Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.     

Significance of electron-beam tomography in the evaluation of the patency of aortocoronary bypasses

PURPOSE: Electron beam tomography (EBT) permits acquisition of images with high spatial and temporal resolution. The value of EBT and other imaging modalities for the depiction of patent coronary artery bypass grafts (ACVB, IMA) are compared to coronary angiography and an overview of current results is given. MATERIAL AND METHODS: Graft patency can be evaluated with indirect methods stress, such as echocardiography, radionuclide ventriculography, myocardial scintigraphy, positron-emission tomography (PET) and direct imaging modalities, such as Doppler/2D echocardiography, EBT, spiral computed tomography (SCT) and magnetic resonance angiography (MRA). RESULTS: With indirect methods graft patency can be evaluated with sensitivity of 64-100% and specificity of 73-100%. EBT and SCT are equivalent in sensitivity (= 94%) in the assessment of open venous grafts and specificity is up to 100%, but EBT is superior in the diagnosis of patent IMA grafts (sensitivity 100% vs 89%). Visualization of high-grade venous bypass stenosis seems possible with EBT. MRA with gradient echo technique is highly accurate in the assessment of patent venous grafts (sensitivity 77-93%) but has limited value in the evaluation of IMAs (sensitivity = 53%). Promising are ultrafast 3D-MRA methods which permit high accuracy (sensitivity = 94-96%) in assessing venous and arterial grafts. DISCUSSION: Indirect imaging methods cannot differentiate between an occluded bypass, progression of coronary artery disease and myocardial infarction. EBT and SCT are equivalent in the diagnosis of open and occluded venous grafts, but EBT is superior in the assessment of patent IMA grafts. Visualization of high-grade venous bypass stenosis seems possible with EBT. MRA techniques, especially ultrafast 3D-MR methods, are highly accurate in the assessment of patent venous and arterial grafts but are still limited to scientific research.     

Comparison of flow capacities of arterial and venous grafts for coronary artery bypass grafting: evaluation with exercise thallium-201 single-photon emission tomography

Stress thallium-201 tomography was performed to compare the flow capacities of arterial and saphenous vein grafts in patients with coronary artery bypass grafting (CABG). One hundred and seven consecutive patients (95 male and 12 female; mean age 58+/-9.1 years) underwent exercise-redistribution 201Tl myocardial single-photon emission tomography 4-5 weeks after CABG. When a reversible perfusion defect was present in the area covered by a patent bypass graft, the flow capacity of the graft was defined as insufficient. Of all 285 grafts, 211 were considered as complete bypass. Reversible perfusion defects were present in 29 (27%) of 108 myocardial areas supplied by patent arterial grafts but in only 5 (5%) of 103 myocardial areas supplied by patent saphenous vein grafts (P<0.0001). In the LAD area reversible defects were observed in 22 of 82 areas covered by arterial grafts, in contrast to only 1 of 29 areas covered by venous grafts (P<0.01); in the RCA area reversible defects were observed in 7 of 17 and 4 of 41 areas respectively (P<0.01). There was no difference between the native coronary artery stenosis bypassed by patent arterial and venous grafts (88%+/-12% vs 86%+/-14% respectively, P=0.27). In conclusion, flow capacities during peak myocardial demand were more frequently insufficient in arterial bypass grafts than in saphenous vein grafts.     

Pulsed Doppler intraoperative flow assessment and midterm coronary graft patency

BACKGROUND: This study was designed to assess the value of hemodynamic measurements taken intraoperatively in predicting midterm patency of coronary bypass grafts. METHODS: A pulsed Doppler flowmeter was routinely used during operation to determine the hemodynamic parameters of coronary bypass grafts. During a 7-year period, 85 patients underwent angiographic evaluation. As a result, a thorough hemodynamic assessment of 214 grafts (89 arterial and 125 venous) at initial operation was available for analysis. RESULTS: The overall patency rate was 88.3%. The mean flow measured intraoperatively in 168 intact grafts was 60+/-3 mL/min (range, 9 to 230 mL/min), and the resistance was 1.8+/-0.1 peripheral resistance units (range, 0.3 to 9.0 peripheral resistance units). The mean flow was 36+/-5 mL/min (range, 2 to 107 mL/min), and the resistance was 5.9+/-2.0 peripheral resistance units (range, 0.6 to 46.0 peripheral resistance units) in 25 grafts found occluded at angiographic evaluation. Multivariate analysis identified three independent variables associated with a reduced patency rate: increased resistance as measured in the graft (p = 0.012), increasing interval of control angiography (p = 0.006), and preoperative cardiogenic shock (p = 0.040). CONCLUSIONS: The prognosis for midterm patency of aortocoronary bypass grafts depends on the intraoperative hemodynamic status.     

