Biomedical subjects
Publications and source records attributed to H Suma.
Percutaneous transluminal balloon dilation of an 8-month-old free graft of the gastroepiploic artery was followed by diffuse and profound graft spasm. Because free arterial grafts are more prone to spasm, suitable precautions, such as administration of calcium channel antagonists, should be taken before attempting any interventions on these vessels.
In 308 right gastroepiploic artery (GEA) grafting procedures performed for myocardial revascularization, 38 GEA, 34 in situ, and four free grafts were used to bypass the left anterior descending coronary artery (LAD). Indications for using the GEA for the purpose of LAD bypass were: unavailability of the internal thoracic artery (ITA) at reoperation, surgical damage to the ITA at the time of the operation, or an apparently better free flow versus that in the left ITA, particularly in patients with diabetes mellitus in whom it was considered inadvisable to use bilateral ITAs. There were 21 male and 17 female patients with a mean age of 62 years (range, 31 to 77 years). Ten patients had undergone a previous myocardial revascularization. The mean number of distal anastomoses was 2.8 (range, 1 to 5). Concomitantly used conduits were the ITA in 27 patients, saphenous veins in 21 patients, the inferior epigastric artery in 4 patients, and the bovine internal thoracic artery in 1 patient. All but 1 patient survived. Follow-up ranged from 3 to 84 months (mean, 27 months). Postoperative angiography was performed in 33 patients. At the short-term evaluation (mean, 1 month), 32 of 33 (97%) GEA grafts were found to be patent; all 4 GEA grafts studied at the long-term evaluation (mean, 25 months) were also found to be patent. In no patients did angina recur postoperatively. In 25 patients who underwent an exercise study postoperatively, the stress test results were negative in 23.(ABSTRACT TRUNCATED AT 250 WORDS)
From May 1988 to March 1990, the bovine internal thoracic artery (ITA) graft, 3 mm in diameter, was used for coronary artery bypass grafting in 29 patients with the approval of the Japanese Ministry of Health. Excluding three postoperative deaths and 6 patients who rejected postoperative angiography, 20 patients (13 men and 7 women; mean age, 62 years; range, 37 to 80 years) were followed up angiographically for up to 4 years. Sites of bovine ITA anastomosis were as follows: anterior descending, 4; circumflex, 5; and right coronary artery, 11. The mean bovine ITA graft blood flow measured by electromagnetic flowmeter was 75.2 mL/min (range, 40 to 150 mL/min). During the mean follow-up of 45 months (range, 30 to 52 months), 12 patients underwent postoperative angiography once, 6 patients twice, and 2 patients three times. It revealed 14 of 16 (88%) bovine ITA grafts were patent within 2 postoperative months. Three of 6 (50%) were patent at 3 to 12 months, of which 2 patent grafts required balloon angioplasty for distal anastomotic stenosis. In 7 patients restudied later than 1 year (20, 24, 25, 44, 48, 50, and 52 months), one of seven grafts (14%) was patent. There was stenosis (> or = 50%) at four distal and one proximal bovine ITA anastomotic sites, but no focal stenosis was found in the trunk at any period. There was one late death due to renal failure, one myocardial infarction, and one mild angina due to bovine ITA graft failure.(ABSTRACT TRUNCATED AT 250 WORDS)
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Coronary artery bypass grafting in a 68-year-old woman with familial hypercholesterolemia and severe calcification of the ascending aorta was successfully performed. The left internal thoracic artery bypassed the left anterior descending artery, the right gastroepiploic artery bypassed the left circumflex artery and the saphenous vein graft bypassed the right coronary artery, the proximal anastomosis was based on segment 1 and the distal anastomosis was on segment 3 of the right coronary artery (coronary-coronary bypass). The operation was performed with aortic no touch technique which consisted of fibrillatory arrest without aortic cross-clamping, and femoral artery perfusion. The post operative angiogram revealed patency of all graft, and she discharged at 20th post operative day. Coronary-coronary bypass was took into consideration in a patient with severe calcification of the ascending aorta and without suitable in situ arterial graft.
