless Coronary Anastomosis Using a Finite Volume Approach. J Cardiovasc Transl Res 2023; 16:916-926. [PMID: 36943615 PMCID: PMC10480236 DOI: 10.1007/s12265-023-10367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics. METHODS A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm2; varied 0.94 - 3.6 mm2) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR). RESULTS The current size ELANA (arteriotomy 1.43 mm2) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm2) surpassed the coronary cross-sectional area (2.69 mm2, i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow. CONCLUSION The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised.
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Affiliation(s)
- Hanneke Crielaard
- LifeTec Group, Eindhoven, The Netherlands
- Department of Cardiovascular Biomechanics, University of Eindhoven, Eindhoven, The Netherlands
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marieke Hoogewerf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Bart P van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frans N van de Vosse
- Department of Cardiovascular Biomechanics, University of Eindhoven, Eindhoven, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - David Stecher
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
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3
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Scicchitano P, De Palo M, Parisi G, Gioia MI, Ciccone MM. Doppler Ultrasound Selection and Follow-Up of the Internal Mammary Artery as Coronary Graft. Biomedicines 2022; 11:biomedicines11010066. [PMID: 36672574 PMCID: PMC9856174 DOI: 10.3390/biomedicines11010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/17/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
The impact of coronary artery disease (CAD) on all-cause mortality and overall disabilities is well-established. Percutaneous and/or surgical coronary revascularization procedures dramatically reduced the occurrence of adverse cardiovascular events in patients suffering from atherosclerosis. Specifically, guidelines from the European Society of Cardiology on the management of myocardial revascularization promoted coronary artery by-pass graft (CABG) intervention in patients with specific alterations in the coronary tree due to the higher beneficial effects of this procedure as compared to the percutaneous one. The left internal mammary artery (LIMA) is one of the best-performing vessels in CABG procedures due to its location and its own structural characteristics. Nevertheless, the non-invasive assessment of its patency is challenging. Doppler ultrasonography (DU) might perform as a reliable technique for the non-invasive evaluation of the patency of LIMA. Data from the literature revealed that DU may detect severe (>70%) stenosis of the LIMA graft. In this case, pulsed-wave Doppler might show peak diastolic velocity/peak systolic velocity < 0.5 and diastolic fraction < 50%. A stress test might also be adopted for the evaluation of patency of LIMA through DU. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow-up after CABG intervention.
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Affiliation(s)
- Pietro Scicchitano
- Department of Cardiology, Hospital ‘F. Perinei’ Altamura, 70022 Altamura, Italy
- Correspondence:
| | - Micaela De Palo
- Department of Cardiac Surgery, University ‘A. Moro’ Bari, 70124 Bari, Italy
| | - Giuseppe Parisi
- Department of Cardiology, Hospital ‘S. Paolo’ Bari, 70124 Bari, Italy
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4
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Kraler S, Libby P, Evans PC, Akhmedov A, Schmiady MO, Reinehr M, Camici GG, Lüscher TF. Resilience of the Internal Mammary Artery to Atherogenesis: Shifting From Risk to Resistance to Address Unmet Needs. Arterioscler Thromb Vasc Biol 2021; 41:2237-2251. [PMID: 34107731 PMCID: PMC8299999 DOI: 10.1161/atvbaha.121.316256] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Fueled by the global surge in aging, atherosclerotic cardiovascular disease reached pandemic dimensions putting affected individuals at enhanced risk of myocardial infarction, stroke, and premature death. Atherosclerosis is a systemic disease driven by a wide spectrum of factors, including cholesterol, pressure, and disturbed flow. Although all arterial beds encounter a similar atherogenic milieu, the development of atheromatous lesions occurs discontinuously across the vascular system. Indeed, the internal mammary artery possesses unique biological properties that confer protection to intimal growth and atherosclerotic plaque formation, thus making it a conduit of choice for coronary artery bypass grafting. Its endothelium abundantly expresses nitric oxide synthase and shows accentuated nitric oxide release, while its vascular smooth muscle cells exhibit reduced tissue factor expression, high tPA (tissue-type plasminogen activator) production and blunted migration and proliferation, which may collectively mitigate intimal thickening and ultimately the evolution of atheromatous plaques. We aim here to provide insights into the anatomy, physiology, cellular, and molecular aspects of the internal mammary artery thereby elucidating its remarkable resistance to atherogenesis. We propose a change in perspective from risk to resilience to decipher mechanisms of atheroresistance and eventually identification of novel therapeutic targets presently not addressed by currently available remedies.
