Duplex Imaging Assessment of the Internal Mammary Arteries in Women after Unilateral Mastectomy and Radiotherapy for Breast Cancer.

BACKGROUND: The effects of incidental radiation exposure on internal mammary arteries remain unclear. The present study was designed to test the hypothesis by comparing diameter and blood flow of the irradiated and nonirradiated internal mammary arteries, using Duplex ultrasound imaging. METHODS: The study was designed as a single-center, transversal, comparative study. The main outcomes were diameter and volumetric blood flow of the internal mammary arteries. The Wilcoxon rank-sum test was used to assess the differences between the irradiated and nonirradiated internal mammary arteries with regard to the diameter and volumetric blood flow. RESULTS: The diameter (median [interquartile range]) of the irradiated internal mammary arteries (0.170 mm [0.160, 0.180]) was smaller than that of the contralateral nonirradiated ones (0.180 mm [0.170, 0.200], P < 0.0001) and that of the internal mammary arteries in the control group (0.180 mm [0.170, 0.190], P < 0.0001). Similarly, blood flow (median [interquartile range]) of the irradiated internal mammary arteries (52.4 ml/min [37.78, 65.57]) was smaller than that of the contralateral nonirradiated ones (62.7 ml/min [46.87, 84.17], P < 0.0001), as well as of the left (56.7 ml/min [46.88, 72.58], P = 0.02) and the right internal mammary arteries in the control group (61.0 ml/min [47.47, 74.52], P = 0 0.0009). CONCLUSIONS: The data indicate that the irradiated internal mammary arteries in patients with a history of total mastectomy followed by radiotherapy for breast cancer had significantly smaller diameter and blood flow compared to the nonirradiated internal mammary arteries.

From a Position of Known Angiographic Perfect Patency: What Happens Next?

BACKGROUND AND AIM: The biological behaviour of coronary graft conduits over time may be considered by serial angiography. METHODS: A single institution retrospective cohort received mostly clinically indicated angiography between 1997 and 2020, following coronary bypass surgery. Only perfectly patent grafts (absence of any lumen irregularity) for each conduit type at the first postoperative angiogram were selected for a later comparison. The latest angiograms were at least 5 years postoperatively, and at least 1 year after first postoperative angiogram. Analysis was done according to each graft (anastomosis). Comparisons used generalised estimating equations, adjusted for binary logistic regression. RESULTS: Of 143 patients, there were 410 of 468 (87.6%) perfectly patent grafts at the first angiogram, analysed at 6.8±4.0 years postoperative, of which 157 were internal mammary arteries, 228 were radial arteries, and 25 were saphenous veins. At the latest angiogram (12.2±3.8 years postoperative), comparison with the first angiogram for each individual graft found preserved perfect patency for internal mammary arteries, 156 of 157 (99.4%), and for radial arteries, 227 of 228 (99.6%) but saphenous veins deteriorated considerably, 13 of 25 (52.0%). The two arterial grafts (internal mammary and radial) were superior to vein grafts (odds ratio 163; 95% confidence interval [CI] 22-1,211; p<0.001), but not different from each other (odds ratio 0.95; 95% CI 0.78-1.16; p=0.584). CONCLUSIONS: From a position of known angiographic perfect patency post-CABG, internal mammary artery and radial artery grafts retained their perfect patency in the longer term, but saphenous vein grafts did not.

[Congenital Left Internal Mammary Artery to Pulmonary Artery Fistula with Aneurysmal Change Diagnosed Incidentally:Report of a Case].

An internal mammary artery to pulmonary artery (IMA-PA) fistula is a very rare vascular abnormality. Patients with this disease are often asymptomatic, but they may develop symptoms such as heart failure and hemoptysis. A 60-year-old woman was incidentally diagnosed with left IMA-PA fistula by chest computed tomography (CT) during an examination for colon cancer. She was asymptomatic, but we determined that surgery was indicated because of the presence of an aneurysmal change. We performed complete surgical resection of the IMA-PA fistula and aneurysm under cardiopulmonary bypass. Her postoperative course was uneventful. Although a specific management strategy for IMA-PA fistula has not yet been established, surgical treatment should be performed to prevent rupture in cases with aneurysmal change.

