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Coronary artery bypass grafting (CABG) remains the preferred revascularization option for patients with complex multi-vessel coronary artery disease. The standard grafting strategy in multi-vessel CABG involves the use of left internal mammary artery (IMA) for grafting of the left anterior descending artery and supplemental saphenous veins for all other target vessels. However, there is emerging evidence predominantly from retrospective, observational studies suggesting improved long-term outcomes with the use of bilateral IMAs. Despite the reported benefits of bilateral IMAs, most surgeons are reluctant to use both IMAs as it is a technically more demanding and time-consuming strategy with marginally higher sternal wound infection rates. This chapter provides an overview of bilateral IMA grafting exploring the rationale, surgical aspects as well as outcomes, concerns and controversies associated with this strategy.

Background: The Gatti and the bilateral internal mammary artery (BIMA) scores were created to predict the risk of deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting. Methods: Both scores were evaluated retrospectively in two consecutive series of patients undergoing isolated multi-vessel coronary surgical procedures - i.e., the Trieste (n = 1,122; BITA use, 52.1%; rate of DSWI, 5.7%) and the Besançon cohort (n = 721; BITA use, 100%; rate of DSWI, 2.5%). Baseline patient characteristics were compared between the two validation samples. For each score, the accuracy of prediction and predictive power were assessed by the area under the receiver-operating characteristic curve (AUC) and the Goodman-Kruskal gamma coefficient, respectively. Results: There were significant differences between the two series in terms of age, gender, New York Heart Association functional class, chronic lung disease, left ventricular function, surgical priority, and the surgical techniques used. In the Trieste series, accuracy of prediction of the Gatti score for DSWI was higher than that of the BIMA score (AUC, 0.729 vs. 0.620, p = 0.0033). The difference was not significant, however, in the Besançon series (AUC, 0.845 vs. 0.853, p = 0.880) and when only BITA patients of the Trieste series were considered for analysis (AUC, 0.738 vs. 0.665, p = 0.157). In both series, predictive power was at least moderate for the Gatti score and low for the BIMA score. Conclusions: The Gatti and the BIMA scores seem to be useful for pre-operative evaluation of the risk of DSWI after BITA grafting. Further validation studies should be performed.

Background: Although many methods are available for breast reconstruction, there are still times where finding the best solution remains a challenge. In selected cases, a laparoscopically harvested omental free flap (LHOFF) can be used for breast reconstruction with excellent results. Aims: The aim of this chapter is to discuss the anatomy, indication, limitations, and surgical technique of the LHOFF for primary or delayed breast reconstruction. Patient selection: Breast reconstruction using an LHOFF is indicated in selected cases: A lean patient with low breast volume and an intact skin envelope with unilateral reconstruction and patient choice to have a solely autologous reconstruction. Sufficient omentum volume must be confirmed through a diagnostic laparoscopy. Technique: The omentum is harvested laparoscopically by a general surgeon and extracted through a 1.5 inch (4 cm) Pfannenstiel incision. Simultaneously, the plastic surgeon’s team members prepare the mammary pocket and acceptor vessels. The gastroepiploic (GE) artery is anastomosed to the internal mammary artery in an end-to-end manner. The accompanying veins are anastomosed using a flow coupler device. The omentum is then carefully fixed in place in the pocket. Conclusion: Autologous breast reconstruction using a LHOFF can be an excellent option in select cases. It is a safe flap with minimal donor site morbidity and scarring with the use of laparoscopic harvesting. The aesthetic results are highly desirable with minimal scarring, good volume, and very soft tissue resembling the natural feeling of a nonreconstructed breast.

Background: conservative therapy for breast tumors respecting the patient psychology is gaining popularity; but it could be followed by deformities especially in dealing with tumors involving the medial part of the breast. The internal mammary artery perforators' flap is widely used for immediate tissue replacement following local excision of tumors in the medial part of the breast. Methods: Ten formalin preserved cadavers from the dissecting room of the Anatomy and Embryology Department, Faculty of Medicine, Alexandria University were used. the beginning of the internal mammary artery was injected with red latex, the perforators of the internal mammary artery were dissected from medial to lateral where the course, length, diameter and branching pattern of each perforator was recorded and photographed. Results: The second internal mammary artery perforator (IMP 2) was the largest constant and the dominant perforator in 55%; it gave arterial supply to the cranial part of the breast; its mean diameter was 2.23± 0.42 mm. The fourth internal mammary artery perforator (IMP 4) was constant in 45%; it gave arterial supply to the caudal part of the breast from the level of the third space and going down. Its mean diameter was 1.95± 0.17 mm. Conclusion: IMPs 2, 3 and 4 could be used in breast reconstruction for the contra lateral breast. IMP 4 could be used to reconstruct the contra lateral breast especially to reconstruct defects following wide local excision in tumors involving the medial part of the contra lateral breast.