Early and mid-term results of right gastroepiploic artery grafting in the children with Kawasaki disease

Thirty-nine children with Kawasaki disease have undergone coronary revascularization since 1976. The attrition rate of saphenous vein grafts (SVG) was so high that we have used the internal thoracic artery (ITA) as the graft since 1984. ITA showed excellent early and mid-term patency. We, however, still had to use SVG for the distal portion of right coronary artery (RCA) and left circumflex artery (LCx) where ITA was difficult to reach. In 1988, we first successfully applied the right gastroepiploic artery (GEA) for revascularization to the posterior descending artery of a six-year-old boy. Nine children were then bypassed with the combination of ITA and GEA. GEA was anastomosed to the distal portion of RCA (7 cases) and the branch of LCx (2 cases). In 4 cases GEA showed string sign 1 month after surgery, but the angiographic finding revealed improvement after 1 year interval in 2 cases. The patency of GEA grafts was excellent after 1 month (100%:9/9) and 1 year (100%:9/9), respectively. The use of GEA in addition to ITA as the arterial graft may contribute to the improvement of long-term graft patency in revascularization of children with Kawasaki disease.     

Isolation and biological properties of osteopontin from bovine milk

The right gastroepiploic artery has been increasingly used as a coronary bypass graft. Short- and mid-term patency rates support the supposition that the right gastroepiploic artery is a satisfactory bypass conduit. However, conclusive angiographic data on long-term patency rates are still lacking. An echo-colour Doppler method was used to detect patency of the right gastroepiploic artery grafts through an upper abdominal approach. A group of 24 patients with a right gastroepiploic artery graft to the right or posterior descending coronary artery, all of whom also had a postoperative angiographic study which showed 100% patency of the graft were used as a reference group. A second group of 89 patients was also investigated only with echo-colour Doppler during the postoperative period (mean 8.0 (range 1-48) months). A patent right gastroepiploic artery graft showed a biphasic velocity pattern. Systolic peak velocity ranged from 8 to 26 cm and diastolic peak velocity from 4 to 13 cm. The right gastroepiploic artery diameter ranged from 1.7 to 2.4 mm and flow from 10.2 to 58.8 ml. Among the second group were three patients who had, at their echo-colour Doppler examination, a possible occlusion of the right gastroepiploic artery graft; an angiographic study was conducted and the graft closure confirmed in all cases. Serial echo-colour Doppler evaluation of the right gastroepiploic artery blood flow pattern and diameter is a non-invasive and safe method to check the patency and flow capacity of the artery graft in follow-up studies.     

Arterial graft patency in coronary artery bypass grafting: what do we really know?

BACKGROUND: With increasing use of beating heart techniques for bypass of the left anterior descending coronary artery with the left internal mammary artery (LIMA), appropriate concerns have been raised of whether graft patency by these techniques compares favorably with conventional, arrested heart techniques. METHODS: All published articles that examine outcome efficacy of the LIMA graft to the left anterior descending coronary artery were reviewed. Because angiography has been considered the "gold standard," only those studies that included angiographic follow-up were analyzed. RESULTS: From 1972 through 1998, there have been 37 peer-reviewed publications that examined outcomes of LIMA grafting in conventional coronary bypass grafting, of which 27 contained angiographic follow-up data. The completeness of angiographic follow-up was variable, but early graft patency (< or =1 month) in studied patients ranged between 94% and 99%. Late graft patency (up to 15 years) ranged from 51% to 98%. Five recent series of minimally invasive direct coronary artery bypass grafting that contained LIMA graft patency data show early graft patency rates between 91% and 99%. CONCLUSIONS: Meaningful comparison of LIMA graft patency between arrested heart, conventional coronary artery bypass grafting, and minimally invasive direct coronary artery bypass grafting is difficult; however, early graft patency by both techniques can confidently be stated as being 90% or greater.     

