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September 1992, Vol 127, No. 9 >
ARTICLE | September 1992

Anatomic and Clinical Considerations of an Internal Mammary Artery Harvest FREE

Thomas J. Francel, MD; Craig R. Dufresne, MD; William A. Baumgartner, MD; Jacquelynn O'Kelley, MA
[+] Author Affiliations

Accepted for publication January 12, 1992.

Reprint requests to the Department of Surgery, Division of Plastic and Reconstructive Surgery, The Jewish Hospital of St Louis, 216 S Kings-highway, St Louis, MO 63110 (Dr Francel).


Arch Surg. 1992;127(9):1107-1111. doi:10.1001/archsurg.1992.01420090115017
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References
Comments

• In an effort to understand the perceived correlation of internal mammary artery harvesting and wound healing difficulties in the inferior margins of the sternotomy incision, we showed the cutaneous vascular perfusion in the sternal and xiphoid areas by India ink injection studies in cadavers. With these studies, we demonstrated an inherent paucity of nutrient supply to the inferior sternum and xiphoid area. The classic internal mammary artery harvest further compromises the blood supply to these areas. We believe that limiting the most inferior dissection of the internal mammary artery and not including the distal bifurcation leaves intact the lateral musculophrenic nutrient supply to the inferior sternum and xiphoid area and to the ipsilateral abdominal rectus muscle. These guidelines will help to prevent ischemic complications of this area and may aid in reconstruction. If the bifurcation is harvested, we believe that the removal of the avascular xiphoid cartilage at the time of the initial bypass procedure may eliminate this as a potential septic focus.

(Arch Surg. 1992;127:1107-1111)

REFERENCES

1 +
Green GE.  Internal mammary artery to coronary artery anastomosis; three year experience with 165 patients . Ann Thorac Surg . 1972;;14:260-271.
2 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Influence of the IMA graft on 10 year survival and other cardiac events . N Engl J Med . 1986;;314:1-6.
3 +
Lytle BW, Cosgrove DM, Saltus GL, Taylor PC, Loop FD.  Multivessel coronary revascularization without saphenous vein: long-term results of BIMA grafting . Ann Thorac Surg . 1983;;36:540-547.
4 +
Grondin CM, Campeau L, L'Esperance J, Enjalbert M, Bourgassa MG.  Comparison of late changes in IMA and saphenous vein grafts in two consecutive series of patients 10 years after operation . Circulation . 1984;;70 ( (suppl 1) ):208-212.
5 +
Shelton ME, Forman MB, Virmant R, Bajaj A, Stoney WS, Atkinson JB.  A comparison of morphologic and angiographic findings in longterm internal mammary artery and saphenous vein bypass grafting . J Am Coll Cardiol . 1988;;11:297-307.
6 +
Lytle BW, Loop FD, Cosgrove DM, Ratliff NB, Easley K, Taylor PC.  Long-term (5-12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts . J Thorac Cardiovasc Surg . 1985;;89:248-258.
7 +
Califf RM, Harrell FE, Lee KL, et al.  The evolution of medical and surgical therapy for coronary artery disease . JAMA . 1989;;261:2077-2086.
8 +
Okies JE, Page US, Bigelow JC, Krause AH, Salomon NW.  The left internal mammary artery: the graft of choice . Circulation . 1984;;70( (suppl 1) ):213-221.
9 +
Siegel W, Loop FD.  Comparison of internal mammary artery and saphenous vein bypass grafts for myocardial revascularization: exercise test and angiographic correlations . Circulation . 1976;;54( (suppl 3) ):1-3.
10 +
Grmoljez PF, Barner HH, Willman VL, Kaiser GC.  Major complications of median sternotomy . Am J Surg . 1975;;130:679-681.
11 +
Culliford AT, Cunningham JN, Zeff RH, Isom OW, Teiko P, Spencer FC.  Sternal and costochondrial infections following open heart surgery . J Thorac Cardiovasc Surg . 1976;;52:714-725.