BACKGROUND Our aim was to investigate the impact of the non-skeletonized (pedicled) versus the skeletonized left internal mammary (LIMA) harvesting technique on the postoperative sternal and parasternal skin perfusion in patients undergoing coronary artery bypass grafting (CABG), as compared to patients undergoing non-CABG heart surgery. METHODS We included 142 patients who underwent non-bypass (N.=39) or CABG surgery (N.=103). CABG cases were differentiated according to the LIMA harvesting technique: skeletonized (N.=74) or non-skeletonized (N.=29). Parasternal and sternal skin perfusion measurements via a Laser Doppler Imaging tool were performed on the preoperative day and 5-7 days postoperatively, using a grid of 15 spatially segregated measurement points across the chest and normalization to a distinct reference point. Data were analyzed retrospectively. RESULTS In the CABG group, the non-skeletonized LIMA harvesting resulted in a near-significant (P=0.057, two-sided Student t-test, 95% CI -[0.111, 0.002]), and the skeletonized LIMA harvesting in a significant (P< 0.001, 95% CI [-0.096, -0.032]) post-surgical decrease of left-sided parasternal skin perfusion in arbitrary perfusion units (APU), as compared to right-sided parasternal skin perfusion. No corresponding differences were found for the non-bypass group (P=0.5, 95% CI [-0.065, 0.033]). The harvesting techniques did not yield significantly different post-surgical parasternal skin perfusion measures in the CABG group (P=0.6). CONCLUSIONS Measurement of parasternal skin perfusion using Laser Doppler Imaging is feasible. Both harvesting techniques resulted in a reduced parasternal/sternal skin perfusion upon removal of the internal mammary artery.

Objective To investigate the role of hydrogen sulfide (H2S) in human internal mammary arteries (IMA) and its interaction with endothelial nitric oxide synthase (eNOS) and phosphodiesterase (PDE)5A activity. Methods Human IMA segments from patients undergoing coronary artery bypass grafting (CABG) were studied by myography for acetylcholine and sodium hydrosulfide (NaHS)-induced relaxation. Locations of 3-mercaptopyruvate sulfurtransferase (3-MPST) and cysteine aminotransferase (CAT) were examined immunohistochemically. Levels of H2S, eNOS, phosphorylated-eNOSser1177, and PDE5A were measured. Results In IMA segments from 47 patients, acetylcholine-induced relaxation (resistant to NG-nitro-L-arginine and indomethacin) was significantly attenuated by aminooxyacetic acid or L-aspartate (CAT inhibitors), iberiotoxin (large-conductance calcium-activated K+ channel blocker), TRAM-34 plus apamin (intermediate- and small-conductance Ca2+-activated K+ channel blockers) or glibenclamide (ATP-sensitive K+ channel blocker). 3-MPST and mitochondrial CAT were found in endothelial and smooth muscle cells while cytosolic CAT was located only in endothelial cells. Acetylcholine significantly increased the H2S levels. The H2S donor, NaHS, increased eNOS phosphorylation and down-regulated PDE5A. Conclusions Human conduit artery endothelium releases H2S under basal and stimulated conditions, involving the 3-MPST/CAT pathway, eNOS phosphorylation, PDE5A activity, and potassium channels. These findings may provide new therapeutic targets for treating vasospasm in CABG grafts and facilitate the development of new vasodilator drugs.

A false aneurysm of the internal mammary artery is a very rare clinical entity. Early and accurate diagnosis and treatment of false aneurysms of internal mammary artery are critical, as it may result in rupture, severe bleeding, and even death. Currently, endovascular therapeutic approaches such as stenting and coil embolization have been considered the first-line treatment. Herein, we report a case of false aneurysm of the internal mammary artery in the light of literature data.