New stent technologies

Poor long-term patency of saphenous vein grafts limits the long-term success of the coronary artery bypass operation. If this is to be improved, either measures that increase the patency of saphenous vein grafts or alternative conduits are required. The benefits of using the left internal mammary artery as a pedicled graft to the left anterior descending coronary artery have prompted increasing use of arterial grafts to further improve outcome. Concurrently advances in the understanding of the pathological processes underlying saphenous vein graft occlusion raise the possibility of improving vein graft patency. In this paper we review the problem of vein graft occlusion and possible solutions, the theoretical benefits of arterial grafts and the clinical results associated with their use.     

Enteral nutrition modifies gut-associated lymphoid tissue in rat regardless of the molecular form of nitrogen supply

OBJECTIVES: It is not known whether the results of randomized trials comparing coronary artery bypass grafting to percutaneous transluminal coronary angioplasty for initial revascularization apply to repeat revascularization in patients with prior bypass grafts. We studied the differences between the patients with prior bypass grafts referred for surgery or angioplasty to identify the clinical and angiographic characteristics that correlated best with either choice and to find clues that might aid in selecting one treatment over the other. METHODS: Between 1992 and 1994, 870 patients underwent first isolated reoperation and 793 patients underwent first balloon angioplasty after a previous operation. A jeopardy score (0 to 8 points) was derived for each patient on the basis of the relative size of the ischemic territory. Clinical and angiographic data were analyzed for association with the revascularization strategy. RESULTS: The following characteristics were more prevalent in the reoperation group: male sex, diabetes, hypertension, valvular disease, normocholesterolemia, and severe left ventricular systolic dysfunction; fewer functioning venous and arterial grafts; and a higher jeopardy score (p < 0.01 for all) than in the angioplasty group. A higher jeopardy score, diabetes, and a lower number of functioning arterial or venous grafts were strong, independent predictors of referral for reoperation (p < 0.01 for all). In hospital death and Q-wave infarction (p < 0.01 for both) were more frequent in the reoperation group. CONCLUSIONS: Reoperation was the revascularization procedure of choice when larger regions of myocardium were in jeopardy. Angioplasty was more frequently chosen in the presence of a patent arterial graft to the left anterior descending coronary artery or multiple functioning bypass grafts. Reoperation was associated with a higher risk of in-hospital complications than angioplasty.     

The direct effect of graft compliance mismatch per se on development of host arterial intimal hyperplasia at the anastomotic interface

To study the direct and sole effect of compliance mismatch on anastomotic intimal hyperplasia of the host arterial wall and to minimize possible confounding factors, dogs with a low thrombotic potential were selected as experimental subjects. Externally supported 6 cm x 5 mm Dacron grafts with a compliance value of approximately 1/300 of the host artery were implanted into the carotid arteries with end-to-end anastomoses on one side and end-to-side anastomoses on the other. The control graft was an autogenous carotid artery segment 4 cm in length transplanted into the femoral artery. Eight cases (24 grafts) were studied for 1 year and three (nine grafts) for 6 months. All were patent throughout the study period except for two noncompliant grafts with end-to-end anastomoses; thrombosis was the documented cause of occlusion. For the patent grafts, follow-up arteriograms showed no progressive narrowing of noncompliant anastomoses. Whether compliant or noncompliant, light microscopy studies showed slight intimal thickening within 1 to 2 mm of the anastomotic line, possibly the result of the normal healing response to stitch and surgical trauma. Quantitatively, 22 measurements representing longitudinal and circumferential thickness of the neointima were taken at each of the 40 patent noncompliant and 22 patent compliant control anastomoses. There was no statistically significant difference in anastomotic neointimal thickness in compliant and noncompliant grafts or for the different implantation periods. These data suggest that graft/host artery compliance mismatch does not cause arterial intimal hyperplasia at the anastomotic interface.     