[Peripheral Pulmonary Artery Aneurysm with Internal Thoracic Artery-Pulmonary Artery Shunt].

An 82-year-old woman with past history of pulmonary nontuberculous mycobacterial infection complained of hemoptysis and was pointed out the strongly stained nodule in the middle lobe of the right lung on chest enhanced computed tomography (CT), which was suggested to be peripheral pulmonary artery aneurysm. Angiography of the right internal thoracic artery (RITA) revealed the peripheral pulmonary artery aneurysm with the shunt from the branch of the RITA, which was considered to be the cause of hemoptysis. Transcatheter arterial embolization was performed for the branch of the RITA 2 times, however, the hemoptysis recurred again after 5 months. Therefore, after the third embolization for the RITA, the right middle lobectomy with amputation of the shunt vessel was performed. The patient has been well without hemoptysis for one year and 6 months after the surgery.

Intralobular pulmonary sequestration in the middle lobe supplied by a right internal mammary artery: a case report.

BACKGROUND: Pulmonary sequestration (PS) is a rare congenital malformation that is more common in the left lower lobe, and the thoracic aorta is the most common arterial supply. CASE PRESENTATION: We describe a case of a 67-year-old man with a chief complaint of intermittent cough and hemoptysis who had been diagnosed by multidetector computed tomography angiography with right middle lobe intralobular pulmonary sequestration supplied by a right internal mammary artery. Finally, he underwent middle pulmonary lobectomy with normal postoperative recovery. DISCUSSION: This is a rare intralobular pulmonary sequestration case for a feeding artery from the right internal mammary. Multidetector computed tomography angiography should be performed for diagnosis and preoperative evaluation once pulmonary sequestration is suspected.

Postoperative intrapulmonary invagination of the left internal mammary artery-An anomalous course deciphered on CT angiography.

We hereby present a case of intrapulmonary invagination of the left internal mammary artery detected on CT angiography. We aim to highlight the role of CT angiography in identifying these course anomalies and their clinical implications.

The impact of the quantitative assessment procedure for coronary artery bypass graft evaluations using high-resolution near-infrared fluorescence angiography.

PURPOSE: Near-infrared angiography (NIR) is used for on-site graft assessment during coronary artery bypass grafting. This study evaluated the results of a quantitative NIR assessment using a new high-resolution NIR device (h-NIR) for graft assessment. METHODS: Forty-three patients were enrolled in our study. Internal thoracic artery (ITA) grafts anastomosed to the left anterior descending artery and examined intraoperatively using h-NIR were included. The ITA grafts were divided into 2 groups for a comparative analysis: patent grafts (P group; n = 37) and failed grafts (F group; n = 6). The graft flow was evaluated by a "quantitative NIR assessment", and the fluorescence luminance intensity (FLI) was measured. Direct observation of the graft and anastomosis with h-NIR was also performed. RESULTS: The FLI was higher in the P group than in the F group. The receiver operating characteristic analysis revealed the following cut-off values for FLIs depending on imaging duration: 21.1% at 1 s, 35.5% at 2 s, 58.4% at 3 s, and 83.3% at 4 s. The sensitivity and specificity for detecting graft failure were 83.3% and 69.8-80.6%, respectively. Furthermore, h-NIR was also able to visualize arterial dissection in ITA grafts. CONCLUSIONS: A quantitative NIR assessment with an h-NIR device can improve the detectability of anastomotic stenosis, and h-NIR successfully detected arterial dissection of grafts.

Investigation of the effects of diabetes mellitus on left internal thoracic artery flow patterns in patients scheduled to undergo coronary bypass graft surgery.