Background Exclusive coronary revascularization with both mammary arteries could result in lower rates of adverse events in the long term. Aim To describe the five-year evolution of a cohort of patients operated on with this technique. Material and methods Follow up analyzing survival of 73 patients aged 59 ± 9 years (82% men) who underwent exclusive coronary surgery with two mammary arteries between December 1,2010 and April 12,2017. We studied their clinical characteristics, surgical results, operative morbidity and mortality and adverse events up to June 30, 2018. Results Six patients had two-vessel lesions and 67 three-vessel lesions. The operative risk calculated by additive and logistic EuroSCORE was 2.5 and 2.3%, respectively. A mean of 3.75 anastomoses /patient were performed, 116 with left mammary artery (73 to the anterior descending artery, 38 to a diagonal artery and 5 for other objectives) and 158 with right mammary artery (69 to a first marginal artery, 23 to a second marginal artery and 64 to posterior descending artery). There was one case of mediastinitis and one (1.5%) patient died. The mean follow-up was 64.6 ± 23.7 months. The 5-year survival was 90.4%. Conclusions Coronary revascularization with two exclusive mammary arteries allowed a complete revascularization of the heart with a low rate of complications and adverse effects at five years.

A 75-year-old woman, with a history of bilateral internal mammary artery–coronary artery bypass graft surgery, developed hypotension and pulmonary oedema posing as cardiogenic shock. Severe bilateral subclavian artery stenosis emerged to be the cause of ischaemic myocardial dysfunction and heart failure. An emergency endovascular treatment was successfully performed. The presence of simultaneous bilateral subclavian artery narrowing as the pathophysiologic mechanism of myocardial ischaemia makes this case remarkable.

Studies are extremely limited for the investigation of the clinical outcome of da Vinci robot-assisted bilateral internal mammary artery (BIMA) grafting in coronary artery bypass grafting (CABG) surgery. This study aimed to explore the short-term outcome of da Vinci robot-assisted BIMA grafting through the left pleural space. Relevant data were collected from patients with multi-vessel coronary artery disease receiving two kinds of CABG: a group of patients receiving da Vinci robot-assisted CABG with BIMA grafting, and another group of patients receiving sternotomy CABG with BIMA grafting. Primary endpoints, which included cardiovascular and renal endpoints, were analyzed between the groups using the chi-square test, analysis of variance test, and Kaplan&ndash, Meier analysis. Compared with the conventional group (n = 22), the robotic group (n = 22) had a significantly longer operation time (12.7 &plusmn, 1.7 vs. 8.5 &plusmn, 1.5 hours, p &lt, 0.01) and a marginally lower mean of serum creatinine at baseline (1.2 &plusmn, 0.3 vs. 2.0 &plusmn, 1.7 mg/dL, p = 0.04). Primary endpoints (5, 22.7% vs. 12, 54.5%, p = 0.03) and renal endpoints (1, 4.5% vs. 7, 31.8%, p = 0.02) at six months were significantly reduced in the robotic group compared with the conventional group. There were no differences in cardiovascular endpoints at six months between the groups (1, 4.5% vs. 0, p = 1.00). The data showed that da Vinci robot-assisted BIMA grafting was safe, with equal cardiovascular events and lowered renal events at six months, as compared to conventional sternotomy BIMA grafting, despite the longer procedure time. The short-term study suggests that da Vinci robot-assisted BIMA grafting may be considered a favorable surgical option for patients with severe coronary artery disease.

Background: The purpose of this study is to describe the vascularised anterior rib flap on sectioned images and surface models using Visible Korean for medical education and clinical training in the field of mandibular reconstructive surgery. Materials and methods: Serially sectioned images of the thorax were obtained from a cadaver. Significant structures in the sectioned images were outlined and stacked to create a surface model. Results: The PDF file (8.45 MB) of the assembled models can be downloaded for free from our website (http://vkh.ajou.ac.kr/Products/PDF/Vascularized_anterior_rib_flap.zip). In this file, important anatomical structures related to the vascularised anterior rib flap can be examined in the sectioned images. All surface models and stereoscopic structures of the vascularised anterior rib flap are expressed in real time. Conclusions: We hope that these state-of-the-art sectioned images, outlined images, and surface models will help students and trainees gain a better understanding of the anatomy of the vascularised anterior rib flap