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Affiliation(s)
- Simon Kraler
- Center for Molecular Cardiology, University of Zürich, 8952 Schlieren, Switzerland
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Paul C. Evans
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Alexander Akhmedov
- Center for Molecular Cardiology, University of Zürich, 8952 Schlieren, Switzerland
| | - Martin O. Schmiady
- Clinic for Cardiac Surgery, University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Michael Reinehr
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Giovanni G. Camici
- Center for Molecular Cardiology, University of Zürich, 8952 Schlieren, Switzerland
- University Heart Center, Department of Cardiology, University Hospital, Zurich, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F. Lüscher
- Center for Molecular Cardiology, University of Zürich, 8952 Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College, London, United Kingdom
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5
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Duijvelshoff R, Cabrera MS, Sanders B, Dekker S, Smits AIPM, Baaijens FPT, Bouten CVC. Transcatheter-Delivered Expandable Bioresorbable Polymeric Graft With Stenting Capacity Induces Vascular Regeneration. ACTA ACUST UNITED AC 2020; 5:1095-1110. [PMID: 33294741 PMCID: PMC7691284 DOI: 10.1016/j.jacbts.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 01/22/2023]
Abstract
We designed a transcatheter balloon-expandable resorbable vascular graft with support capacity. After 2 months in vivo, grafts show native-like tissue reconstruction with endoluminal elastin. The concept convenes regenerative grafting, minimally invasive delivery, and clinical stenting.
As the next step in the translation of vascular tissue engineering, this study uniquely combines transcatheter delivery and in situ tissue regeneration using a novel bioresorbable electrospun polymer graft that can be implanted minimally invasively. Once delivered inside a small-diameter vessel, the electrospun microstructure supports the vessel wall, facilitates cellular infiltration, and guides organized tissue formation.
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Key Words
- BVS, bioresorbable vascular scaffold(s)
- ECM, extracellular matrix
- GPC, gel permeation chromatography
- Mw, weight-average molecular weight
- PBS, phosphate-buffered saline
- SEM, scanning electron microscopy
- SMA, smooth muscle actin
- SMC, smooth muscle cell
- T-TEVG, transcatheter tissue-engineered vascular graft
- TE, tissue engineering
- elastin
- regeneration
- tissue engineering
- transcatheter delivery
- vascular graft
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Affiliation(s)
- Renee Duijvelshoff
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Institute for Complex Molecular Systems, Eindhoven, the Netherlands
| | | | | | - Sylvia Dekker
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Anthal I P M Smits
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Institute for Complex Molecular Systems, Eindhoven, the Netherlands
| | - Frank P T Baaijens
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Institute for Complex Molecular Systems, Eindhoven, the Netherlands
| | - Carlijn V C Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Institute for Complex Molecular Systems, Eindhoven, the Netherlands
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Nishigawa K, Fukui T, Hagiya K, Tobaru T, Uemura K, Takanashi S. Propensity score-matched analysis of coronary artery bypass grafting versus second-generation drug-eluting stents for triple-vessel disease. Eur J Cardiothorac Surg 2019; 55:1152-1159. [PMID: 30561571 DOI: 10.1093/ejcts/ezy415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/05/2018] [Accepted: 11/03/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to compare the mid-term results of coronary artery bypass grafting (CABG) with those of percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DESs) for triple-vessel disease. METHODS Between February 2010 and December 2015, 607 patients underwent primary isolated CABG and 264 patients underwent PCI with second-generation DESs (everolimus-eluting stent, biolimus-eluting stent or zotarolimus-eluting stent) for triple-vessel disease with or without left main disease. We compared the CABG group with the second-generation DES group using propensity score matching analysis. The study end points were major adverse cardiac and cerebrovascular events. RESULTS After propensity score matching, 238 pairs of patients were successfully matched (C-statistic 0.762). The mean number of distal anastomoses in the CABG group was 4.7 and that of implanted stents in the second-generation DES group was 2.8. The 30-day mortality was similar between the groups (0.8% vs 0.4%; P = 0.564). The median follow-up period was 3.4 years in the CABG group and 3.8 years in the second-generation DES group. Although there was no significant difference in the incidence of all-cause death and cerebrovascular accidents, the incidence of myocardial infarction [hazard ratio (HR) 11.76; 95% confidence interval (CI) 2.32-214.15, P = 0.003] and repeat revascularization (HR 3.78; 95% CI 2.35-6.38; P < 0.001) was significantly higher in the second-generation DES group than in the CABG group. This resulted in a higher incidence of major adverse cardiac and cerebrovascular events (HR 2.27; 95% CI 1.61-3.24; P < 0.001). CONCLUSIONS CABG might be superior to PCI with second-generation DESs for treatment of triple-vessel disease in terms of major adverse cardiac and cerebrovascular events.