PURPOSE: Diabetes mellitus (DM) plays a key role in the formation and prognosis of cardiovascular diseases. In this study, we aimed to investigate the effects of DM and glycemic control on left internal thoracic artery (LITA) Doppler flow in patients scheduled to undergo coronary artery bypass graft (CABG) surgery. METHODS: Patients who were hospitalized with a planned isolated CABG operation to our clinic between October 1, 2019 and March 1, 2020 were consecutively included in this prospective study. The patients were divided into three groups as those without DM (Group 1), those with DM and HbA1c values of below 7.5 (Group 2), and those with DM and HbA1c values of 7.5 and above (Group 3). The differences between the LITA Doppler flow patterns of the patients were analyzed. RESULTS: The mean ages of Group 1 (n = 103), Group 2 (n = 42), and Group 3 (n = 47) were 59.8 ± 9.6 years, 60.5 ± 9.3 years, and 61.9 ± 8.1 years, respectively. The groups differed in terms of diameter, volume, Vmax, pulsality index (PI), and resistive index (RI) values, both when the groups were compared among themselves (P < .001, for all), and when they were compared between those with (Groups 2 and 3) and without DM (Group 1) (P < .001, for all). Volume (R = -0.627, P < .001) and Vmax (R = -.450, P < .001) were moderately negatively correlated, while PI (R = .523, P < .001) and RI (R = 0.598, P < 0.001) were moderately positively correlated with HbA1c levels. CONCLUSION: In this study, we showed that increased HbA1c levels may be associated with significant functional and structural changes of LITA.

Left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting.

OBJECTIVE: The objective of this qualitative review is to summarize the pathophysiological and clinical data behind the clinical entity of left internal mammary artery (LIMA) side branch coronary steal as well as the potential diagnostic and therapeutic modalities available. BACKGROUND: The presence of persistent unligated LIMA side branches following coronary artery bypass grafting has previously been associated with stable angina and acute coronary syndromes. However, despite numerous attempts to objectively demonstrate a coronary steal phenomenon, the pathophysiology of LIMA side branch flow diversion remains elusive and the clinical utility of intervention is not well elucidated. METHODS: A review of literature and available data including case reports, case series, and investigational studies was performed. RESULTS: Therapeutic closure of LIMA side branches has been reported in at least 44 patients and in at least 31 publications since 1990 and is associated with an 87.5% rate of freedom from angina amongst technically successful initial interventions. In all patients with pre- and post- stress testing, intervention was associated with an improvement and/or resolution of previously observed reversible ischemia. CONCLUSIONS: LIMA side branch coronary steal should remain an ongoing consideration in symptomatic patients with large unligated side branches on angiography, particularly when there is clear evidence of reversible ischemic on perfusion imaging.

Is stealing still a crime? Comment on left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting.

Post-coronary artery bypass graft surgery (CABG) angina has been attributed unligated thoracic side branches competing with LIMA-LAD flow. Case reports suggest thoracic branch occlusion can relieve angina. Phasic arterial blood flow and direct measurements argue against the existence of LIMA steal.

Use of quantitative cardiovascular magnetic resonance myocardial perfusion mapping for characterization of ischemia in patients with left internal mammary coronary artery bypass grafts.

BACKGROUND: Quantitative myocardial perfusion mapping using cardiovascular magnetic resonance (CMR) is validated for myocardial blood flow (MBF) estimation in native vessel coronary artery disease (CAD). Following coronary artery bypass graft (CABG) surgery, perfusion defects are often detected in territories supplied by the left internal mammary artery (LIMA) graft, but their interpretation and subsequent clinical management is variable. METHODS: We assessed myocardial perfusion using quantitative CMR perfusion mapping in 38 patients with prior CABG surgery, all with angiographically-proven patent LIMA grafts to the left anterior descending coronary artery (LAD) and no prior infarction in the LAD territory. Factors potentially determining MBF in the LIMA-LAD myocardial territory, including the impact of delayed contrast arrival through the LIMA graft were evaluated. RESULTS: Perfusion defects were reported on blinded visual analysis in the LIMA-LAD territory in 27 (71%) cases, despite LIMA graft patency and no LAD infarction. Native LAD chronic total occlusion (CTO) was a strong independent predictor of stress MBF (B = - 0.41, p = 0.014) and myocardial perfusion reserve (MPR) (B = - 0.56, p = 0.005), and was associated with reduced stress MBF in the basal (1.47 vs 2.07 ml/g/min; p = 0.002) but not the apical myocardial segments (1.52 vs 1.87 ml/g/min; p = 0.057). Extending the maximum arterial time delay incorporated in the quantitative perfusion algorithm, resulted only in a small increase (3.4%) of estimated stress MBF. CONCLUSIONS: Perfusion defects are frequently detected in LIMA-LAD subtended territories post CABG despite LIMA patency. Although delayed contrast arrival through LIMA grafts causes a small underestimation of MBF, perfusion defects are likely to reflect true reductions in myocardial blood flow, largely due to proximal native LAD disease.

