Arterial Grafting for Myocardial Revascularization: Indications, Surgical Techniques and Results

154 Pages·1990·8.179 MB·English

by  Ludwig K. von Segesser M.D., F.A.C.S. (auth.)

Arterial Grafting for
Myocardial Revascularization
Indications, Surgical Techniques and Results
Ludwig K. von Segesser
With 127 Figures and 6 Tables
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo Hong Kong Barcelona
Ludwig K. von Segesser, M.D., F.A.C.S.
Clinic for Cardiovascular Surgery
Zurich University Hospital
CH-8091 Zurich, Switzerland
ISBN-13:978-3-642-75711-2 e-ISBN-13:978-3-642-75709-9
DOl: 10.1007/978-3-642-75709-9
Library of Congress Cataloging-in-Publication Data
Segesser, Ludwig K. von. Arterial grafting for myocardial revascularization : indications, surgical
techniques, and results / Ludwig K. von Segesser.
Includes bibliographical references. Includes index.
ISBN-13:978-3-642-75711-2
1. Myocardial revascularization. 2. Internal thoracic artery
- Transplantation. 3. Arterial grafts. 1. Title.
[DNLM: 1. Coronary Artery Bypass. 2. Thoracic Arteries-transplantation. WG 169S454a]
RD 598.35.M95S44 1990
617.4'12--dc20
DNLM/DLC
for Library of Congress 90-10302 CIP
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Foreword
Cardiovascular disease, the leading cause of With increased experience using the inter
death in industrialized societies, not only nal mammary artery, these groups of sur
strikes down a significant fraction of the geons eventually applied the procedure to a
population without warning, but also causes larger population of patients. Eventually,
prolonged suffering and disability in even the mammary artery was used in sequential
larger number. Until the development of fashion to bypass more than one artery, and,
heart surgery and the introduction of diag in some patients, both mammary arteries
nostic techniques including cineangiogra were used. Using these new techniques, sur
phy, stress electrocardiography, echocardio geons could bypass almost every area of the
graphy, and myocardial scanning, the diseased coronary system except the distal
treatment of arteriosclerotic heart disease circumflex branches and distal right branch
was confined to medical measures that were es. Then, in 1983 and in 1985, Campeau and
usually only partially effective. Lytle published the results of their long-term
After the introduction of selective coro studies of mammary artery bypass. These
nary angiography by Sones, surgeons, led by important reports showed significantly dif
Favaloro and Johnson, began to apply the ferent results in favor of the internal mam
principle of bypass to coronary arterial dis mary artery over the saphenous vein graft.
ease. Similar vascular techniques had al As a consequence of these studies, more sur
ready been developed for peripheral arterial geons reconsidered use of the internal mam
occlusions in .the femoral and popliteal ves mary artery for the bypass conduit.
sels and employed the long saphenous vein During the early period of coronary ar
as a conduit to extend pulsatile flow to the tery bypass surgery at the Texas Heart Insti
distal pedal arteries. The numbers of coro tute, we usually reserved the mammary ar
nary bypass operations increased dramati tery conduit for grafting to the left anterior
cally following the procedure's introduc descending coronary artery in younger pa
tion. tients, or for whenever the saphenous vein
Although the saphenous vein functioned was not available. Because we believed in
very well, many patients were returning for complete revascularization and treated
reoperation between 5 and 10 years. Thus, many patients who were older and many
the need for another bypass conduit became who had diffuse disease, our use of the mam
apparent. The internal mammary artery was mary graft was limited. As the technique
the obvious choice. In 1964, Spencer first used to perform mammary bypass changed
anastomosed an internal mammary artery over the years, however, to allow more com
to a large coronary artery. Four years later plete revascularization, we began to use the
Green reported that he routinely used mi internal mammary artery whenever possi
crosurgical techniques to bypass even ble.
smaller coronary vessels with the internal Thus, the internal mammary progressed
mammary artery. Others had expressed ear from the "no-conduit" days of internal
ly interest in the mammary artery conduit, mammary ligation of the 1930s to the indi
including Barner, Mills, and Loop. The rect conduit of the 1960s; to the direct con
mammary artery was used in most of these duit of the 1970s; and to the double mam
early series in selected patients and in select mary, with or without sequential grafting in
ed arteries, in particular the left anterior de the 1980s. There is no question that in the
scending artery. 1990s complete revascularization using a
VI Foreword
proper combination of one or two mam success and its convenient anatomic location
mary artery grafts, in addition to saphenous near the heart.