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Affiliation(s)
- Kosaku Nishigawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Kenichi Hagiya
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Tetsuya Tobaru
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Kohei Uemura
- Biostatistics and Bioinformatics Course, The University of Tokyo, Tokyo, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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7
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Histomorphometric analysis of the human internal thoracic artery and relationship with cardiovascular risk factors. PLoS One 2019; 14:e0211421. [PMID: 30682154 PMCID: PMC6347214 DOI: 10.1371/journal.pone.0211421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/31/2018] [Indexed: 11/19/2022] Open
Abstract
In this study, we aimed at performing a histomorphometric analysis of human left internal thoracic artery (ITA) samples as well as at correlating the histomorphometric findings with the clinical profile, including risk factors and medication. Distal segments of ITA were obtained from 54 patients undergoing coronary artery bypass grafting. Histological observation was performed in paraffin-embedded transverse sections of ITA through four staining protocols: hematoxylin-eosin, van Gieson, Masson’s trichrome and von Kossa. Morphometric analysis included the intimal width (IW), medial width (MW) and intima/media ratio (IMR). No overt atherosclerotic lesions were observed. Mild calcifications were observed across the vascular wall layers in almost all samples. Multivariable linear regression analysis showed associations between IW and IMR and the following clinical variables: age, gender, kidney function expressed as eGFR and myocardial infarction history. Age (odds ratio = 1.16, P = 0.004), female gender (odds ratio = 11.34, P = 0.011), eGFR (odds ratio = 1.03, P = 0.059) and myocardial infarction history (odds ratio = 4.81, P = 0.040) were identified as the main clinical predictors for intimal hyperplasia. Preatherosclerotic lesions in ITA samples from patients undergoing coronary revascularization were associated not only with classical cardiovascular risk factors such as age and gender, but also with other clinical variables, namely kidney function and myocardial infarction history.