12 +
Kouchoukos NT, Wareing TH, Murphy S, Pelate C, Marshall WG.  Risks of bilateral internal mammary artery bypass grafting . Ann Thorac Surg . 1990;;49:210-219.
13 +
Loop FD, Lytle BW, Cosgrove DM III, et al.  Wound complications after coronary bypass surgery with vein grafts only, one internal thoracic artery graft, or two internal thoracic artery grafts . Ann Thorac Surg . 1990;;49:179-187.
14 +
Sarr MG, Gott VL, Townsend TR.  Mediastinal infection after cardiac surgery . Ann Thorac Surg . 1984;;38:415-423.
15 +
Nagachinta T, Stephens M, Reitz B, Polk BF.  Risk factors for surgical wound infection following cardiac surgery . J Infect Dis . 1987;;156:967-973.
16 +
Arnold M.  The surgical anatomy of sternal blood supply . J Thorac Cardiovasc Surg . 1972;;64:596-610.
17 +
Palmer JH, Taylor GI.  The vascular territories of the anterior chest wall . Br J Plast Surg . 1986;;39:287-299.
18 +
Nakajima H, Marayama Y, Koda E.  The definition of vascular skin territories with prostaglandin-E- the anterior chest, abdomen, thigh, and inguinal region . Br J Plast Surg . 1981;;34:258-263.
19 +
McGregor IA, Morgan G.  Axial and random pattern flaps . Br J Plast Surg . 1973;;26:202-213.
20 +
Seyfer AE, Shriver CD, Miller TR, Graeber GM.  Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries . Surgery . 1988;;104:899-904.
21 +
Reid CD, Taylor GI.  The vascular territories of the acromiothoracic axis . Br J Plast Surg . 1984;;37:194-212.
22 +
Boyd JB, Taylor GI, Corlett R.  The vascular territories of the superior epigastric and the deep inferior epigastric systems . Plast Reconstr Surg . 1984;;73:1-14.
23 +
Green GE.  Internal mammary—coronary anastomosis for myocardial ischemia . In: Sabiston DC, Spencer FC, eds. Gibbon's Surgery of the Chest 3rd edition . Philadelphia, Pa: WB Saunders Co; 1976;:1379.
24 +
European Coronary Surgery Study Group.  Long-term results of prospective, randomized study of coronary artery bypass surgery in stable angina pectoris . Lancet . 1982;;2:1173-1180.
25 +
Schuster EH, Griffith LS, Bulkley BH.  Preponderance of acute proximal left anterior descending coronary artery lesions in fatal myocardial infarction: a clinicopathologic study . Am J Cardiol . 1981;;47:1189-1196.
26 +
Jurkiewicz MJ, Bostwick J, Hester TR, Bishop JB, Craver J.  Infected median sternotomy wound . Ann Surg . 1980;;191:738-744.
27 +
Nahai F, Morales L, Bone DK, Bostwick J.  Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function . Plast Reconstr Surg . 1982;;70:471-474.
28 +
Pearl SN, Dibell DG.  Reconstruction after median sternotomy infection . Surg Gynecol Obstet . 1984;;159:47-52.
29 +
Cheung EH, Carver JM, Jones EL, Murphy DA, Hatcher CR, Guyton RA.  Mediastinitis after cardiac valve operations: impact upon survival . J Thorac Cardiovasc Surg . 1985;;90:517-522.
30 +
Majure JA, Albin RE, O'Donnell RS, Arganese TJ.  Reconstruction of the infected median sternotomy wound . Ann Thorac Surg . 1986;;42:9-12.
31 +
Pairolero PC, Arnold PG.  Management of infected median sternotomy wounds . Ann Thorac Surg . 1986;;42:1-2.
32 +
Nahai F, Rand RP, Hester TR, Bostwick J, Jurkiewicz MJ.  Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases . Plast Reconstr Surg . 1989;;84:434-441.
33 +
lacobucci JJ, Stevenson TR, Hall JD, Deeb GM.  Sternal osteomyelitis: treatment with rectus abdominis muscle . Br J Plast Surg . 1989;;42:452-459.
34 +
Martin RD.  The management of infected median sternotomy wounds . Ann Plast Surg . 1989;;22:243-251.
35 +
Fernando B, Muszynski C, Mustoe T.  Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries . Ann Plast Surg . 1988;;21:468-471.
36 +
Miller LB, Bostwick J, Hartrampf CR, Hester TR, Nahai F.  The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study . Plast Reconstr Surg . 1988;;81: 713-720.