First case report of bilateral breast necrosis following coronary artery bypass graft using left internal mammary artery.

Coronary artery bypass grafting (CABG) using internal mammary artery is a frequently performed procedure for the treatment of coronary artery disease nowadays. Ipsilateral breast necrosis is a rare and seldom reported complication that may mimic breast cancer on presentation. However, contralateral breast necrosis has not been reported to date. We are reporting the first case of bilateral breast necrosis after CABG using the left internal mammary artery. We discuss the different underlying mechanisms and possible co-factors behind the development of this rare complication, and we also share a successful management approach to conserve the breast and improve the patient's outcome.

Subclavian artery aneurysmal rupture and left internal mammary artery extravasation secondary to advanced Marfan syndrome.

This case highlights the unusual life-threatening findings found in a patient with Marfan syndrome (MFS) in the emergency department setting. MFS is a rare autosomal dominant disease that affects 1 in 3000-5000 individuals and has a highly variable range of clinical severity. This case is a 63-year-old male with COPD, scoliosis, aortic and mitral valve replacements on warfarin, and MFS who presented with acute onset hemoptysis, tachypnea, and oxygen saturation of 77% on 4 l nasal cannula. Emergent chest computed tomography angiography (CTA) revealed both a contained rupture of a left subclavian artery aneurysm and active extravasation from his left internal mammary artery (LIMA) into his left chest. The patient was on warfarin and reversed with IV vitamin K and prothrombin complex concentrate. Vascular surgery emergently took the patient to the operating room for embolization of his LIMA and stenting of the contained ruptured left subclavian artery aneurysm. The patient was discharged home one month after admission. This case report illustrates the potential severe sequelae of MFS and the importance of rapid recognition by emergency physicians. An expanded understanding of the pathophysiology of MFS has resulted in great advancement in medical therapies and lifestyle modification and thus has significantly prolonged life expectancy in these patients. Increased awareness and familiarity will facilitate continued high-quality management and treatment by emergency physicians.

Avoiding the Internal Mammary Artery During Parasternal Blocks: Ultrasound Identification and Technique Considerations.