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8
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Fonseca DA, Antunes PE, Antunes MJ, Cotrim MD. Vasomotion as an oscillatory sign of functional impairment in the human internal thoracic artery: A study based on risk factors and vessel reactivity. Exp Physiol 2018; 103:1030-1038. [PMID: 29714043 DOI: 10.1113/ep087002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/24/2018] [Indexed: 01/14/2023]
Abstract
NEW FINDINGS What is the central question of this study? Vasomotion has been viewed as a rhythmic oscillation of the vascular tone that is physiologically important for optimal tissue perfusion. Also, it has been studied primarily in the microcirculation. However, the precise underlying mechanisms and the physiological significance remain unknown. What is the main finding and its importance? Vasomotion is not specific to the microcirculation, as shown by our findings. In human arteries from patients undergoing cardiac surgery, an increased incidence was associated with endothelial dysfunction settings. Therefore, this oscillatory behaviour might be a signal of functional impairment and not of integrity. ABSTRACT Vasomotion has been defined as the rhythmic oscillation of the vascular tone, involved in the control of the blood flow and subsequent tissue perfusion. Our aims were to study the incidence of vasomotion in the human internal thoracic artery and the correlation of this phenomenon with the clinical profile and parameters of vascular reactivity. In our study, vasomotion was elicited with a single-dose contractile stimulation of noradrenaline (10 μm) in internal thoracic artery segments, from patients undergoing coronary artery bypass grafting, mounted in tissue organ bath chambers. The incidence was 29.1%. Vessel samples with vasomotion presented significantly higher contractility in response to both potassium chloride (maximal response or Emax of 7.65 ± 5.81 mN versus 4.52 ± 3.73 mN in control vessels, P = 0.024) and noradrenaline (Emax of 7.60 ± 5.93 mN versus 2.96 ± 4.41 mN in control vessels, P < 0.001). Predictive modelling through multivariable logistic regression analysis showed that female sex (odds ratio = 9.82) and increasing maximal response to noradrenaline (odds ratio = 1.19, per 1 mN increase) were associated with a higher probability of the occurrence of vasomotion, whereas increasing kidney function (expressed as estimated glomerular filtration rate) was associated with a lower probability (odds ratio = 0.97, per 1 ml min-1 (1.73 m)-2 ]. Our results provide a characterization of the phenomenon of vasomotion in the internal thoracic artery and suggest that vasomotion might be associated with endothelial dysfunction settings, as determined by a multivariable analysis approach. Considering the associations observed in our results, vasomotion might be a signal of functional impairment and not of integrity.
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Affiliation(s)
- Diogo A Fonseca
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,CNC.iCBR, University of Coimbra, Coimbra, Portugal
| | - Pedro E Antunes
- Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine of Coimbra, Coimbra, Portugal
| | - Manuel J Antunes
- Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine of Coimbra, Coimbra, Portugal
| | - Maria Dulce Cotrim
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,CNC.iCBR, University of Coimbra, Coimbra, Portugal
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9
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Ultrastructural and histomorphologic properties of the internal thoracic artery: implications for coronary revascularization. Coron Artery Dis 2017; 28:518-527. [PMID: 28678142 DOI: 10.1097/mca.0000000000000527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Coronary artery disease represents a major health problem worldwide for which coronary artery bypass surgery remains a standard of care. Among the several grafts that are available, the internal thoracic artery (ITA) has long been considered the best as several advantages have been described compared with other vessels (e.g. saphenous vein or radial artery), namely, an absent to minor atherosclerotic development. In fact, several studies showed the presence of preatherosclerotic lesions, such as intimal and/or medial thickening, medial fibrosis, among others, in the presence of certain cardiovascular risk factors as well as established atherosclerotic lesions (i.e. type II or more lesions). This paper primarily aimed at reviewing the current knowledge on the histomorphological characteristics of ITA as well as the comparative histomorphology of ITA with other vessel grafts currently in use in coronary surgery. As some of the evidence is not clear or consensual, this paper also aimed at reviewing the main histopathological, histomorphometrical, and ultrastructural findings in ITAs from patients with known cardiovascular risk factors (e.g. aging, obesity, hypertension, diabetes, smoking, and others). As the presence of preatherosclerotic and/or atherosclerotic lesions may compromise the success of the myocardial revascularization and lead to graft failure, contributing toward the associated morbidity and/or mortality, it is essential to improve the scientific knowledge on the structural characterization of ITAs and its correlation with the cardiovascular risk profile.