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1 +
Green GE.  Internal mammary artery to coronary artery anastomosis; three year experience with 165 patients . Ann Thorac Surg . 1972;;14:260-271.
2 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Influence of the IMA graft on 10 year survival and other cardiac events . N Engl J Med . 1986;;314:1-6.
3 +
Lytle BW, Cosgrove DM, Saltus GL, Taylor PC, Loop FD.  Multivessel coronary revascularization without saphenous vein: long-term results of BIMA grafting . Ann Thorac Surg . 1983;;36:540-547.
4 +
Grondin CM, Campeau L, L'Esperance J, Enjalbert M, Bourgassa MG.  Comparison of late changes in IMA and saphenous vein grafts in two consecutive series of patients 10 years after operation . Circulation . 1984;;70 ( (suppl 1) ):208-212.
5 +
Shelton ME, Forman MB, Virmant R, Bajaj A, Stoney WS, Atkinson JB.  A comparison of morphologic and angiographic findings in longterm internal mammary artery and saphenous vein bypass grafting . J Am Coll Cardiol . 1988;;11:297-307.
6 +
Lytle BW, Loop FD, Cosgrove DM, Ratliff NB, Easley K, Taylor PC.  Long-term (5-12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts . J Thorac Cardiovasc Surg . 1985;;89:248-258.
7 +
Califf RM, Harrell FE, Lee KL, et al.  The evolution of medical and surgical therapy for coronary artery disease . JAMA . 1989;;261:2077-2086.
8 +
Okies JE, Page US, Bigelow JC, Krause AH, Salomon NW.  The left internal mammary artery: the graft of choice . Circulation . 1984;;70( (suppl 1) ):213-221.
9 +
Siegel W, Loop FD.  Comparison of internal mammary artery and saphenous vein bypass grafts for myocardial revascularization: exercise test and angiographic correlations . Circulation . 1976;;54( (suppl 3) ):1-3.
10 +
Grmoljez PF, Barner HH, Willman VL, Kaiser GC.  Major complications of median sternotomy . Am J Surg . 1975;;130:679-681.
11 +
Culliford AT, Cunningham JN, Zeff RH, Isom OW, Teiko P, Spencer FC.  Sternal and costochondrial infections following open heart surgery . J Thorac Cardiovasc Surg . 1976;;52:714-725.
12 +
Kouchoukos NT, Wareing TH, Murphy S, Pelate C, Marshall WG.  Risks of bilateral internal mammary artery bypass grafting . Ann Thorac Surg . 1990;;49:210-219.
13 +
Loop FD, Lytle BW, Cosgrove DM III, et al.  Wound complications after coronary bypass surgery with vein grafts only, one internal thoracic artery graft, or two internal thoracic artery grafts . Ann Thorac Surg . 1990;;49:179-187.
14 +
Sarr MG, Gott VL, Townsend TR.  Mediastinal infection after cardiac surgery . Ann Thorac Surg . 1984;;38:415-423.
15 +
Nagachinta T, Stephens M, Reitz B, Polk BF.  Risk factors for surgical wound infection following cardiac surgery . J Infect Dis . 1987;;156:967-973.
16 +
Arnold M.  The surgical anatomy of sternal blood supply . J Thorac Cardiovasc Surg . 1972;;64:596-610.
17 +
Palmer JH, Taylor GI.  The vascular territories of the anterior chest wall . Br J Plast Surg . 1986;;39:287-299.
18 +
Nakajima H, Marayama Y, Koda E.  The definition of vascular skin territories with prostaglandin-E- the anterior chest, abdomen, thigh, and inguinal region . Br J Plast Surg . 1981;;34:258-263.
19 +
McGregor IA, Morgan G.  Axial and random pattern flaps . Br J Plast Surg . 1973;;26:202-213.
20 +
Seyfer AE, Shriver CD, Miller TR, Graeber GM.  Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries . Surgery . 1988;;104:899-904.
21 +
Reid CD, Taylor GI.  The vascular territories of the acromiothoracic axis . Br J Plast Surg . 1984;;37:194-212.
22 +
Boyd JB, Taylor GI, Corlett R.  The vascular territories of the superior epigastric and the deep inferior epigastric systems . Plast Reconstr Surg . 1984;;73:1-14.
23 +
Green GE.  Internal mammary—coronary anastomosis for myocardial ischemia . In: Sabiston DC, Spencer FC, eds. Gibbon's Surgery of the Chest 3rd edition . Philadelphia, Pa: WB Saunders Co; 1976;:1379.
24 +
European Coronary Surgery Study Group.  Long-term results of prospective, randomized study of coronary artery bypass surgery in stable angina pectoris . Lancet . 1982;;2:1173-1180.
25 +
Schuster EH, Griffith LS, Bulkley BH.  Preponderance of acute proximal left anterior descending coronary artery lesions in fatal myocardial infarction: a clinicopathologic study . Am J Cardiol . 1981;;47:1189-1196.
26 +
Jurkiewicz MJ, Bostwick J, Hester TR, Bishop JB, Craver J.  Infected median sternotomy wound . Ann Surg . 1980;;191:738-744.
27 +
Nahai F, Morales L, Bone DK, Bostwick J.  Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function . Plast Reconstr Surg . 1982;;70:471-474.
28 +
Pearl SN, Dibell DG.  Reconstruction after median sternotomy infection . Surg Gynecol Obstet . 1984;;159:47-52.
29 +
Cheung EH, Carver JM, Jones EL, Murphy DA, Hatcher CR, Guyton RA.  Mediastinitis after cardiac valve operations: impact upon survival . J Thorac Cardiovasc Surg . 1985;;90:517-522.
30 +
Majure JA, Albin RE, O'Donnell RS, Arganese TJ.  Reconstruction of the infected median sternotomy wound . Ann Thorac Surg . 1986;;42:9-12.
31 +
Pairolero PC, Arnold PG.  Management of infected median sternotomy wounds . Ann Thorac Surg . 1986;;42:1-2.
32 +
Nahai F, Rand RP, Hester TR, Bostwick J, Jurkiewicz MJ.  Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases . Plast Reconstr Surg . 1989;;84:434-441.
33 +
lacobucci JJ, Stevenson TR, Hall JD, Deeb GM.  Sternal osteomyelitis: treatment with rectus abdominis muscle . Br J Plast Surg . 1989;;42:452-459.
34 +
Martin RD.  The management of infected median sternotomy wounds . Ann Plast Surg . 1989;;22:243-251.
35 +
Fernando B, Muszynski C, Mustoe T.  Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries . Ann Plast Surg . 1988;;21:468-471.
36 +
Miller LB, Bostwick J, Hartrampf CR, Hester TR, Nahai F.  The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study . Plast Reconstr Surg . 1988;;81: 713-720.

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