The internal mammary artery 'string phenomenon'. Analysis of 10 cases

The internal mammary artery (IMA) string sign has been described as a narrowing of IMA grafts in the late course after coronary artery bypass grafting. It has been assumed that this phenomenon was due to competitive flow in grafts connected to only mildly stenosed coronary arteries. We analyzed 10 cases of IMA string sign operated on between March 1988 and June 1991. Bilateral IMA was used in six cases and unilateral IMA in four. The mean interval between operation and reangiography was 14 +/- 11 months. String sign of the whole length of the IMA was detected in nine cases, and of the distal part between two sequential anastomoses in one. In all cases, the stenosis of the vessel bypassed with the narrowed graft proved to be only mild (50% or less) at reangiography. In all six cases with bilateral IMA grafts, the contralateral IMA was widely patent. These were all connected to highly stenosed or occluded coronary arteries. With respect to this observation, there is a high index of suspicion that the string phenomenon occurs due to competitive flow in only mildly stenosed coronary arteries. We decided, for our strategy in coronary artery surgery, still to aim at complete revascularization using IMAs as much as possible, but to avoid connecting IMA grafts to only mildly or moderately stenosed coronary arteries.     

Validation of an LC-MS assay for the quantification of the enantiomers of Org 4428 in human plasma

OBJECTIVE: The aim of this study was to assess the long-term results of use of the radial artery as a conduit for coronary artery bypass grafting. METHODS: After revival of the technique in 1989, the radial artery was used as a conduit in 910 patients undergoing coronary artery bypass grafting. A complete follow-up was obtained for the first 102 consecutive patients from 4 to 7 years after the operation (mean 5.27 +/- 1.30 years). Fifty-nine percent of the patients were receiving calcium-channel inhibitors. An electrocardiographic stress test was obtained for 51 patients, with no contraindications found. Routine follow-up angiography was performed in 50 cases, including those of all patients with symptoms. Thus 64 radial artery and 48 left internal thoracic artery grafts were followed up from 4 to 7 years after the operation (mean 5.6 +/- 1.40 years). RESULTS: The actuarial survival was 91.6% at 5 years, and the actuarial rate of freedom from angina was 88.7% at 5 years. Four patients underwent percutaneous transluminal angioplasty during the period of follow-up, and there were no reoperations for revision of the bypass. The electrocardiographic stress test showed negative results in 73% of cases, electrocardiographic changes alone in 21%, and clinically positive results in 6%. Angiography showed that the patency rate of the radial artery grafts was 83%. The patency rate of the left internal thoracic artery grafts (n = 47) was 91%. The difference in patency could be related to the implantation sites of the grafts, mainly the circumflex artery (51%) for the radial artery grafts and almost exclusively the left anterior descending artery (94%) for the left internal thoracic artery. CONCLUSION: The use of the radial artery for coronary bypass grafting provides excellent clinical and angiographic results at 5 years. Routine use of the radial artery in combination with the left internal thoracic artery can be recommended.     

Age specific prostate specific antigen reference ranges: population specific

BACKGROUND: Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA). METHODS: From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting. RESULTS: All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%. CONCLUSIONS: The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.     

The inferior epigastric artery as a coronary artery bypass graft]

From January 1992 through December 1993, 31 patients underwent myocardial revascularization with the inferior epigastric artery (IEA) graft. There were one emergency case and four coronary reoperation cases. IEA grafts were taken down through the left side paramedian incision and dilated with papaverine hydrochloride solution. The distal anastomoses were made to left anterior descending (3 cases), diagonal (14 cases), obtuse marginal (9 cases), postero-lateral (I case) and right coronary artery (4 cases). The proximal anastomoses were made to the aorta (22 cases), the hood of a new vein graft (4 cases) and the hood of an old vein graft (4 cases). When IEA was not long enough to reach the ascending aorta, it was anastomosed to the internal thoracic artery (2 cases) or the gastroepiploic artery (1 case) graft. There was one hospital death, and early patency rate (within one month) was 90% (19/21). The postoperative angiography performed at 1.3 years or 2 years showed excellent IEA graft patency. These results suggested that the IEA is suitable as a coronary artery bypass graft. Further long-term patency must be evaluated.     

