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Posts Tagged ‘left internal thoracic artery’

LIMA is a critical conduit for CABG.It  is  the most suitable vessel for  CABG for various reasons.(Radial artery falls far short of expectations  due to anatomical and histological , physiological  reasons !)

Anatomical variations , kinks and bends , loops are more common in LIMA  than we recognise.This may not have major implication but  can be threat to it’s  hemodynamic superiority  .

This man who had a two loops in LIMA and the one above almost tied a knot .(Please note it is an end on view of a loop that mimic a knot )

Can a surgeon un-do the loop before grafting ?

It may be possible in the distal ends where the LIMA is dissected out. I dont think it would be possible high up.

Surgeons should answer this . . .

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LIMA (Left internal mammary or thoracic )  is an unique  artery ,   incidentally runs close to  heart ,  has  a  privilege  of supporting   of human  heart in its hour of crises ! .  CABG  surgery was started with saphenous grafts in 1967 .  We have  since moved  on ,  from venous grafts to  total arterial grafts .  LIMA as a graft for coronary artery was a  great innovation for cardiac surgery  .Now , it can be stated  ” CABG should not be done without a LIMA graft “

Advantages of LIMA

LIMA   has good anatomical  match for LAD. The 10 year  patency  rate is very favorable (60-80%) .LIMA is also a live graft enriched with nitric oxide , as it has native  communication with subclavian artery  .

Anatomy

The internal mammary artery  originates  from the under surface of the first portion of the subclavian, opposite the thyrocervical trunk. It descends behind  the  upper six ribs at a distance of about 1.25 cm. from the margin of the sternum, and at the level of the sixth intercostal space divides into the musculophrenic and superior epigastric arteries.

The branches of the internal mammary are:
Pericardiacophrenic. Intercostal.
Anterior Mediastinal. Perforating.
Pericardial. Musculophrenic.
Sternal. Superior Epigastric.

There are few Anatomical issues for LIMA

Subclavian -LIMA ostial stenosis : Rare

Looping of LIMA is rarely an issue in hemodynamic point of view. But some  believe  a looped up LIMA is slightly prone for graft disease.Complex looping are reported rarely.

A loop and a early branch of LIMA : What is the implication ?

Abnormal  or premature branching pattern  of LIMA  needs clipping as it may divert blood supply to LAD.Terminal branches can be used as a sequential graft to a branch of LAD  usually a diagonal. In spite of all these issues , LIMA is  rarely unsuitable either anatomically or physiologically .It is a safest vessel to graft.

Future of LIMA  graft assessment.

Currently selective LIMA angiogram is the gold standard.

MDCT (64 slice) gives stunning images of LIMA graft , but unfortunately , it has little value for functional assessment .

Functional assessment of LIMA graft By  angiographic frame count  is being attempted in our institute.Will be reported in 2012.

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