vein grafts appropriately placed to major To use the internal mammary artery well,
vessels and their branches, is the state however, we must understand its function
of the art in elective coronary artery and its indications. Ludwig von Segesser
surgery. has carefully and studiously compiled all of
Surgeons as well as cardiologists have the information we need to know about the
been impressed by the superior results that internal mammary artery. Arterial Graft
arterial conduits have over veins for bypass ing for Myocardial Revascularization is a
procedures. Consequently, they have looked comprehensive contribution - from history,
elsewhere in the human anatomy for other anatomy, and pathology to experimental and
sources of nonessential arteries. Early in the clinical studies, from clinical application to
coronary bypass experience, the radial ar results, from complications to long-term fol
tery as a free graft was used, but curiously low-up - and will be a reference of ines
that artery seemed to be susceptible to timable value both to cardiologists and car
atherosclerotic change. More recently, two diovascular surgeons as they meet the needs
arteries from the truncal anatomy (namely, of patients with coronary artery disease.
the right gastroepiploic artery and the inferi
or epigastric artery) have been used with Denton A. Cooley, M. D.
promising results. Meanwhile, surgeons will Surgeon-in-Chief
continue their enthusiastic use of the inter Texas Heart Institute
nal mammary artery because of its proven Houston, Texas
Contents
Foreword V
Preface . XI
1 Introduction 1
2 Myocardial Revascularization and the Internal Mammary Artery 2
2.1 History of Myocardial Revascularization. . . . . . . . . . 2
2.2 Indications for Surgical Coronary Artery Revascularization Today 4
2.3 Early and Late Results of Coronary Artery Bypass Grafting:
Attrition of Saphenous Vein Grafts . . . 5
3 Anatomy of the Internal Mammary Artery 10
3.1 Normal Anatomy. . 10
3.1.1 Macroscopic Studies 10
3.1.2 Microscopic Studies . 10
3.2 Anatomical Variations . 12
4 Pathology of the Internal Mammary Artery and the Subclavian Artery 15
4.1 Angiographic Studies 15
4.2 Microscopic Studies. 21
5 Experimental Studies 23
5.1 Flow Studies in Animals . 23
5.1.1 Normal Internal Mammary Artery Flow. 23
5.1.2 Internal Mammary Artery Flow and Vasoactive Drugs . 23
5.1.3 Internal Mammary Artery Flow Under Pathological Hemodynamic
Conditions. . . . . . 24
5.1.3.1 Material and Methods. 24
5.1.3.2 Results ...... . 25
5.1.3.3 Discussion . . . . . . 28
5.2 Physiological and Pathophysiological Basis for the Superiority of
Internal Mammary Artery Grafts in Comparison to Saphenous Vein
Grafts ........................... . 29
5.2.1 Internal Mammary Arteries and Prostacyclin Production. . . . . . 31
5.2.2 Endothelium-dependent Relaxations of the Internal Mammary Artery 31
5.2.3 Early Postoperative Changes of Saphenous Vein Grafts 32
5.3 Expanded Use of the Internal Mammary Artery . . . . . 32
5.3.1 Free Internal Mammary Artery Grafts (Canine Experiments) 33
5.3.2 Retrograde Internal Mammary Artery-Coronary Artery
Anastomoses (Canine Experiments) 33
5.3.2.1 Material and Methods. 34
5.3.2.2 Results ........... . 35
5.3.2.3 Discussion. . . . . . . . . . . 36
5.4 Alternative Grafts for Coronary Artery Revascularization 37
5.4.1 Autologous Alternative Graft Materials . 37
5.4.2 Homologous Alternative Graft Materials 38
5.4.3 Biological Substitutes . . . . . . . . . 38
VIII Contents
5.4.4 Synthetic Grafts 39
5.4.5 Grafts of the Future 39
6 Clinical Studies. . . 41
6.1 Flow Studies in Humans . 41
6.2 Expanded Use of the Internal Mammary Artery in Clinical Coronary
Artery Revascularization .................. . 44
6.2.1 Sequential Internal Mammary Artery-Coronary Artery Anastomoses 44
6.2.2 Free (Aortocoronary) Internal Mammary Artery Grafts . . . 45
6.2.3 Bilateral Internal Mammary Artery - Coronary Artery Grafting 45
6.2.4 "Prophylactic" Coronary Artery Bypass Grafts . . . . . . . 46
7 Clinical Application of Internal Mammary Artery - Coronary Artery
Bypass Grafting ..................... . 48
7.1 Indications for Internal Mammary Artery-Coronary Artery Bypass
Grafting ......................... . 48
7.2 Contraindications for Internal Mammary Artery-Coronary Artery
Bypass Grafting . . . . . . . . . . . . . . 51
7.2.1 Limited Flow in the Early Postoperative Period . 51
7.2.2 Increased Intrathoracic Injury . . . . . . . . 52
7.2.3 More Difficult and Time-Consuming Procedure . 52