Back Ground: The internal mammary artery was the most effective conduit for coronary artery bypass surgery and it was associated with significantly better long term patency, survival, and reintervention rates compared to other bypass conduits. The internal mammary artery (IMA) is not immune to atherosclerosis. IMA interventions constitute low percentage out of all coronary interventions. In addition to the tortuous course, the long length of IMA than native coronaries adds procedural difficulties to IMA PCI.Aim: To analyze the acute outcomes of Percutaneous intervention procedures to the internal mammary artery and to found any association with clinical and demographic parameters to the procedural success at a single tertiary care hospital from IndiaMaterials And Methods: This study was a retrospective analysis of post CABG patient who required and undergone the IMA intervention. We collected the clinical, demographic and procedural details of the IMA intervention. We defined as failure of the procedure when the stent could not be delivered to the lesion site through IMA.Results: Total 21 patients were included in this retrospective analysis. Mean age of the study population was 56.1± 9.98 years and 18 patients were male. Twelve (57.1%) patients presented with chronic stable angina and six (28.6%) had Left ventricular dysfunction (LVD) (mild LVD in 5 and one patient had severe LVD). Mean stent diameter was 2.75±0.442 mm and the mean stent length was 17.71 ±5.63 mm. Transient slow flow occurred in 5 patients, but the end result of PCI procedure was good in them. In 4 (19.1%) patients stent could not be delivered. No LIMA dissections were observed. On binary logistic regression, there was no significant difference between successful PCI to the failed PCI with respect to age (p=0.9, z=0.16, OR=0.99, 95%CI=0.83to1.17), male sex (p=0.7, Z=0.34, OR=1.68), type of presentation (p=0.7, Z=0.38, OR=1.60, 95%CI= 0.14 to 17.7), presence of Left ventricular dysfunction (p=0.7, z=0.38, OR=1.60, 95%CI= 0.14 to 16.97) and with pre-dilatation during PCI (p=0.9, z=-0.16, OR=0.99).Conclusion: PCI to the internal mammary artery was associated with 80.95% of success. Not able to deliver the stent to the target lesion was the major problem with LIMA PCI, in addition, to slow or no flow. The success or failure of PCI were not dependent on the age, sex, type of presentation or LV dysfunction.

Internal mammary artery perforator (IMAP)-based fasciocutaneous flaps have recently gained popularity in sternal wound reconstruction due to their decreased donor site morbidity. However, patients with significant macromastia or who are obese present a challenge when using these flaps due to their anatomy and associated comorbid conditions. Despite the prevalence of this population, there is a relative paucity of data on the use of local fasciocutaneous flaps and techniques to close sternotomy wounds in the obese population with hypertrophic or ptotic breasts. The authors describe a novel technique using simultaneous unilateral breast reduction with a fifth intercostal IMAP-based flap for closure of a median sternotomy wound through a case presentation, an anatomical injection study, and review of the literature. Five fresh female cadavers were used to conduct 8 trials of injection of the IMAP arteries, isolation of the fifth IMAP branch, and elevation of a local flap. The literature was comprehensively reviewed with a total of 33 cases of IMAP flaps for sternal reconstruction being described. The most commonly used perforators with the second and sixth IMAPs. Overall complication rate was reported to be 9.1% (3/33), with 2 cases reporting dehiscence and 1 with flap tip necrosis. No cases reported use of the fifth IMAP or formal breast reduction procedures, which was successfully performed in a 40-year-old diabetic female patient history of multiple left-sided thoracic surgeries and radiation with a chronic sternal wound.

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.

Purpose We aimed to explore the value of contrast-enhanced ultrasonography (CEUS) in guidance of percutaneous biopsy of anterior mediastinal lesions. Methods Ninety patients with solitary anterior mediastinal lesions (55 males, 35 females; mean age, 46±4 years) were included. Patients were randomly divided into CEUS group (n=45) and conventional ultrasonography (US) group (n=45). Real-time US-guided core needle (16 G) percutaneous biopsies were performed in all lesions. The display of internal mammary arteries, internal necrosis, and active areas were recorded and compared. Biopsy success rate and diagnostic accuracy were compared between the two groups. Results Display rate of unenhanced internal necrosis was higher in the CEUS group than in the US group (88.9% vs. 46.7%, P = 0.041). With real-time CEUS guidance, internal mammary arteries were effectively displayed and avoided during biopsies in 68.9% of the lesions (31/45). Of the lesions, 88.9% (80/90) were histologically proven, including 13 benign lesions and 67 malignancies. There was a significant difference in the rate of successful puncture attempts between the two groups (P = 0.041). CEUS group had a higher biopsy success rate (100% vs. 95.5%, P = 0.045) and higher diagnostic accuracy (97.8% vs. 82.2%, P = 0.035) compared with the US group (P = 0.035). Conclusion CEUS guidance is a promising technique in depicting internal necrotic areas, viable areas, and internal mammary arteries during percutaneous biopsy of anterior mediastinal lesion, with satisfying safety, accuracy, and success rates.