Ultrasonographic evaluation of the anterior recess in the normal hip: a prospective study on 166 asymptomatic children

Bypass graft patency with ultrafast computed tomography (= Electron Beam Tomography, EBT) was examined in 72 bypass grafts (47 saphenous veins, 25 internal mammary arteries) in 30 patients and compared with coronary angiography. Angiography was performed a mean of 4.4 +/- 3.5 months (range 1-13) from the EBT examination. Contrast material (120 ml) was continuously administered via a peripheral vein and 40 axial slices (3 mm slice thickness, 110 ms scan time) without overlap sequences were obtained, ECG triggered with the single slice scanner mode. Imaging of internal mammary artery grafts began at the thoracic inlet, for saphenous vein grafts, at the undersurface of the aorta. Sixty of 63 angiographically patent bypass grafts were determined patent by EBT (sensitivity 95%), 8 bypass grafts could not be detected by EBT, and 9 were angiographically occluded (specificity 89%). Twenty-four of 25 internal mammary artery grafts were patent at EBT and coronary angiography, one was occluded. In 27 of the 30 patients (90%), all of the angiographically patent grafts could be confirmed as open with EBT. Obstructions of 10 grafts could not be visualized with EBT. Graft insertion into native coronary vessels could be visualized in axial slices, although morphologic quantification of graft insertion stenosis (75-90%) in two cases was not possible. Three dimensional reconstruction of the 40 axial slices allowed graft anatomy to be delineated. Visualization of bypass insertion into the native coronary vessel was less successful because of opacification of the left and right ventricle. Electron beam computed tomography is a minimally invasive procedure capable of evaluating the patency of saphenous vein and internal mammary artery grafts. The morphologic quantification of graft obstruction and visualization of the insertion of the bypasses into the native coronary vessels is less successful with present technology and imaging modalities.     

Venous rupture complicating hemodialysis access angioplasty: percutaneous treatment and outcomes in seven patients

OBJECTIVE: To evaluate percutaneous treatment options for preserving hemodialysis access after angioplasty-related venous rupture, we retrospectively reviewed the charts for all dialysis access angioplasties performed over a 33-month period. Seven cases of venous rupture after venous angioplasty were identified (four men and three women; mean age, 63.5 years). Treatment included observation only (n = 1), a second prolonged balloon inflation at the rupture site (n = 2), stent insertion (n = 5), and manual graft occlusion (n = 1). Treatment was successful in eliminating contrast extravasation in all patients while maintaining immediate graft function in six out of seven patients. None of the patients required emergent surgical intervention. The mean primary and secondary patency rates of the salvaged grafts after intervention were 2.3 and 9.3 months, respectively. Five of seven access sites were still patent at the most recent follow-up. CONCLUSION: Prolonged balloon inflation or placement of a stent may salvage hemodialysis access in most patients after angioplasty-related venous rupture. Primary and secondary patency have proven to be satisfactory.     

The internal mammary artery malperfusion syndrome: late angiographic verification

BACKGROUND: Here we report our experience with the incidence and the surgical treatment of the internal mammary artery (IMA) malperfusion syndrome, evaluate the predictive role of previously described risk factors for the syndrome, and assess the late patency of IMA grafts in patients in whom an IMA malperfusion syndrome was diagnosed and treated by additional saphenous vein grafting of the left anterior descending coronary artery. METHODS: From June 1992 to November 1995, 969 IMAs were anastomosed to the left anterior descending coronary artery system. In 11 patients, IMA malperfusion syndrome was diagnosed and treated by additional saphenous vein grafting of the LAD. There were 8 men and 3 women with a mean age of 58.9 years. The angiographic and clinical data for each patient were reviewed, and all but 1 surviving patient underwent late angiographic control (mean follow-up, 18 months; range, 4 to 46 months). RESULTS: One patient died in the hospital. No previously described risk factor was strongly associated with the occurrence of IMA malperfusion syndrome. Late angiography revealed a malfunctioning IMA graft in 7 of the 9 patients. A string sign was observed in 1 patient and a normally functioning IMA anastomosed to a diagonal branch not connected to the LAD, in another. In no patient was a widely patent and normally functioning IMA graft observed. CONCLUSIONS: In our series, a high proportion of IMA grafts were found to be malfunctioning at late angiography. This observation, in contrast to previous reports, suggests that IMA malperfusion syndrome can often be attributable to technical problems in harvesting the IMA or in performing the IMA anastomosis. Functional IMA insufficiency seems to play only a marginal role in determining the IMA malperfusion syndrome.     