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10
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Martínez-González B, Reyes-Hernández CG, Quiroga-Garza A, Rodríguez-Rodríguez VE, Esparza-Hernández CN, Elizondo-Omaña RE, Guzmán-López S. Conduits Used in Coronary Artery Bypass Grafting: A Review of Morphological Studies. Ann Thorac Cardiovasc Surg 2017; 23:55-65. [PMID: 28202895 DOI: 10.5761/atcs.ra.16-00178] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is a significant variety of vascular conduits options for coronary bypass surgery. Adequate graft selection is the most important factor for the success of the intervention. To ensure durability, permeability, and bypass function, there must be a morphological similarity between the graft and the coronary artery. The objective of this review was to analyze the morphological characteristics of the grafts that are most commonly used in coronary bypass surgery and the coronary arteries that are most frequently occluded. We included clinical information regarding the characteristics that determine the behavior of the grafts and its permeability over time. Currently, the internal thoracic artery is the standard choice for bypass surgery because of the morphological characteristics of the wall that makes less prone to developing atherosclerosis and hyperplasia. The radial and right gastroepiploic arteries are the following second and third best options, respectively. The ulnar artery is the preferred choice when other conduits are not feasible.
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Affiliation(s)
- Brenda Martínez-González
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Cynthia Guadalupe Reyes-Hernández
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Alejandro Quiroga-Garza
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Víctor E Rodríguez-Rodríguez
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Claudia N Esparza-Hernández
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Rodrigo E Elizondo-Omaña
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
| | - Santos Guzmán-López
- Faculty of Medicine, Human Anatomy Department and University Hospital "Dr. Jose Eleuterio González", Universidad Autonoma de Nuevo León (UANL), Monterrey NL, Mexico
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11
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Endothelial dysfunction of internal thoracic artery graft in patients with chronic kidney disease. J Thorac Cardiovasc Surg 2017; 153:317-324.e1. [DOI: 10.1016/j.jtcvs.2016.09.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 07/26/2016] [Accepted: 09/08/2016] [Indexed: 11/21/2022]
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12
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Yoshida S, Numata S, Tsutsumi Y, Monta O, Yamazaki S, Seo H, Samura T, Ohashi H. Short- and long-term results of radial artery and saphenous vein grafts in the right coronary system: a propensity-matched study. Surg Today 2016; 47:335-343. [PMID: 27506754 DOI: 10.1007/s00595-016-1396-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 06/14/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE The selection of optimal grafts for the right coronary artery remains controversial. This study aims to evaluate the short- and long-term results of radial artery (RA) grafts and saphenous vein grafts (SVGs) to the right coronary artery. METHODS We reviewed, retrospectively, isolated coronary artery bypass grafts, placed between 1997 and 2007, and compared the long-term results of patients who received RA (n = 110) grafts with those of patients who received SVGs (n = 264) using propensity-score matching for risk. The preoperative predictors of graft occlusion were investigated on a per case basis. RESULTS Superior survival was noted in the unmatched RA group, but late outcomes after propensity-score matching yielded 91 patient pairs that were similar in the two groups. Graft failure was not correlated with mortality, but showed strong correlation with cardiac events in all patients. The predictors of graft occlusion in the RA group were mild proximal stenosis and low indexing glomerular filtration rates for body surface area, whereas those in the SVG were female gender and off-pump coronary artery bypass grafting. CONCLUSIONS There were no significant differences in long-term outcomes between the RA and SVG groups. Predictors of graft occlusion differed between the groups. Notably, renal dysfunction impaired radial patency, emphasizing the importance of careful graft selection.
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Affiliation(s)
- Shohei Yoshida
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan.
| | - Yasushi Tsutsumi
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Osamu Monta
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Sachiko Yamazaki
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Hiroyuki Seo
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Takaaki Samura
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
| | - Hirokazu Ohashi
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui, 910-0833, Japan
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Nakajima T, Tachibana K, Takagi N, Ito T, Kawaharada N. Histomorphologic superiority of internal thoracic arteries over right gastroepiploic arteries for coronary bypass. J Thorac Cardiovasc Surg 2016; 151:1704-8. [PMID: 26971376 DOI: 10.1016/j.jtcvs.2016.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/15/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In this study, we compared the histologic and morphometric properties of both internal thoracic arteries and the right gastroepiploic artery (GEA) in patients undergoing coronary artery bypass grafting (CABG). METHODS We microscopically examined transverse sections of segments of both internal thoracic arteries and the right GEA obtained from 83 consecutive patients who underwent CABG. RESULTS There were no significant differences between the internal thoracic arteries. Significant differences were found between the left and right internal thoracic arteries and GEA in the intimal width (21.8, 21.5, and 71.7 μm, respectively; P < .01), intima-to-media ratio (0.286, 0.256, and 0.749, respectively; P < .01), and media width (148.5, 157.5, and 164.8 μm, respectively; P = .43). No atherosclerotic lesions, medial calcification, or intimal thickening were seen in the internal thoracic arteries; however, atherosclerotic lesions were seen in the GEA. The intima of the GEA was thicker than that of the internal thoracic arteries. Intimal thickening of the GEA, but not the internal thoracic arteries, was positively correlated with risk of arteriosclerosis. In patients with diabetes mellitus, dietary/drug therapy and insulin therapy were associated with GEA intimal thickness (P = .02 and .01, respectively). CONCLUSIONS The internal thoracic arteries have equivalent histologic and morphometric properties that differ from those of the GEA only in intimal width. The former had no intimal thickening, and is thus preferable to the GEA for CABG.
