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During routine dissection of a 64-year-old male cadaver, multiple variations were observed in the arteries of the upper extremities. The first part of the axillary artery did not give any branches. The second part, after giving superior thoracic and thoracoacromial arteries divided into deep and superficial brachial arteries. Superficial brachial artery gave lateral thoracic artery and continued into the arm. After giving anterior circumflex humeral artery, the deep brachial artery trifurcated into the subscapular artery, posterior circumflex humeral artery, and profunda brachii artery. Understanding upper limb arterial variations are important for performing safer clinical procedures. [ABSTRACT FROM AUTHOR]

In this study, we aimed at performing a histomorphometric analysis of human left internal thoracic artery (ITA) samples as well as at correlating the histomorphometric findings with the clinical profile, including risk factors and medication. Distal segments of ITA were obtained from 54 patients undergoing coronary artery bypass grafting. Histological observation was performed in paraffin-embedded transverse sections of ITA through four staining protocols: hematoxylin-eosin, van Gieson, Masson’s trichrome and von Kossa. Morphometric analysis included the intimal width (IW), medial width (MW) and intima/media ratio (IMR). No overt atherosclerotic lesions were observed. Mild calcifications were observed across the vascular wall layers in almost all samples. Multivariable linear regression analysis showed associations between IW and IMR and the following clinical variables: age, gender, kidney function expressed as eGFR and myocardial infarction history. Age (odds ratio = 1.16, P = 0.004), female gender (odds ratio = 11.34, P = 0.011), eGFR (odds ratio = 1.03, P = 0.059) and myocardial infarction history (odds ratio = 4.81, P = 0.040) were identified as the main clinical predictors for intimal hyperplasia. Preatherosclerotic lesions in ITA samples from patients undergoing coronary revascularization were associated not only with classical cardiovascular risk factors such as age and gender, but also with other clinical variables, namely kidney function and myocardial infarction history. [ABSTRACT FROM AUTHOR]

Background: Whether the use of the radial artery (RA) can improve clinical outcomes in coronary artery bypass graft surgery remains unclear. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral internal thoracic artery (BITA) over single left internal thoracic artery (SITA). In the ART, a large proportion of patients (≈20%) also received an RA graft instead of a saphenous vein graft (SVG). We aimed to investigate the associations between using the RA instead of an SVG to supplement SITA or BITA grafts and outcomes by performing a post hoc analysis of the ART.Methods: Patients enrolled in the ART (n=3102) were classified on the basis of conduits actually received (as treated). The analysis included 2737 patients who received an RA graft (RA group; n=632) or SVG only (SVG group; n=2105) in addition to SITA or BITA grafts. The primary end point was the composite of myocardial infarction, cardiovascular death, and repeat revascularization at 5 years. Propensity score matching and stratified Cox regression were used to compare the 2 strategies.Results: Myocardial infarction, cardiovascular death, and repeat revascularization cumulative incidence was 2.3% (95% confidence interval [CI], 1.1-3.4), 3.5% (95% CI, 2.1-5.0), and 4.4% (95% CI, 2.8-6.0) in the RA group and 3.4% (95% CI, 2.0-4.8), 4.0% (95% CI, 2.5-5.6), and 7.6% (95% CI, 5.5-9.7) in the SVG group, respectively. The composite end point was significantly lower in the RA group (8.8%; 95% CI, 6.5-11.0) compared with the SVG group (13.6%; 95% CI, 10.8-16.3; P=0.005). This association was present when an RA graft was used to supplement both SITA and BITA grafts (interaction P=0.62).Conclusions: This post hoc ART analysis showed that an additional RA was associated with lower risk for midterm major adverse cardiac events when used to supplement SITA or BITA grafts.Clinical Trial Registration: URL: https://www.situ.ox.ac.uk/surgical-trials/art. Unique identifier: ISRCTN46552265. [ABSTRACT FROM AUTHOR]