Expansion of CTG repeats from human disease genes is dependent upon replication mechanisms in Escherichia coli: the effect of long patch mismatch repair revisited

OBJECTIVE: New techniques for minimally invasive coronary artery bypass grafting have recently emerged. The purpose of this study was to determine the safety and efficacy of Port-Access (Heartport, Inc., Redwood City, Calif.) coronary revascularization and to evaluate with angiography the early graft patency rate with this new approach. METHODS: From October 1996 to May 1997, 31 patients underwent Port-Access coronary artery bypass grafting with an anterior minithoracotomy and endovascular-occlusion cardiopulmonary bypass. There were 26 men and 5 women with a mean age of 62 years (range 42 to 82 years). Fifteen patients underwent single bypass; 12 patients underwent double bypass, and 4 patients underwent triple bypass. Bypass conduits included the left internal thoracic artery (n = 30), right internal thoracic artery (n = 2), radial artery (n = 10), and saphenous vein (n = 6). Three sequential grafts were used. Angiographic studies of the bypass grafts were performed in 27 of 31 patients (87%). RESULTS: There were no deaths, neurologic deficits, myocardial infarctions, or aortic dissections. Conversion to sternotomy was not required in any case. There were two reoperations for bleeding, one reoperation for tamponade, and one reoperation for pulmonary embolus. Postoperative angiography revealed anastomotic patency of the left internal thoracic artery to left anterior descending artery in 26 of 26 grafts (100%) with overall anastomotic patency in 43 of 44 grafts (97.7%). CONCLUSION: These results demonstrate that Port-Access coronary artery bypass can be performed accurately and safely with acceptable morbidity. This approach allows for multivessel revascularization on an arrested, protected heart with excellent anastomotic precision and reproducible early graft patency.     

Percutaneous angioplasty for infrainguinal graft-related stenoses

OBJECTIVE: To assess the success of percutaneous transluminal angioplasty (PTA) in treating infrainguinal graft-related stenoses. DESIGN: Retrospective analysis of stenoses undergoing PTA over 6 years. MATERIALS: Fifty-seven stenoses in 42 grafts. METHODS: Site, length and type of stenoses recorded. Follow-up till discharge, graft occlusion or death. RESULTS: PTA was successful in 48/57 stenoses in 36 grafts (G), with a poor result in seven. Further PTA was required in seven stenoses (7 G). One graft occluded at PTA and one stenosis was inaccessible. Overall graft (G) patency (median 13 months) was 82% (1 year patency 84%). Of 48 successful PTAs (37 G), 36 remained patent (28 G), eight (4 G) occluded and four were lost to follow-up (4 G). Fourteen of thirty-six stenoses which remained patent required further intervention (seven PTA, six jump grafts, one vein patch). The four occlusions were associated with small veins (two), multiple stenoses (one) and a PTFE graft which occluded 10 days following PTA. Of the seven PTAs with a poor angiographic result, five remained patent, three after further intervention. CONCLUSION: PTA is the best treatment for localised stenoses. Stenoses > 2 cm or multiple (three or more) stenoses are best treated surgically. Follow-up is essential, as 20% require further intervention.     

Bacteria-specific lymphocyte proliferation in peripheral blood in reactive arthritis and related diseases

The inferior epigastric artery has been proposed as a suitable conduit for myocardial revascularization but its mid-term patency rate has not been assessed. A prospective clinical and angiographic study on the use of the inferior epigastric artery as an additional arterial conduit together with bilateral internal thoracic artery grafting was conducted in 38 patients. No deaths or major postoperative complications occurred. Twenty-three patients underwent repeat angiography after an average of 21.2 months. The left and right internal thoracic artery grafts patency rate was 95.6% (44/46), while inferior epigastric artery patency rate was 52.2% (12/23). By relating patency to the grafted coronary branch, the following results were obtained: 100% for the left anterior descending (3/3), right coronary (1/1) and ramus medianus (1/1); 40% (4/10) and 37.5% (3/8) for diagonals and obtuse marginals respectively. The low patency rates observed when the inferior epigastric artery is used on diagonals and obtuse marginals indicate that this vessel cannot be considered a suitable conduit for extensive application of arterial revascularization. We suggest that the inferior epigastric artery should only be used in patients presenting with contraindications to bilateral internal thoracic artery or right gastroepiploic artery grafting, or exhibiting unsuitable saphenous veins.