Fascial plane chest wall blocks are an integral component to optimal multimodal postoperative analgesia in breast and cardiothoracic surgery, facilitating faster functional recovery and earlier discharge. Pectoral nerves block and serratus plane block have been used to treat postsurgical pain after breast and cardiothoracic surgeries; however, they cannot be used to anesthetize the anterior chest wall. Ultrasound parasternal block, or pectointercostal fascial block and transversus thoracis muscle plane block are two novel ultrasound-guided anesthetic and analgesic techniques that block the anterior cutaneous branches T2 to T6 intercostal nerves, providing anesthesia and analgesia to the anterior chest wall. Ultrasound parasternal block/pectointercostal fascial block and transversus thoracis muscle plane block are performed in the region of the internal mammary artery and could be considered to treat post-thoracotomy pain. This anatomic region is innervated by the anterior cutaneous branches T2-to-T6 intercostal nerves, which are obliterated during cardiac surgery artery harvesting. At the level of the fourth parasternal rib interspace, the internal mammary artery can be identified between the internal intercostal muscle and transversus thoracis muscle as a longitudinal pulsatile structure approximately 1.5 cm from the lateral border of the sternum. The transversus thoracis muscle is variable in many people and, thus, is an unreliable target and is difficult to visualize with ultrasound. Moreover, patients with a history of coronary artery bypass grafting could have tissue disruption in the transversus thoracis plane because of the internal mammary artery harvest, making transversus thoracis muscle identification more difficult. Despite ultrasound parasternal block and transversus thoracis muscle plane block having good safety profiles and reduced risk of complications, pneumothorax, local anesthetic systemic toxicity, and internal mammary artery injury or hematoma should be considered. If the block is performed before cardiac surgery, both the right and left internal mammary arteries could be damaged. The injury could render the internal mammary artery unusable for bypass grafting. If the block is performed after left internal mammary artery harvesting at the end of coronary artery bypass grafting, only the right internal mammary artery could be damaged. In patients in whom the internal mammary artery has been surgically used and the transversus thoracis muscle is difficult to visualize, ultrasound parasternal block should be considered. In patients in whom the internal mammary artery could be difficult to visualize or considering that it is in the vicinity of the transversus thoracis muscle plane block target and that the transversus thoracis muscle is difficult to visualize with ultrasound after internal mammary artery harvesting, then ultrasound parasternal block should be considered. The authors believe that ultrasound parasternal block is the safer regional technique for protecting the internal mammary artery and the pleura because it is more superficial. For this reason, ultrasound parasternal block also could be performed by inexperienced anesthesiologists. Although ultrasound parasternal block is more superficial, its superiority in terms of safety is yet to be proven. Additional studies are warranted to validate the authors' hypothesis.

How to recycle a misused left internal thoracic artery: Tips and tricks.

In this case report, we describe how to recycle the left internal thoracic artery (LITA) when misused but not damaged. Eight years after a left anterior small thoracotomy followed by left anterior descending (LAD) stenting for STEMI in first postoperative day, a 67-years-old woman had an NSTEMI with angiographic evidence of intrastent re-stenosis with a perfectly patent LITA, harvested only from the fourth to the sixth intercostal space. During redo surgery, LITA was harvested as a pedicle from the anastomosis to the fourth intercostal space and primarily from the first to the fourth intercostal space. Special attention was paid at the level of the fourth intercostal space where the vessel was stuck to the sternum: a 15-blade was used being scissors or cautery too dangerous. At the end of harvesting, the LITA was full-length available for a new coronary anastomosis on LAD, distal to the previous one.

Coronary artery bypass using bilateral internal thoracic artery grafts in polyarteritis nodosa.

Polyarteritis nodosa (PAN) affects small- and medium-sized arteries but rarely occurs in coronary artery aneurysms and stenosis. For patients with PAN, coronary artery bypass grafting (CABG) can be challenging, especially with respect to graft selection. We performed CABG using a bilateral internal thoracic artery (ITA) graft for a 21-year-old patient with PAN, with successful postoperative outcomes. Arterial grafts have the risk of stenosis in PAN, but the patient's condition was controlled by steroids and immunosuppressants, and angiography showed no stenosis. We decided to use the ITA graft as a bypass conduit and found that long-term follow-up and continuous treatment are necessary.

Chest wall infarction following bilateral internal thoracic harvesting for coronary revascularization in a patient with previous aortic abdominal aneurysm surgery: A rare complication.

A 75 years old man with previous aortic abdominal aneurysm surgery through a transverse laparotomy underwent bilateral internal thoracic artery to coronary artery bypass grafting. He immediately thereafter developed a severe chest and upper abdominal walls ischemia with metabolic acidosis, and finally deep sternum wound infection and upper abdominal wall necrosis. He benefitted from sternal reconstruction and vaccum assisted treatment, with delayed pectus major flap reconstruction. Chest and abdominal wall infarction following bilateral internal thoracic artery (BITA) harvesting is a very rare but life-threatening complication. Caution use of BIMA should be in order in patients with inferior epigastric artery flow impairment.

Reopening of the occluded saphenous vein composite grafts after coronary artery bypass grafting.