Coronary artery bypass grafting was performed on a 31-year-old female for treatment of active aortitis syndrome with unstable angina. Preoperative coronary angiography revealed ostial stenosis of coronary arteries. The ascending aorta was intensely inflamed. In the proximal anastomosis, the ascending aorta was sutured with an autogenous pericardial patch and anastomosed with the saphenous vein (SV) to be jointed to left anterior descending (LAD). At the same time, gastroepiploic artery (GEA) was connected to LAD by taking into account a degenerative change in remote stage. Right coronary artery was anastomosed with right internal thoracic artery (RITA). The postoperative course was satisfactory. On graft angiography SV and RITA were adequately patent, but GEA was unsatisfactorily patent because of its competition with SV for patency. This surgical procedure seemed to be an option to be indicated for a patient with unstable angina at an active inflammatory stage.
We report a case of 50-year-old male underwent reoperative coronary artery bypass grafting (CABG) through the left thoracotomy. He had undergone primary CABG with a saphenous vein graft to the left anterior descending coronary artery (LAD) to revascularize the left main trunk lesion a year ago, which was occluded, and recurred angina. The second operation was performed through the left thoracotomy under the the hypothermic cardiopulmonary bypass. The left internal thoracic artery was anastomosed to LAD, and a new saphenous vein was anastomosed to the descending aorta proximally, and to the left circumflex artery distally, under a hypothermic circulatory arrest (9 minutes and 8 minutes for each anastomosis). He recovered well without any major complications, and postoperative angiogram showed two new grafts patent.
We report a case of successful reoperation of coronary revascularization without cardiopulmonary bypass. The patient was a 62-year-old man, who had undergone coronary artery bypass grafting (CABG) to the LAD and CX with two saphenous vein grafts (SVG) for the left main lesion 12 years before. He required reoperation for unstable angina due to progressive ischemic heart disease and the diseased SVG. Preoperative coronary angiogram revealed total occlusion of major 3 branches and the diseased SVG to the LAD. The reoperation was performed without cardiopulmonary bypass through the repeated median sternotomy for revascularization of the LAD and RCA. The left internal thoracic artery and the gastroepiploic artery were anastomosed to the LAD and RCA under the beating heart without any hemodynamic or electrocardiographic deteriorations. The operation was uneventfully finished in 3 hr 40 min. without the use of blood products. Postoperative angiogram showed both new grafts were widely patent, and he was discharged 14 days after the operation without angina. We also performed 4 other cases of reoperative CABG without cardiopulmonary bypass, and conclude that this technique is a safe and effective alternative in a carefully selected group of patients for reoperative CABG to reduce several technical problems related to coronary reoperation.
A 75-year-old female who had underwent coronary artery bypass grafting (CABG) reoperation 2 years before was readmitted because of unstable angina. Two arterial grafts and one saphenous vein graft (SVG) were all occluded one and half year after the primary operation. The second operation was approached via the repeated sternotomy. LAD and RCA were revascularized with a Y-shaped SVG which had only one inflow. Coronary angiogram revealed stenosis of LMT and RCA and occlusion of the inflow of the Y-shaped SVG. We performed the 3rd CABG via the left thoracotomy without cardiopulmonary bypass for revascularization of the LAD area. A new SVG was anastomosed from the descending aorta to the old SVG just proximal to the anastomotic site with LAD. Local coronary occlusion time was 7 min without any hemodynamic or electrocardiographic deteriorations. The operation was successfully performed in 3 hr 55 min. The patient recovered well uneventfully. Postoperative angiogram showed that the new SVG was adequately patent and she was discharged without angina. We conclude that CABG without cardiopulmonary bypass via the left thoracotomy is an useful alternative to decrease mortality and morbidity for reoperative myocardial reveascularization.
Isolated stenosis of the left main coronary artery was surgically enlarged by patch angioplasty using a distal flap of the left internal mammary artery. The remaining proximal mammary artery pedicle was anastomosed to the anterior descending coronary artery as an in situ graft for security. The patient's recovery was uneventful, and postoperative angiography at 2 weeks showed good patency of both the left main trunk and the internal mammary artery graft.