Use of coronary artery bypass grafting (CABG) has had a resurgence, as clinical trial data emerged showing that it remains the standard of care for patients with complex lesions. Debate exists regarding various factors, including endoscopic vs open vein-graft harvesting, single vs bilateral mammary artery grafts, radial artery vs saphenous vein grafts, right internal mammary artery vs radial artery grafts, and on-pump vs off-pump surgery. More recent developments include minimally invasive approaches, robotics, and hybrid revascularization, which are changing the risk-benefit ratio for this patient population.

Summary Background Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. Methods A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. Results A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. Conclusions The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

Background: This is an investigation of complete arterial coronary artery bypass grafting (CACABG) using bilateral internal mammary arteries (IMA) and the T-graft technique either on- or off-pump as a routine approach to treat coronary artery disease. Methods: Between January 2000 and December 2012, 3,445 patients underwent on-pump (n = 2,216) or off-pump (n = 1,229) CACABG. A 30-day follow-up was performed prospectively, a long-term follow-up by a questionnaire, and coronary angiography in selected patients. Results: End points at 30 days were death, myocardial infarction, stroke, repeat revascularization, renal replacement, reoperation, sternal wound infection and atrial fibrillation. FitzGibbon A patency rates were 89.8 vs. 91.4% (p = 0.464) with consecutive percutaneous coronary intervention in the grafted area of 1.8 vs. 1.1% (p = 0.693) on- vs. off-pump, and no reoperation in the grafted area in both groups. Conclusion: CACABG by use of skeletonized bilateral IMA with the T-graft technique performed either on- or off-pump is a safe and effective approach.

The aim of this paper was to review the origins and history of deltopectoral flaps and the pectoralis major myocutaneous flap.The first published paper on the deltopectoral flap was written by Aymard in 1917. He described raising a medially based fasciocutaneous flap from the shoulder skin, which was then tubed and used for staged nasal reconstruction. Conley introduced the laterally based deltopectoral flap, which was supplied by the lateral thoracic and thoracocranial branches. Bakamjian used a medially based deltopectoral flap for pharyngoesophageal reconstruction; this was an axial flap based medially on the intercostal perforating vessels of the internal mammary artery. Krizek reviewed the literature and stated that Aymard flap was the keystone to the conception and execution of Bakamjian flap. Hueston was the first to combine a skin flap and pectoralis major muscle for repair of the large defects of the chest wall. The pectoralis major myocutaneous flaps described by Ariyan and Baek are a hybrid of Conley's laterally based deltopectoral flap and Hueston's inclusion of the pectoralis major muscle in the skin flap.When the authors develop what appears to be a new surgical technique, the authors are prone to be excited. However, at such a moment the authors must perform a literature review. In most patients, the authors will realize that the previous authors have already developed a given concept. The authors must not commit plagiarism due to their ignorance or laziness in conducting a literature review.

Regarding to coronary artery bypass grafting (CABG), the end-to-side anastomosis (ESA) has been performed as a gold standard. Recently, the effectiveness of the distal side-to-side anastomosis (SSA) in CABG using internal mammary artery has been reported. The benefit of SSA comparing to ESA also has been disclosed by computing simulation. However, use of SSA by venous conduit for individual CABG has not been reported. In this study, we investigated feasibility of SSA. From January 2013 to October 2014, we conducted 114 CABGs. There were 92 venous distal anastomoses without sequential anastomotic site (61 SSA and 31 ESA). The anastomosis was evaluated before discharge and at 1 year after the procedure by angiography or multi-detector row computed tomographic coronary angiography. The median values for time to anastomosis were 13 min in the two group (p = 0.89). There was no revision of anastomosis in both groups. Additional stitches for hemostasis were required significantly less in SSA than ESA (18.0 vs 45.2 %, respectively, p