BACKGROUND: We have observed reopening of the occluded "no-touch" saphenous vein (NT SV) composite grafts on follow-up angiograms in patients who underwent coronary artery bypass graftings (CABGs). METHODS: Between 2008 and 2018, 1283 patients received NT SV conduits without or with surrounding pedicle tissue as composite grafts based on the in situ left internal thoracic artery (ITA) for CABG and underwent early postoperative angiographies. Among the 1283 patients, 53 patients showed 55 occluded SV conduit anastomoses, and 46 patients who had 48 occluded SV anastomoses were re-evaluated by 1-year postoperative angiographies. RESULTS: Early postoperative angiographies in 1283 patients demonstrated overall occlusion rates of 1.2% (56/4518); occlusion rates of the ITA and SV were 0.08% (1/1259) and 1.7% (55/3260), respectively. One-year angiograms demonstrated that 14 occluded SV anastomoses (29.2% [14/48 occluded SV]) of 14 patients became patent. Reopening of occluded SV conduits occurred more frequently in NT SV with pedicle tissue than in NT SV without pedicle tissue (45.0% [9/20] vs. 17.9% [5/28]; p = .057). When we examined the preoperative and 1-year postoperative angiograms, reopening of the occluded SV conduits was not related with progression (p = .258) or preoperative reversibility score (p = .115) of native target coronary artery disease. CONCLUSIONS: More than a quarter of the occluded SV composite grafts on early postoperative angiograms were patent in the 1-year angiograms. The reopening rates were higher in patients who had received NT SV conduits with pedicle tissue than those who had received NT SV conduits without pedicle tissue.

Coronary artery bypass grafting after sternal turnover procedure and a review of the literature.

We report a case of complete revascularization after a sternal turnover procedure through median sternotomy in a patient with multivessel coronary artery disease. The patient had unusual anatomical features, such as the anterior protrusion of the middle-to-distal sternum and absent bilateral internal thoracic arteries (ITAs). The single-blade sternum retractor and the Omni-Tract retractors are simple and reliable tools for lifting and widening the thoracic wall around the xiphoid process. The bilateral radial arteries and the great saphenous vein were used as bypass grafts. Computed tomography was used to visualize the sternum supplied by the superior epigastric arteries (SEAs); presurgical abdominal ultrasonography revealed the course and crossing point of the developed SEAs. Since ITAs were absent, we preserved the SEAs to prevent sternal ischemia. No sternal complications or graft occlusion were observed during follow-up.

Risk of Pneumothorax With Internal Mammary Vessel Utilization in Autologous Breast Reconstruction.

BACKGROUND: Complications associated with autologous breast reconstruction are well reported in the literature. Regardless of the type of free flap harvested, the anastomosis is most commonly performed to the recipient internal mammary vessels. Although pneumothorax is a known possible complication of breast surgery, incidence of pneumothorax in breast reconstruction involving the use of the internal mammary vessels is rarely discussed. The aim of our study was to determine the incidence of pneumothorax in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: A single-institution review was performed examining the incidence of pneumothorax in cases of DIEP flap breast reconstruction with anastomosis to the internal mammary vessels over a 4-year period. Intraoperative irrigation was used to visually assess for evidence of pneumothorax during recipient vessel dissection and anastomosis. Anteroposterior chest radiographs were obtained on the first postoperative day to assess for pneumothorax. Additional variables analyzed included type of retractor used during recipient vessel dissection and history of radiation. RESULTS: A total of 180 patients underwent autologous DIEP breast reconstruction at our institution. The overall incidence of pneumothorax was 1.4 per 100 recipient vessel dissections and 2.2 per 100 patients undergoing breast reconstruction. There was a total of 4 cases of pneumothorax. Three were attributed to unknown causes, and 1 was due to direct injury to the parietal pleura via electrocautery. CONCLUSION: The use of the internal mammary artery and vein as recipient vessels continues to be the most common and reliable recipient for autologous breast reconstruction. Based on our data, pneumothorax does not seem to be a common complication of this procedure. If concern for iatrogenic injury to the pleura arises intraoperatively, we suggest the use of a saline bubble test to investigate the possible injury. Routine postoperative radiographs are not indicated unless the patient develops symptoms suggestive of pneumothorax.