Coronary artery bypass grafting (CABG) was performed using saphenous vein grafts anastomosed in reversed Y-shaped in two patients because of the atherosclerotic ascending aorta. Postoperative course was uneventful, however, the common part of reversed Y-shaped grafts was occluded in both patients within two years after operations. The arms of reversed Y-shaped grafts were patent, and played a role of major collateral between LAD and RCA. They were treated successfully with reoperation in one patient and PTCA in another.
59 cases of late cardiac tamponade following open heart surgery were studied. The incidence was 2.1%. Postoperative prolonged heart failure, anticoagulants, and blood in the pericardium left undrained may play a role in its pathogenesis. Echocardiography was the sure method of diagnosis. Insertion of a drainage tube into the pericardium through the subxiphoid approach was effective with minimal invasion and a treatment of choice.
A 74 year old female with lung cancer had undergone coronary artery bypass graft surgery (CABGS) and survived for 9 months after subsequent chemotherapy. She had been suffering from severe chest pain since 2 years before that time, and deteriorated intractably. At the same time, lung cancer was suggested radiologically, and revealed as small cell lung cancer by bronchial biopsy. Coronary angiogram study was done to verify the coronary artery disease and severe triple artery disease was shown. CABGS was done to relieve her condition to start chemotherapy. Post-operative course was fine and CODE therapy [cisplatin, oncovin (vincristine), doxorubicin (adriamycin), etoposide] was done subsequently to CABGS. Cancer focus and swollen lymph node were vanished in radiographic examination. She had discharged and spent at home for a while. However, multiple metastatic lesions emerged later, and deceased finally 9 mouths after CABGS. We conclude, CABGS done for her was a reasonable therapy to relief her condition and was successful to carry out chemotherapy.
Coronary artery reoperation has been performed in 51 patients (4%) including 5 second reoperations among 1,245 CABGs during past 9 years. There were 40 males and 11 females with a mean age of 58 year old ranging from 19 to 75 year old. Extent of coronary artery disease were; single vessel disease in 2 patients, double vessel disease in 18 patients, triple vessel disease in 22 patients and left main disease in 9 patients. Preoperative ejection fraction ranged from 0.24 to 0.69 (mean 0.48) and 21 patients (41%) showed unstable angina. Interval between primary CABG and reoperation ranged from 1 month to 20 years with a mean of 6 years. There were two groups which had early reoperation at the mean of 6 months (14 patients) and late reoperation at the mean of 9 years (37 patients) after primary CABG. Causes of reoperation varied from graft failure (29 patients), progression of native CAD (2 patients), both of them (19 patients), and incomplete revascularization (1 patient). There were 32 patients who had patent old graft at the time of reoperation. Re-entry approaches used were midsternal in 41 patients and left thoracotomy in 10 patients. The ITA, GEA, IEA and SV grafts were used in 30, 38, 5 and 28 patients, respectively. There were 4 patients who underwent CABG without cardiopulmonary bypass. The mean number of bypass was 2.1 and the mean duration of aortic crossclamp and cardiopulmonary bypass were 63 minutes and 114 minutes, respectively. As a result, there were 4 early and 1 late death. Postoperative angiography revealed that patency rate of ITA, GEA, IEA and SV grafts were 100% (22/22), 97% (30/31), 75% (3/4) and 87% (20/23), respectively. In conclusion, risk of coronary artery reoperation is still high and use of arterial graft is important to obtain high patency rate and low reoperation rate.
OBJECTIVES: This report describes our early experience and results with percutaneous transluminal coronary angioplasty of gastroepiploic artery grafts in 12 patients. BACKGROUND: Angioplasty has been successfully performed in saphenous vein and internal thoracic artery grafts; however, experience with angioplasty in gastroepiploic artery/coronary artery bypass grafts is limited. METHODS: Balloon angioplasty was performed in 12 patients (11 men, 1 woman; mean age 58 +/- 8 years) with either total occlusion (6 patients) or severe stenosis (6 patients) of a gastroepiploic artery/coronary artery anastomosis. In seven patients, a guide wire/balloon catheter system was used through a 7F sheath inserted into the celiac trunk. In seven patients, including two who had unsuccessful wire/balloon angioplasty, an over the wire system was used through a 6.5F Cobra or 7F JR4 guide catheter, selectively inserted into the gastroduodenal artery. RESULTS: Angioplasty was successful in five (83%) of six patients with stenosis and in one of six patients with total occlusion (p = 0.08, 1 - beta = 0.68). The guide wire could not be advanced through the lesion in five patients, and the balloon catheter did not cross the lesion in one patient whose gastroepiploic artery was tortuous. Catheters exhibited better trackability and pushability when the over the wire system was used, and five of the six successes were achieved using this approach. Follow-up arteriography was performed in five patients, and all of the gastroepiploic artery grafts were patent without stenosis. CONCLUSIONS: Angioplasty can be safely performed in stenosed gastroepiploic artery grafts. An over the wire system that uses a thin balloon catheter inserted through a guide catheter in the gastroduodenal artery seems optimal.
