Flow capacity of the human retrograde internal mammary artery: Surgical considerations

doi:10.1016/0003-4975(90)90475-L

The Annals of Thoracic Surgery

Volume 50, Issue 3, September 1990, Pages 360-366

https://doi.org/10.1016/0003-4975(90)90475-L Get rights and content

Abstract

The diastolic flow of the retrograde internal mammary artery (IMA) was calculated in 30 patients and compared with the expected coronary flow of the left ventricle and that of specific branches. Arterial pressure and free flow were measured in the proximal and distal IMA as well as in the superior epigastric and musculophrenic arteries. Systolic and mean arterial pressure were significantly higher in the proximal IMA than in any other site, but diastolic pressure was comparable. Overall and diastolic antegrade IMA flows (77 ± 6 and 44 ± 3 mL/min) were significantly greater than the retrograde flows through the distal IMA (18.5 ± 2 and 11.5 ± 1 mL/min), musculophrenic artery (13.3 ± 1 and 7.9 ± 1 mL/min), and superior epigastric artery (5.3 ± 0.4 and 3.1 ± 0.2 mL/ min). Only patient size-related variables correlated significantly with retrograde IMA flow. Diastolic retrograde IMA flow represented 8.5% ± 0.6% of the expected left ventricle coronary flow and in 12 patients (40%) was greater than the expected flow of at least one posteroinferior coronary artery. Based on these data, the retrograde IMA may adequately perfuse the posterior descending or other posterolateral coronary branches in select patients. Previous measuring of the retrograde flow is mandatory.

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Cited by (13)

Physiology and surgical anatomy of the internal mammary artery: What should be known during its skeletonized harvesting?
2021, Cirugia Cardiovascular
Las características anatómicas e histológicas excepcionales de la arteria mamaria interna (AMI) la convierten en el hemoducto ideal para la cirugía de revascularización miocárdica. La técnica para su disección esqueletizada solo con clips y tijeras, permite la construcción de un injerto con más flujo y la conservación de una mayor circulación colateral residual al esternón, con la consiguiente mejor protección ante futuros eventos isquémicos o infecciosos.
Sin embargo, ese método de disección es el menos practicado por ser más lento y no estar exento de lesiones de ramas laterales de la arteria. En las últimas décadas se han introducido varios adelantos tecnológicos en el procedimiento de disección de la AMI, pero las técnicas actuales no aprovechan sus especiales características morfofisiológicas para potenciar la obtención de un hemoducto con más flujo y con menos riesgo de lesión vascular y sangrado.
En esta revisión se comentan las particularidades de la anatomía quirúrgica de la AMI, y se proponen modificaciones a la técnica clásica de disección esqueletizada con clips y tijeras para obtener un hemoducto de mayor calidad.
The exceptional anatomical and histological characteristics of the internal mammary artery make it the ideal graft for myocardial revascularization surgery. The technique for its skeletonized harvesting with only clips and scissors, allows the construction of a graft with more flow and the conservation of a greater residual collateral circulation to the sternum, with the consequent better protection against future ischemic or infectious events.
However, this harvesting method is the least practiced because it is slower and is not exempt from injuries to the lateral branches of the artery. In recent decades, several technological advances have been introduced in the internal mammary artery harvesting procedure, but current techniques do not take advantage of its special morphophysiological characteristics to enhance obtaining a hemoduct with more flow and with less risk of vascular injury and bleeding.
In this review, the peculiarities of the internal mammary artery surgical anatomy are discussed, and modifications of the classic skeletonized harvesting technique with only clips and scissors are proposed to obtain a higher quality graft.
Right gastroepiploic artery used as a pedicled graft in a retrograde fashion
1993, The Annals of Thoracic Surgery
The right gastroepiploic artery is currently regarded as a most valuable arterial conduit for myocardial revascularization. We have documented a particular case wherein the proximal (pyloric) part of the right gastroepiploic artery could not be freed and was damaged because of previous cholecystectomy. The pedicle was divided at the pyloric side and raised up to be anastomosed to the posterior descending artery in a retrograde fashion. The purpose of this report is to emphasize the fact that a previous abdominal operation does not necessarily hamper the use of the gastroepiploic artery as a pedicled graft. It is also pointed out that retrograde flow in the pedicle was sufficient in this case to provide good revascularization.
Physiologic characteristics of coronary artery bypass grafts
1993, The Annals of Thoracic Surgery
To investigate the hemodynamic characteristics of arterial grafts for coronary artery bypass grafting, we measured phasic pressure and flow patterns in three types of grafts in a canine model (n = 18). A graft from the ascending aorta (AAG), a graft from the descending aorta at the first lumbar level (DAG), analogous to a right gastroepiploic artery, and an internal thoracic artery (ITA) were anastomosed to each other. The composite graft was anastomosed to the left anterior descending coronary artery, and then the left anterior descending coronary artery was ligated. Before grafting, the AAG showed high sustained diastolic pressure, but the ITA and DAG showed rapid fall of diastolic pressures. Mean diastolic pressures were 83 ± 2, 72 ± 3, and 57 ± 2 mm Hg in the AAG, ITA, and DAG (p < 0.05). Free flow in the AAG was markedly greater than in the ITA or the DAG. After grafting to the left anterior descending coronary artery, no changes were observed in diastolic pressures compared with the pregrafting values. Total blood flows were 72 ± 6, 80 ± 7, 57 ± 7, and 44 ± 6 mL/min in the left anterior descending coronary artery, AAG, ITA, and DAG, respectively. There were no differences in systolic graft flow between the three types of grafts. Diastolic blood flow in the ITA (29 ± 4 mL/min) and DAG (18 ± 3 mL/min) was smaller than in the AAG (48 ± 4 mL/min) (p < 0.01). Regression equations between mean diastolic pressure (X) and diastolic graft flow (Y) were Y = 0.46X + 8.6 (r = 0.79; p < 0.01) in the AAG, Y = 1.3X − 68 (r = 0.83; p < 0.001) in the ITA, and Y = 1.2X − 54 (r = 0.91; p < 0.0001) in the DAG, respectively. These results indicate that arterial grafts have disadvantages over ascending aorta-originated grafts in the ability to supply blood to the diastolic-dominant coronary circulation.
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Bifurcated ('Y') internal thoracic-coronary artery grafts [6]
1992, Journal of Thoracic and Cardiovascular Surgery
Inverted internal mammary artery for myocardial revascularization
1991, The Annals of Thoracic Surgery

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Original articleFlow capacity of the human retrograde internal mammary artery: Surgical considerations

Abstract

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Retrograde mammary-coronary anastomosis and its place among other methods of myocardium revascularization

Vestn Khir

Coronary artery surgery using inverted internal mammary artery

Br Heart J

Original article
Flow capacity of the human retrograde internal mammary artery: Surgical considerations