Coronary artery bypass graft (CABG) is a surgical procedure able to improve the blood supply to the myocardium. In the present study, the distal segments of grafts taken from the internal thoracic artery (ITA), radial artery (RA) and saphenous vein (SV) for use in aortocoronary bypass surgery were examined. The morphologies of the grafts were investigated in order to draw conclusions concerning their patency and viability. In addition, clinical and laboratory risk factors considered to be significant predictors of lesion severity in graft vessels used in CABGs were investigated. In total, 54 distal graft segments of ITAs, RAs and SVs from 20 men and 6 women aged between 42 and 78 years, were evaluated. Histological analyses were used to visualize graft lesions. Morphometrically, the intimal thickness index (ITI) and luminal narrowing were assessed as an indication of graft patency. The histological changes observed in the graft vessel walls included the presence of distinct atheromatous plaques (fatty streaks in 2 cases) or thickening of the intima (20 cases) and media (17 cases). Morphometric analysis showed that the mean ITI of the vessel conduits was 0.37 in the SVs, 0.95 in the RAs, and 1.66 in the ITAs. No patient had >50% conduit stenosis. By assessing the association between risk factors and graft lesions, it was found that all the patients showed risk factors for atherosclerosis, such as age (61.54%), arterial hypertension (65.38%), hyperlipidemia (65.38%), smoking (34.61%), diabetes mellitus (38.46%) and obesity (15.38%). The presence of pre-existing lesions in bypass grafts may contribute to a reduction in their viability, particularly in the case of venous grafts. Further long-term follow-ups are mandatory to evaluate the consequences of such lesions upon the patency of the grafts. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Bilateral internal thoracic artery (BITA) grafting is extensively underused in coronary artery bypass graft surgery and it is mostly preserved for patients under the age of 70. The purpose of the present study was to compare outcomes in propensity scorematched patients aged 70 years or greater using a BITA, with patients using a single internal thoracic artery (SITA) graft. METHODS: Among 18 761 patients operated on in our unit until December 2006, we selected 3496 patients aged 70 years or greater; of these, 1328 received a BITA (BITA group) and 2168 received a SITA (SITA group). Propensity score matching was used to reduce the preoperative patient variability. The 3-month and 10-year survival, stroke, myocardial infarction and sternal wound complication rate (defined as sternal instability or need for refixation) were compared between the two groups. RESULTS: After the correction, 892 patients per group were selected. Survival at 3 months was 90.6% in the SITA group and 91.6% in the BITA group (P = 0.34) and at 10 years was 38.9 and 57.5% (P = 0.02), respectively. The rates of stroke (1.01 vs 1.12%, P = 1), myocardial infarction (1.91 vs 2.13%, P = 0.86) and sternal wound complications (3.30 vs 5.42%, P = 0.17) were all similar between the SITA and BITA groups, respectively. CONCLUSIONS: The use of BITA grafting in elderly patients improves the 10-year survival rate, with similar postoperative morbidity. Thus, using adequate selection criteria, this technique should be routinely extended also to patients older than 70 years. [ABSTRACT FROM AUTHOR]

Serious complications related to percutaneous vertebral augmentation procedures, vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. We describe an adult patient who underwent multi-level, thoracic percutaneous vertebral augmentation procedures for painful osteoporotic compression fractures. The patient's percutaneous vertebroplasty performed at the T9 level was complicated by the asymptomatic, direct embolization of the right T9 segmental artery with penetration of cement into the radicular artery beneath the pedicle. We review the literature regarding the unusual occurrence of direct arterial cement embolization during vertebral augmentation procedures, discuss possible pathomechanisms, and alert clinicians to this potentially catastrophic vascular complication. [ABSTRACT FROM AUTHOR]