The internal mammary artery (IMA) has been used as a systemic-to-pulmonary artery shunt in selected patients with congenital heart disease. Growth and development of hypoplastic pulmonary arteries have been described. We discuss the surgical and anesthetic management of an infant with an atretic-thrombosed right pulmonary artery originating from the ascending aorta in whom the IMA was used to create a systemic-to-pulmonary artery shunt after failure of a previous shunt and later successful pulmonary artery reconstruction. The IMA should be considered as an alternative conduit in patients requiring a systemic-to-pulmonary artery shunt for growth of pulmonary arteries.

Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.

Background and Aims: Skeletonization has been proposed as a technique to minimize the risk of sternal devascularization during bilateral internal thoracic artery harvest for coronary artery bypass grafting. The impact of this strategy on late radiologic pleuropulmonary changes has not been addressed. Material and Methods: Post-operative chest radiographs from patients ( n = 253 per group) undergoing bilateral internal thoracic artery harvest using skeletonized and non-skeletonized techniques were reviewed by blinded radiologists. The primary outcome was the incidence of atelectasis and pleural effusion. Multivariable linear regression models were derived to assess the relationship of radiologic pleuropulmonary outcomes to patients and operative variables. Results and Conclusion: Patients in the skeletonized group were older ( p

Aim: to evaluate the biomechanical remodeling of polymer grafts modified with vascular endothelial growth factor (VEGF) after implantation into rat abdominal aorta.Materials and methods. Vascular grafts of2 mmdiameter were fabricated by electrospinning from polycaprolactone (PCL) and a mixture of poly (3-hydroxybutyrate-co-3-hydroxyvalerate) and PCL. The grafts were modified with VEGF by biphasic electrospinning. Morphology of the grafts was assessed by scanning electron microscopy. Physico-mechanical properties of PCL and PHBV/PCL grafts were estimated using uniaxial tensile test and physiological circulating system equipped with state-of-theart ultrasound vascular wall tracking system. Physico-mechanical testing of PCL/VEGF and PHBV/PCL/VEGF was performed before and after implantation into rat abdominal aorta for 6 months. The modeling of coronary artery bypass grafting (CABG) was performed by finite element analysis for modified grafts.Results. Durability of PCL and PHBV/PCL grafts did not differ from that of human internal mammary artery; however, elasticity and stiffness of these grafts were higher compared to internal mammary artery. Viscoelastic properties of the grafts were comparable to those of native blood vessels. Modification of the grafts with VEGF reduced material stiffness. Six months postimplantation, PCL/VEGF and PHBV/PCL/VEGF were integrated with aortic tissue that induced changes in the physico-mechanical properties of the grafts similar to the native vessel. Biomechanical modeling confirmed the functioning of modified grafts in bypass position for CABG.Conclusion. PCL/VEGF and PHBV/PCL/VEGF grafts have satisfactory physico-mechanical properties and can be potentially used in the reconstruction of blood vessels.

Background The vertical posteromedial thigh (vPMT) perforator flap is a new reliable flap with versatility. The purpose of this article was to report our experience with the use of free vPMT flap for reconstruction of the breast. Patients and Methods From May 2015 to December 2015, seven patients received immediate unilateral breast reconstruction with seven free vPMT flaps. The flaps were raised based on the first medial perforator of the profunda femoris artery (PFA). The internal mammary artery and vein were dissected as recipient vessels. Results The flap sizes varied from 25 × 9 cm to 30 × 10 cm. The average weight of the flap and mastectomy specimen was 431 g (range: 390 to 470 g) and 410 g (range: 360 to 450 g) respectively. The average pedicle length was 10.4 cm (range, 8.5 to 12.5 cm) and the average arterial diameter was 2.1 mm (range, 1.8 to 2.6 mm). All of the flaps survived completely after surgery. The donor sites were all primarily closed with minimal morbidities. Follow-up observations were conducted from 3 to 9 months. All of patients were satisfactory with the reconstruction. Conclusion The vertical vPMT is suitable for breast reconstruction in women with small to moderate breast size; the vertical pattern of the PMT avoids some of the problems related to other flaps with transverse patterns and represents an alternative design that can be successfully used for breast reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