7.3 Surgical Techniques of Clinical Internal Mammary Artery
Coronary Artery Bypass Grafting. . . . . . 53
7.3.1 Take-Down of the Internal Mammary Arteries . . . . . 53
7.3.2 Evaluation of the Internal Mammary Artery . . . . . . 62
7.3.3 Cannulation, Cardiopulmonary Bypass and Cardioplegia . 62
7.3.4 Internal Mammary Artery-Coronary Artery Anastomoses 65
7.3.4.1 End-to-Side Anastomosis Between the Internal Mammary Artery and
the Coronary Arteries . . . . . . . . . . . . . . . . . . . . . 65
7.3.4.2 Sequential Internal Mammary Artery-Coronary Artery Grafting and
Side-to-Side Anastomoses . . . . . . . . . . . . . . . . . . 68
7.3.4.3 Internal Mammary Artery - Coronary Artery Y -Anastomoses . . . 72
7.3.4.4 Bilateral Internal Mammary Artery-Coronary Artery Anastomoses 73
7.3.4.5 Maximization of Internal Mammary Artery Length . . . . . . . 74
7.3.4.6 Free (Aortocoronary) Internal Mammary Artery Graft Anastomoses 75
7.3.5 Weaning from Cardiopulmonary Bypass 77
7.3.6 Hemostasis .. . . . . . . . . . . . . . . . . . . . . 78
7.3.6.1 Autotransfusion . . . . . . . . . . . . . . . . . . . . 78
7.3.6.2 Preservation and/or Reactivation of Platelets and Coagulation
Factors ................ . 78
7.3.6.3 Improved Cardiopulmonary Bypass Equipment 79
7.3.7 Drainage .............. . 79
7.3.8 Closure of the Pericardial Sac and the Chest . 79
8 Results of Internal Mammary Artery - Coronary Artery Bypass
Grafting . ...................... . 81
8.1 Early Results .................... . 81
8.1.1 Actual Series of Internal Mammary Artery-Coronary Artery
Grafting ...... . 81
8.1.1.1 Material and Methods. 81
8.1.1.2 Results ..... . 81
8.1.1.2.1 Preoperative Variables . 81
8.1.1.2.2 Operative Variables . . 83
8.1.1.2.3 Postoperative Variables 85
Contents IX
8.1.1.2.3.1 Mortality 85
8.1.1.2.3.2 Morbidity 86
8.1.1.2.3.3 Follow-up 88
8.1.2 Early Results of Expanded Internal Mammary Artery Grafting in
Comparison to Classic Saphenous Vein Grafting 90
8.1.3 Evolution of Perioperative Mortality in Coronary Artery
Revascularization. . . . . . . . . . . . . . . . . . 91
8.2 Medium-Term Results of Internal Mammary Artery-Coronary Artery
Grafting ..... . 92
8.2.1 Patients and Methods 92
8.2.2 Results ..... . 94
8.2.3 Comments .... . 95
8.3 Late Results of Internal Mammary Artery-Coronary Artery Grafting 96
9 Complications of Internal Mammary Artery Grafting . . . . . . . . 102
9.1 Inadequate Flow After Internal Mammary Artery-Coronary Artery
Revascularization. . 102
9.1.1 Patients and Methods 102
9.1.2 Results ..... . 102
9.1.3 Comments .... . 103
9.2 Spasms After Coronary Artery Revascularization 104
9.2.1 Coronary Artery Spasm Immediately After Saphenous Vein Grafting 105
9.2.2 Spasm After Internal Mammary Artery Grafting . . . . . . . . . 105
9.3 Mechanical Circulatory Support After Internal Mammary Coronary
Artery Grafting ..................... . 106
9.4 Sternal Infections Following Internal Mammary Artery-Coronary
Artery Grafting ................... . 107
9.5 Other Complications After Internal Mammary Artery Grafting . 108
10 ~ong Term Follow-up After Internal Mammary Artery-Coronary
Artery Revascularization . . . . . . . . . . . . . . . . . . 109
10.1 Freedom From Reinfarction After Coronary Artery Revascularization 109
10.2 Objective Assessment of the Results of Internal Mammary Artery
Coronary Artery Revascularization 110
10.2.1 Scintigraphic Evaluation. . . . . . . . . . . . . . 110
10.2.2 Angiographic Evaluation . . . . . . . . . . . . . 111
10.3 Late Patency Rates of Internal Mammary Artery Grafts 115
Redo Coronary Artery Revascularization After Internal Mammary
Artery Grafting. . . . . . . . . . . . . . . . . . . . . . 120
11.1 Percutaneous Transluminal Angioplasty After Internal Mammary
Artery Grafting ................ . 120
11.2 Reoperatioh After Internal Mammary Artery Grafting . 121
11.2.1 Completely Occluded Internal Mammary Artery Graft . 121
11.2.2 Patent, but Stenosed Internal Mammary Artery Graft 121
11.2.3 Patent, not Stenosed Internal Mammary Artery Graft 123
12 Conclusion 125
References. . 127
SUbject Index 141
Suppliers of Material 145
Preface
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The importance of the internal mammary knowledge as reported in the literature and
artery in treatment of coronary artery dis to develop a philosophy of optimized inter
ease has changed over the years. This is illus nal mammary artery grafting for coronary
trated not only by the fact that this vessel artery revascularization.