Background: Although bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) is associated with low morbidity and good long-term results, controversy exists about the age after which BITA grafting is no longer beneficial. We sought to determine if such an age cutoff point exists. Methods: The study cohort consisted of 5,601 consecutive patients from a cardiac surgery registry who underwent isolated CABG (1,038 [19%] BITA grafts, 4,029 [72%] single internal thoracic artery [SITA] grafts, 534 [10%] vein-only grafts) between 1995 and 2008. A Cox model was used to compare survival by use of bilateral, single, or no internal thoracic artery (ITA) grafts, adjusting for baseline clinical and demographic characteristics. Results: Mean follow-up was 7.1 years. Patients undergoing BITA grafting had the lowest 1-year mortality (2.4% versus 4.3% SITA grafting and 8.2% vein-only grafting; p < 0.0001). Relative to SITA grafting, a crude survival benefit of 54% existed for BITA grafting (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.37 to 0.57; p < 0.0001) with worse survival for vein-only grafts (HR, 1.16; 95% CI, 0.99 to 1.37; p = 0.07). After adjustment, the benefit of BITA grafting was no longer statistically significant (HR, 0.87; 95% CI, 0.69 to 1.08; p = 0.2). However age may be an effect modifier: a spline analysis plotting HR (BITA grafting versus SITA grafting) against age suggested a potential survival advantage associated with BITA grafting in patients younger than 69.9 years. Conclusions: Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to age 70 years. As benefits of arterial grafting become more obvious over time, a longer period of follow-up will be needed to confirm the advantage of a BITA grafting strategy. In the meantime the BITA grafting advantage for patients older than 70 years is not clear. [ABSTRACT FROM AUTHOR]

Objective: This study assessed the safety and efficacy of off-pump bilateral internal thoracic artery grafting in patients with left main disease. Methods: We reviewed the records of 768 patients who underwent off-pump bilateral internal thoracic artery grafting between September 2004 and June 2009. Bilateral internal thoracic artery grafts were used for the left coronary system in all patients, of whom 268 had left main disease and 500 did not. We compared operative and postoperative variables and early and 1-year angiographic patency rates of the bilateral internal thoracic artery between the 2 groups. Results: The perioperative mortality and incidence of postoperative complications were not significantly different between groups. In patients without left main disease, the left and right internal thoracic arteries were used for the left anterior descending artery in 87.4% and 12.2% of patients, respectively. In patients with left main disease, the left and right internal thoracic arteries were used for the left anterior descending artery in 70.5% and 29.1% of patients, respectively. In patients with left main disease, the patency rates for the left and right internal thoracic arteries at 1-year postoperative follow-up were 97.0% and 93.2%, respectively. In patients without left main disease, the patency rates for the left and right internal thoracic arteries at 1-year follow-up were 97.6% and 91.6%, respectively. The patency rates of the left and right internal thoracic arteries did not differ significantly in patients with or without left main disease (P = .9803 and P = .7205 in left and right internal thoracic arteries, respectively). Conclusions: Off-pump bilateral internal thoracic artery grafting was safe and effective in patients with left main disease. The patency rates of both grafts were comparable to those of patients without left main disease. [ABSTRACT FROM AUTHOR]

We retrospectively evaluated early clinical results of coronary revascularization using none but arterial grafts in patients aged 65 years and older. The cases of 449 consecutive patients who had undergone isolated myocardial revascularization were divided into 2 groups: the arterial conduit group (n=107) received a left internal mammary artery (LIMA) graft and 1 or both radial arteries (RAs), while the mixed-conduit group (n=342) received a LIMA graft and 1 or more saphenous vein grafts (SVGs), with or without an RA. There was no significant difference between the groups' rates of mortality. The arterial conduit group had a significantly shorter overall postoperative hospital stay than did the mixed-conduit group (mean, 6.6 ± 0.9 vs 7.2 ± 5 days; P=0.04). Linear regression analysis revealed that the presence of hypertension (β=0.13; 95% confidence interval [CI], 0.054-0.759; P=0.02) and high EuroSCORE (β=0.24; 95% CI, 0.053-0.283; P=0.004) were the major predicting factors for long hospital stay. Graft-harvest-site infection was statistically more frequent in the mixed-conduit group than in the arterial conduit group (6.4% vs 0, respectively; P=0.007). Angiography was performed postoperatively (mean, 24.9 ± 16.3 mo; range, 11-65 mo) in 21 patients. In these patients, all LIMA grafts were patent, as were 86.9% of the SVGs and 90.9% of the RA grafts. Myocardial revascularization using all arterial grafts (at least 50% RAs) in patients aged 65 years and older is safe and reliable, produces short-term results equal to those of saphenous vein grafting, and can reduce graft-harvest-site infections. [ABSTRACT FROM AUTHOR]