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Affiliation(s)
- Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Kazutoshi Tachibana
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuyuki Takagi
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiro Ito
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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14
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Mamchur S, Bokhan N, Vecherskii Y, Malyshenko E. Micromorphology of Skeletonized and Pedicled Internal Thoracic and Radial Arteries. Semin Thorac Cardiovasc Surg 2015; 27:115-20. [PMID: 26686435 DOI: 10.1053/j.semtcvs.2015.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/11/2022]
Abstract
The objective of the study was to estimate the internal thoracic arteries (ITA) and radial arteries (RA) micromorphologic features by light microscopy after harvesting them using the skeletonization and pedicled methods in patients undergoing coronary artery bypass grafting. The micromorphologic characteristics of ITA and RA were studied by luminous microscopy in 61 patients undergoing coronary artery bypass grafting. A total of 122 ITA and RA segments harvested during surgery, fixed in formalin, and stained with hematoxiline and eosin were evaluated. The mean intima-media thickness of ITA was 9.2 and 134.7 µm and that of RA was 9.1 and 334.2 µm, respectively. In the distal segment of ITA the media-intima relation was 1.5 times bigger than in the proximal segment. None of ITA specimens contained atherosclerotic plaques or lipid inclusions. Atherosclerotic plaques were found in 3 (5%) RA specimens. Other degenerative changes were detected in 30%-74.2% of the specimens: splitting of internal elastic lamina, reduced tortuosity of the internal elastic lamina, and thickening and detachment of the intima; their incidence was associated with the skeletonization of the vessels. In conclusion, the incidence of ITA and RA degenerative changes varies from 30%-74.2% and its increase is associated with the skeletonization of the vessels, which is statistically significant. The media of the RA is 2.5 times thicker than that of the ITA (P < 0.01). This fact shows that RA has higher spasmogenic potential than that of ITA. The distal segment of the ITA has 1.5 times bigger media-intima relation than the proximal segment. Therefore, in case of enough graft length, it is recommended to avoid the distal segment and cut it off.
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Affiliation(s)
- Sergey Mamchur
- Department of diagnosis of cardiovascular diseases, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation.
| | - Nikita Bokhan
- Department of diagnosis of cardiovascular diseases, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
| | - Yuri Vecherskii
- Department of Cardiovascular Surgery, Research Institute of Cardiology, Tomsk, Russian Federation
| | - Egor Malyshenko
- Department of Cardiovascular Surgery, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
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15
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Kinoshita T, Asai T. Reply to Gomes. Eur J Cardiothorac Surg 2014; 47:942. [PMID: 25143241 DOI: 10.1093/ejcts/ezu301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 06/26/2014] [Indexed: 11/12/2022] Open
Affiliation(s)
- Takeshi Kinoshita
- Division of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Tohru Asai
- Division of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Japan
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16
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Gomes WJ. The left and right internal thoracic arteries may not have equivalent histological structures. Eur J Cardiothorac Surg 2014; 47:941. [PMID: 25143240 DOI: 10.1093/ejcts/ezu300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/26/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
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17
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Affiliation(s)
- James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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