VIliasERG: CORONARY ARTERY INSUFFICIENCY 325

14 Years' Experience in the Surgical Treatment ofHuman Coronary ArLery InsufficiencyARTHUR M. VINEBERG, M.D., Ph.D., F.A.C.S., Montreal

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92

ABSTRACT

Atherosclerosis obstructs the main stems ofcoronary arteries, restricting the coronaryartery inflow tract. Nature develops intra-myocardial collaterals but fails to formextracoronary collateral channels. It is onlythrough surgical measures that extra-coronary collateral channels may be formed,for example, by internal mammary arteryimplantation and omental graft withoutpedicle operations. Preoperative assessment,with particular reference to anginal pain,disease activity, indications for and contra-indications to surgery, is outlined. The im-portance of cine coronary arteriography isstressed. The results of internal mammaryartery implantation with or withoutomental graft in patients followed up fortwo to 14 years are presented. Operativemortality in 103 consecutive patients was2.9%. There was marked improvement inover 70% of 115 patients reviewed. Post-operative examination of 29 implanted in-ternal mammary arteries showed that 76%were open when examined up to 10 yearspostoperatively; many of these were studiedby cineangiography.

SOMMAIRE

L'ath6roscl6rose a pour effet d'obstruer lesbranches principales des art.res coronaires,y diminuant d'autant la circulation. Lanature cr& des collat6rales intramyo-cardiques, mais ne parvient pas . formerdes collat6rales extracoronaires. Celles-ci nepeuvent .tre form&es que par des moyenschirurgicaux, par exemple grAce A l'implan-tation de l'art.re mammaire interne et pargreffe d'6piploon sans modification dup6dicule vasculaire. L'auteur souligne l'im-portance d'une 6valuation pr6-op6ratoirepr6cise, notamment en ce qul concerne ladouleur angineuse, le degr6 d'activit6 de lamaladie, les indications et les contre-indica-tions. II insiste sur l'importance d'une cin6-art6riographie des coronaires. II donne lesr6sultats de l'implantation de l'art.re mam-maire interne, avec ou sans greffed'.piploon, chez des malades qui ont 6t.suivis pendant des p6riodes variant de 2 A14 ans. La mortalit. post-op6ratoire a 6t6de 2.9% chez les 103 patients op6r6s con-s6cutivement. Chez 70% des 115 maladesqui ont 6t6 pass6s en revue, l'am6liorationa 6t6 consid6rable. L'examen post-op6ratoirede 29 cas d'implantation de la mammaireinterne a r6v616 que Ia lumi.re de l'art.re6tait rest6e ouverte dans 76% des cas, m.me10 ans apr.s l'intervention. Cet examen a6t6 effectu6 en de nombreux cas par cin6-angiographie.

326 VINEBERG: CORONARY ARTERY INSUFFICIENCY

bgh.corona r.ja rte r

mainstein:SLt7,, stem: 277.

branches: 25 7.

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92

4. Myocardial Arterioles are ComparativelyDisease-Free

Myocardial arterioles are comparatively disease-free, except in cases of severe hypertension andadvanced diabetes. The intact myocardial arteriolarsystem makes possible the development of by-passoperations that promote anastomoses between sys-temic vessels and the myocardial arterioles. Throughthese anastomoses large quantities of systemic oxy-genated blood bypass diseased coronary arteriesto reach the myocardial arteriolar system andthence the myocardial fibres.

5. Anginal PainAnginal pain is a reflection of myocardial fibre

ischemia and is said not to occur unless one majorcoronary branch is completely occluded. Persistentmyocardial ischemia leads to myocardial fibrechange or fibre loss. This may occur slowly orrapidly and leads to myocardial infarction withor without death of the patient.

SURGICAL RELIEF OF MYOCARDIAL I5GHEMIA

The major purpose of revascularization surgeryis to relieve anginal pain, prevent death of heartmuscle and death of the patient.

Bypass OperationsWhen I first studied this problem in 1945, it was

clear that a direct attack upon obstructed coronaryarteries would be impracticable. For this reasonvarious bypass operations have been developedwhich introduce systemic oxygenated blood intothe myocardium though channels of arteriolar orlarger size. In addition, operative procedures havebeen developed which we have shown to be ofvalue in promoting homocoronary and intercoron-ary anastomoses. The development of intercoronaryanastomoses allows systemic oxygenated blood in-troduced into one area to flow to all parts of themyocardium.