In this paper, a new computer tomography (CT) lung nodule computer-aided detection (CAD) method is proposed for detecting both solid nodules and ground-glass opacity (GGO) nodules (part solid and nonsolid). This method consists of several steps. First, the lung region is segmented from the CT data using a fuzzy thresholding method. Then, the volumetric shape index map, which is based on local Gaussian and mean curvatures, and the "dot" map, which is based on the eigenvalues of a Hessian matrix, are calculated for each voxel within the lungs to enhance objects of a specific shape with high spherical elements (such as nodule objects). The combination of the shape index (local shape information) and "dot" features (local intensity dispersion information) provides a good structure descriptor for the initial nodule candidates generation. Antigeometric diffusion, which diffuses across the image edges, is used as a preprocessing step. The smoothness of image edges enables the accurate calculation of voxel-based geometric features. Adaptive thresholding and modified expectation- maximization methods are employed to segment potential nodule objects. Rule-based filtering is first used to remove easily dismissible nonnodule objects. This is followed by a weighted support vector machine (SVM) classification to further reduce the number of false positive (FP) objects. The proposed method has been trained and validated on a clinical dataset of 108 thoracic CT scans using a wide range of tube dose levels that contain 220 nodules (185 solid nodules and 35 GGO nodules) determined by a ground truth reading process. The data were randomly split into training and testing datasets. The experimental results using the independent dataset indicate an average detection rate of 90.2%, with approximately 8.2 FP/scan. Some challenging nodules such as nonspherical nodules and low-contrast part-solid and nonsolid nodules were identified, while most tissues such as blood vessels were excluded. The method's high detection rate, fast computation, and applicability to different imaging conditions and nodule types shows much promise for clinical applications. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal thoracic artery graft to the left anterior descending coronary artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary artery bypass grafting in such patients who developed non-LAD territory jeopardy. Methods: From 1971 to 2000, 4,640 patients with prior coronary artery bypass grafting that included left internal thoracic artery to LAD grafting were found on angiography during active follow-up to have a patent left internal thoracic artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary artery bypass grafting or percutaneous intervention. Results: In the intent-to-treat analysis, propensity-adjusted early (<1 year) survival was similar for all patients, but late survival was slightly better after percutaneous intervention than with medical management (p ≤ 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups. Conclusions: Patients with patent left internal thoracic artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal thoracic artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit. [Copyright &y& Elsevier]

: BackgroundThe expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia.: MethodsFast-track anesthesia using an ultra-short-acting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 μg · kg−1 · min−1).: ResultsOperating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation.: ConclusionsImmediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising. [Copyright &y& Elsevier]

A 53-year-old woman with no classic risk factors for aneurysm disease presented with the sudden onset of chest pain and dyspnea. A large descending thoracic aortic aneurysm with focal type B dissection was identified and excluded by emergency thoracic endografting. Further postoperative evaluation revealed a history of epistaxis, perioral telangiectasias, hepatic hypervascularity, and a mutation in the gene expressing activin receptor-like kinase 1 (ALK1), leading to a diagnosis of hereditary hemorrhagic telangiectasia. Aortic aneurysms associated with hereditary hemorrhagic telangiectasia are extremely rare, and to our knowledge, this is the first report of thoracic endografting in this patient population. [Copyright &y& Elsevier]

A 67-year-old man with a large thoracoabdominal aneurysm was treated utilizing the endovascular approach with multiple stent graft implantation. The proximal thoracic and distal abdominal necks of the aneurysm had favorable anatomy for insertion of multiple endovascular stents. The proximal end was located just distal to the left subclavian artery, and stents were placed to the region of the celiac axis. The infrarenal aneurysm was treated with a bifurcated stent graft to the iliac arteries. The patient has had a smooth post-stent insertion course and remains well after 3 months of follow-up. [Copyright &y& Elsevier]

A letter to the editor is presented in response to the article "Diagnostic accuracy of Doppler ultrasonography for assessment of internal thoracic artery graft patency." by K. Yay, E. Boysan and others in the May 2014 issue, along with a response from the author of the article.

The author reflects on prospects of retrospective studies that compares the effectiveness of bilateral internal thoracic arteries (BITA) grafting with single internal thoracic arteries (SITA) grafting.