was renamed the internal thoracic artery but For this purpose, I have analyzed many
also by periods during which it was ligated studies on the internal mammary artery -
with the idea of improving the coronary dealing with anatomy, pathology, experi
artery blood flow. Later on, the internal mental behavior in vitro and in vivo - and
mammary artery was implanted into the clinical reports. I have also established
myocardium and microvascular anasto guidelines for internal mammary artery
moses were documented. However, the new grafting that include indications, contra
blood flow brought to the myocardium was indications, surgical techniques, and steps
too limited to be effective. Since the intro for preventing or treating complications.
duction of coronary artery bypass grafting I wish to thank my teachers in surgery,
in the treatment of coronary artery disease B. Vogt (Lucerne), M. Allgower (Basel), A.
in 1967, coronary artery revascularization Rohner (Geneva), R. Megevand (Geneva),
has become the fastest growing form of B. Faidutti (Geneva), D. A. Cooley
surgery. Over many years, reversed saphe (Houston), and M. Turina (Zurich), and all
nous veins were the preferred graft material of my colleagues for the encouragement and
for coronary artery revascularization. In the assistance they have given me in my clinical
meanwhile, however, higher long-term pa work and writing.
tency rates have been achieved with internal I am grateful to M. Hegetschweiler, C. de
mammary artery grafts than with saphenous Sirnio, O. Reinhard, and S. Wehrli for pre
vein grafts. These observations led to an ex paring artwork, and to the Experimental
ponential increase in the use of the internal Surgical and Photoillustration Units of the
mammary artery for coronary artery revas Department of Surgery at Zurich University
cularization and the emergence of a number Hospital for their help. Finally, my thanks
of new techniques, increasing its versatility. go to Springer-Verlag and its staff for the
However, there have also been some nega outstanding work in the production of this
tive experiences with this graft. The various book.
experimental and clinical studies now avail
able provide a growing basis for a scientific
approach in internal mammary artery graft
mg.
The idea was for this book to relate my Zurich, January 1990
personal experience with the current state of Ludwig K. von Segesser
1 Introduction
Diseases of the cardiovascular system were United States from 1970 through 1978 in
responsible for 39.1 % of all deaths regis creased approximately 25 %. In contrast,
tered during 1986 in Switzerland (range over coronary artery operations increased nearly
the last 25 years: 39 % -44 %) as reported by 700 % during those years. An estimated
the Bundesamt fur Statistik and dominated 180000 coronary artery operations are per
all other causes such as malignant tumors formed annually in the United States
(24.9 %), accidents (8.3 %), diseases of the (Lefrak 1987).
respiratory system (6.7 %), diseases of the Coronary artery bypass surgery improves
nervous system (6.4%), metabolic disorders the blood supply to territories supplied by
(3.9%), diseases of the digestive system blocked or narrowed arteries and it is gener
(3.3%), and others (7.4%). As in other ally agreed to be highly effective (Takaro
countries of the western hemisphere the dis et a!. 1976; Kennedy et a!. 1980; National
eases of the cardiovascular system were also Heart Lung and Blood Institute 1981; Loop
the most frequent cause of hospitalization 1981; European Coronary Surgery Study
(21.9%), consultation of a medical doctor Group 1982; Braunwald et a!. 1983; Turina
(14.8 %), and prescription of an ambulatory 1987). Percutaneous transluminal angio
treatment (17.6%) (Pharma Information plasty is another direct approach for limited
1988). Apart from the obviously severe con coronary artery lesions (Gruntzig et al.
sequences of cardiovascular diseases for the 1979; Meier eta!' 1985; Finci eta!' 1987a)
individual (morbidity and mortality), there as well as thrombolysis. Pure medical treat
can be no doubt about the micro- and ment, however, reduces angina by increasing
macroeconomic impact of these diseases. the efficiency of the heart and reducing de
This might explain the extremely rapid ex mand but it is much less sucessful than
pansion in treatment of a single segment of surgery in relieving symptoms and does little
cardiovascular diseases, that is coronary ar to improve the defective blood supply.
tery disease. Surgical advances include improved myo
The construction of aortocoronary by cardial protection and better perioperative
pass grafts with reversed saphenous vein care, which have resulted in a decrease in
was introduced by Favaloro in 1967 (Fava peri operative morbidity and mortality on
loro et al. 1968b). This procedure has been one hand, and increasing technical skills, re
recognized as one of the most significant sulting from experience and expanded use of
surgical advances ever. According to Loop the internal mammary arteries, leading to
et al. (1981) all operations performed in the improved long term results on the other.