EXPERIMENTAL Smmi.s

It has been necessary to develop laboratorymethods against which the various revascularizationoperative procedures can be tested. Our tests havebeen simple and their results leave little room fordoubt that revascularization results from these pro-cedures.We have succeeded in slowly constricting the

main stems of canine coronary arteries.4'5 Thesurvival of animals and the survival of myocardiumhave been our criteria of the value of any revascu-larization procedure under study. In addition, wehave used injections with Schlesinger mass (whichonly enters arterioles 40 microns or larger in di-ameter) to outline the extravascular channelsthough which oxygenated systemic blood reachesthe ischemic myocardium following the operativeprocedure. In internal mammary artery implanta-

b r

VINEBERG: CORONARY ARTERY INSUFFICIENCY 327

I

+ + + ++ +

++ ++++++ + ++4-I- +

+ + +++ + +

No deaths ++under +50%

Ant.Desending

No deaths under40% occlusionCircumflex

+ +

+

+

+

TOTAL CORONARY ARTERYINFLOW TRACT (ANIMAL)

reduction 50% average ofcross sectional area or moreof anterior deccending andcircumflexno anastomoses betweenright and left = DEATH

+

I

25% 50% 75% 100%Occlusion of Circumflex Coronary Artery

reduction 50% average, of crosssectional area or more ofanterior descending andcircumflexlarge anastomoses betweenright and left coronary arteries

= 15% SURVIVAL

7) . V

100%

0

0C0

00CU00). C 5Q%'DC'DOO

00. 25%0C

0

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92

mediastinal vessels can grow either though sheetsof Ivalon sponge or a free omental graft.

The Free Omental GraftThe free omental graft is capable of maintaining

an entire animal heart when all three coronaryarteries have been occluded. It does so becausenew arteries grow into the graft from the aorta,mediastinum and pericardium. The arteries of theomental graft join the coronary arteries and myo-cardial arterioles2' 11, . (Fig. 5).

CLINICAL STUDIES

The three operations noted above have beenused to treat over 160 human patients sufferingfrom coronary artery insufficiency.The by-pass operations have the great advant-

ages of leaving the patient's own arterial systemintact, of introducing oxygenated systemic bloodinto the ischemic myocardium immediately, and ofrapidly opening up homocoronary and intercoron-ary anastomoses.

Selection of Patients for RevascularizationSurgeryIndicationsDisabling anginal pain persisting for one to two

years in spite of good medical treatment is a simpleindication established by Drs. W. P. Hill and JohnShanks, who have selected our patients for surgicaltreatment since 1950. It must be satisfactorilydemonstrated that the pain is due to myocardialischemia by changes in the electrocardiogram(ECG) after exercise in the two-step or treadmilltest.

In the past three years evidence obtained by cinecoronary arteriography has greatly helped in theselection of cases. It is my belief that surgery isindicated when two major coronary arteries shownarrowing in their main stems or when one majorcoronary artery is completely occluded.

Analysis of anginal pain is important. We havefound that pain which occurs at rest without ex-citing cause is associated with extensive disease ofthe coronary artery inflow tract; usually in suchpatients only one pin-point opening remains patentin all three arteries (Fig. 6). Such patients 'have ahigher operative risk, 20%, than patients who donot have angina at rest without exciting cause (3%).

Previous myocardial infarctions had occurred in54% of the patients on whom we operated. Suchpatients have done quite well; there is alwayssufficient myocardium left into which systemic oxy-genated blood can be introduced.

Ccmtraindications1. Recent myocardial infarction. In such patients

it is necessary to wait at least six months beforeperforming surgery.

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92 VINEBERG: CORONARY ARTERY INSUFFICIENCY 329

city blocks before anginal pain occurs. The recordof pain which comes on after eating, and requiresnitroglycerin when persistent, forms an excellentbaseline for postoperative evaluation. Many of ourpatients have continued to have pain after internalmammary artery implantation until about the thirdweek after operation, when it disappears; this is thetime at which the internal mammary artery formssubstantial mammary-coronary anastomoses, there-by providing oxygenated blood to the myocardium.

Pain which occurs at night during sleep, althoughindicating advanced disease, should not be con-sidered as angina decubitus; this designation isapplied only when the patient has pain at rest with-out exciting cause.

In our experience, anginal pain radiating throughbetween the shoulder blades has been associatedwith constriction of the main left coronary arteryjust proximal to its bifurcation. Originally thisassociation was confirmed by palpation at opera-tion; it can now be visualized prior to operation,by means of cine coronary arteriography. Althoughthe electrocardiogram has been helpful in manyinstances, the patient's history has been of thegreatest value in determining whether the diseasehas been stationary or progressive, and in particularwhether there has been recent myocardial infarc-tion. The knowledge of recent infarction is of thegreatest importance; if there is the slightest doubton this point, the patient is returned home to waitanother six months from the time of the suspectedmyocardial infarction.The history is not complete until a member of

the family has been questioned concerning thepatient's activities. Men have a tendency to mini-mize their symptoms, and questioning the wifeusually brings out the facts of the case. Recentlya man who held a Ph.D. in Genetics was referredby a cardiologist for revascularization surgery. Thepatient stated that he only developed anginal painon severe exercise. He had had two previous infarc-tions. Cine coronary arteriography showed a dis-eased right coronary artery and severe left-sideddisease, and his electrocardiogram was abnormal.His wife stated that after his last myocardial infarc-tion he had had frequent anginal pain during theday and "the nights had become unbearable night-mares

Work Record and ActivitiesThe patient's work record is often most revealing,

in particular his ability to keep his job. Themajority of patients have been forced to changejobs and accept positions that carry a lower finan-cial return. Others were working part-time.