From March 1986 to September 1991, the right gastroepiploic artery has been used for coronary artery bypass grafting in 200 patients (171 male and 29 female patients, mean age 58 years, range 6 to 80 years. They were followed up from 6 to 70 months with a mean of 27 months. There were 16 reoperations and 176 patients had triple vessel or left main disease. The gastroepiploic artery (182 in situ and 18 free grafts) was anastomosed to 11 anterior descending, 3 diagonal, 26 circumflex, and 160 right coronary arteries. The internal thoracic artery was concomitantly used in 192 patients. The mean number of distal anastomoses was 2.3 with arterial grafts and 3.3 including additional saphenous vein grafts. Postoperative angiography was performed in 152 patients within 6 months after the operation (mean 2 months) and after the operation second angiograms were done sequentially 1 to 5 years (mean 2 years) after the operation in 40 patients. There were 6 early and 4 late deaths. A new Q wave was noted in 4 patients. Duration of the operation and postoperative complications did not increase with the use of the gastroepiploic artery. Relief of angina was noted in 186 patients. Gastroepiploic artery graft patency was 95% (144/152) in the early postoperative period and 95% (38/40) in the late postoperative period. Percutaneous transluminal coronary angioplasty was done successfully through the in situ gastroepiploic artery graft for anastomotic stenosis in four cases. In stress myocardial scintiscans, performed sequentially preoperatively and in the immediate, 1-year, and 2-year postoperative periods in 11 patients, washout rate of the gastroepiploic artery-grafted area improved from 35% +/- 10% to 45% +/- 15% (p < 0.05) and was maintained to 43% +/- 6% and 48% +/- 9% at respective periods. In conclusion, the gastroepiploic artery is a suitable conduit for coronary artery bypass grafting in terms of low surgical risk, high patency rate, and excellent patient outcome.
Hemodynamic situation immediately after cardiopulmonary bypass was studied in cases of CABG using bilateral ITAs and right GEA. Though cardiac output was kept greater than 4.0 l/min, the blood pressure soon after weaning from cardiopulmonary bypass was low in patients who necessitated further circulatory assist, intraaortic balloon pumping (IABP) and/or additional surgical bypass procedure. In cases of CABG using arterial grafts and no vein graft, the perfusion pressure is most important to stabilize the hemodynamic status because low pressure may provoke peripheral vasoconstriction resulting in spastic reaction of the ITA and GEA. These arterial grafts seemed to keep the characteristics as the peripheral artery. Some papers pointed out less flow capacity of arterial grafts compared with that of saphenous vein graft, but CABG with arterial grafts alone was safe clinically if care is taken for keeping the perfusion pressure as high as preoperatively.
While annual attrition and high break-down rate of saphenous vein graft (SVG) used for CABG has widely noted in Western countries, no sizable studies have yet available in Japan. We studied 142 SVGs of 77 pts, which we divided into two groups; 80 SVGs of 44 pts in mid-term period (5 to 8 years after surgery) and 62 SVGs of 33 pts in long-term period (9 to 17 years after surgery). The patency rate of SVGs was 69% in mid-term and 77% in long-term. Whereas these patency rates at each periods were superior to those reported from USA and European countries, a quarter of SVGs in mid-term period and a half in long-term period had significant stenotic changes (over 50%). Of patent SVGs, diseased SVGs reached 36% in mid-term period and 73% in long-term period. In conclusion, although the patency rate of SVGs in Japanese patients was higher than that of the Western countries, vein graft disease apparently occurred in a large proportion of patent SVGs.