This study aimed to evaluate the efficacy of low-level laser therapy (LLLT) and light-emitting diodes (LEDs) for reducing pain in hyperglycemic and normoglycemic patients who underwent coronary artery bypass surgery with internal mammary artery grafts.This study was conducted on 120 volunteers who underwent elective coronary artery bypass graft (CABG) surgery. The volunteers were randomly allocated to four different groups of equal size (n = 30): control, placebo, LLLT [λ = 640 nm and spatial average energy fluence (SAEF) = 1.06 J/cm(2)], and LED (λ = 660 ± 20 nm and SAEF = 0.24 J/cm(2)). Participants were also divided into hyperglycemic and normoglycemic subgroups, according to their fasting blood glucose test result before surgery. The outcome assessed was pain during coughing by a visual analog scale (VAS) and the McGill Pain Questionnaire.The patients were followed for 1 month after the surgery. The LLLT and LED groups showed a greater decrease in pain, with similar results, as indicated by both the VAS and the McGill questionnaire (p ≤ 0.05), on the 6th and 8th postoperative day compared with the placebo and control groups. The outcomes were also similar between hyperglycemic and normoglycemic patients. One month after the surgery, almost no individual reported pain during coughing.LLLT and LED had similar analgesic effects in hyperglycemic and normoglycemic patients, better than placebo and control groups.

Background:Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply wh

Summary Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Such a combination poses a considerable technical challenge for revascularization because of multiple comorbidities and higher surgical risk. Here, we conducted a literature review on different revascularization strategies, on-pump and off-pump bypass grafting outcomes, harvested internal mammary artery numbers, and potential complications (e.g., steal syndrome) in managing patients with ESRD and comorbid CAD.

The rupture of an internal mammary artery (IMA) aneurysm in a patient with type 1 neurofibromatosis (NF-1) is a rare but life-threatening complication requiring emergency management. A 50-year-old man with NF-1 was transferred to the emergency department of Kyungpook National University Hospital, where an IMA aneurysmal rupture and hemothorax were diagnosed and drained. The IMA aneurysmal rupture and hemothorax were successfully repaired by staged management combining endovascular treatment and subsequent video-assisted thoracoscopic surgery (VATS). The patient required cardiopulmonary cerebral resuscitation, the staged management of coil embolization, and a subsequent VATS procedure. This staged approach may be an effective therapeutic strategy in cases of IMA aneurysmal rupture.

Background: To assess and compare the postoperative complications in patients who are undergoing Left Internal Mammary artery harvesting for coronary artery bypass grafting surgery with pleurotomy and without pleurotomy.Methods: The study was conducted on the patients admitted in a single unit of department of cardiothoracic surgery,NIMS, Hyderabad during the period of July 2017 to December2017.The study was a randomized open labelled controlled trial of two interventions.A total of 90 patients undergoing Coronary artery bypass surgery were enrolled in the study,with 60 among them having their Internal mammary harvesting done with pleurotomy and 30 undergoing the same without pleurotomy.Results: In the non pleurotomy group, 16 (53.33%) were male and 14 (46.66%) were female.In the pleurotmy group males and females were 41 (68.33%) and 19 (31.66%) respectively.There was no statistical significance between both the groups with respect to posteroperative bleeding, icu stay, reexploration rate,duration of ventilation,PaO2 and PCo2 values or wound infection rates. The only difference between both the groups which showed statistical significance(0.051) was the occurence of pleural effusion on POD 5 .In the closed pleurotomy group only 2(6.66%) patients had pleural effusion upto POD5, whereas in the open pleurotomy group 14 (23.33%) patients had pleural effusion persisting till POD5.Conclusions: There is a higher incidence of Pleural effusion in the pleurotomy group although this did not translate into higher postop pain score,ICU/Hospital stay, wound infection rates.

Aneurysms of the internal mammary artery are extremely rare. Immediate treatment is necessary because of the high risk of rupture that can be life-threatening. Here we describe a case of idiopathic internal mammary artery aneurysm in a 54-year-old woman in the setting of aberrant right subclavian artery. The aneurysm was successfully treated with coil embolization without complications.

Background:Modern breast reconstruction often involves microvascular reconstruction. The most common recipient vessels are the internal mammary artery and vein. Recently, there has been great focus on efficiency, but much of this emphasis has been directed to faster flap harvest or recovery protocol