In the section of this report that deals with theresults of surgical treatment it is interesting to notehow many of our patients are still working at theiroriginal occupations. Many of the patients have notonly returned to work at their original occupations

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92

vious myocardial infarction. However, our resultsindicate quite clearly that the implant operation isworth while despite previous myocardial infare-tions.More recently we have studied the extent of

coronary artery disease by cine coronary arterio-graphy, and when more than one coronary arteryis diseased we have combined internal mammaryartery implantation with the free omental graft(Table II). In 36 patients undergoing this com-bined operation, cine coronary arteriographydemonstrated 111 diseased main-stem arteries, thatis, 3.1 lesions per heart. The arteries involved, inorder of frequency, were the anterior descending(94%), circumflex (92%), right coronary artery75%), and left coronary artery (47%).

TABLE 11.-PREOPERATIVE PATENCY OF CORONARYARTERIES AS SHOWN BY CINE CORONARY ARTERIOGRAPHY

(36 CAsEs)

Coronary artery AnteriorRight Left descending Circumflex

Blocked. 13 1 9 1Narrowed 14 16 25 32Total diseased.. 27 (75%) 17 (47%) 34 (94%) 33 (92%)36 patients: 111 diseased coronary

arteries = 3.1 lesions per patientSchlesinger (1941).2.5 lesions per patient

RESULTS

The patients who underwent internal mammaryartery implants have been followed up for fromtwo to 14 years. The operative mortality (TableIII) for 72 consecutive cases subjected to thisoperative procedure since 1954 was 2.7%. For 31patients with "triple" coronary artery disease (thatis, involvement of the right, anterior descendingand circumflex vessels) in whom internal mammaryartery implantation and free omental graft opera-tions were performed, the operative mortality was3.2%. For the total of 103 patients operated onsince 1954, the operative mortality was 2.9%. Whenone considers the severity of the disease in thepatients who were operated upon and the highpercentage of previous myocardial infarctions inthis group, an operative mortality of 2.9% for 103patients is low. The results indicate that if thepatients are properly prepared and are operatedupon at a time when the disease is stabilized, theoperations of internal mammary artery implanta-

TABLE 111.-OPERATIvE MORTALITY (VINEBERG INTERNALMAMMARY ARTERY IMPLANT OPERATION), 115 CASES

No. of OperativeNo angina at rest: cases deaths

Implant:1950 to 1954 (consecutive cases) 12 4 (33%)

Implant:1954 to 1964 (consecutive cases) 72 2 (2.7%)

Implant plus omental graft:Cases with triple coronary artery

disease (consecutive cases).31 1 (3.2%)Operative mortality for 103 cases..2.9%

Canad. Med. Ass. J.Feb. 13, 1965, vol. 92 VINEBERG: CORONARY ARTERY IN5TJFFICIENCY 331

TABLE IV.-INTERNAL MAMMARY ARTERY IMPLANTOPERATION FOLLOWED UP TO 14 YEARS

No. of patients in original group.84Living at time of survey (April 1964)**.52 (62%)Improved.48 (57%)Same.3Worse.1Still working.48 (57%)Implant plus free omental graft:

No. of patients withtriple coronary artery disease.31

Living at time of survey(6 - 16 months after operation).29

Improved.26 (84%)Same.3Working.24

**There were three accidental deaths and one cancer death.

tion, epicardiectomy and free omental graft have alow operative hazard.Our follow-up study, of up to 14 years, of the

patients subjected to internal mammary implantprocedures (Table IV) shows that 62% of theoriginal implant patients are still living, that 57%of the original group are still improved, and 50%of the group are still working.

This group of patients, as we have previouslyreported,'5 includes patients who are doing hardwork. For example, a man operated upon in 1951,who is now over 70 years of age, still runs a verylarge machine shop. Another man over 60 years ofage who was operated upon in 1952 ploughs 1600acres of land each year. A patient who was oper-ated upon in 1953 and who at that time was totallydisabled is now a train conductor. Many othersin all walks of life have likewise been successfullyrehabilitated.

Reason for Developing Supplements to theInternal Mammary Artery Implant OperationFor many years it has been clear that the internal

mammary artery when it remains fully patent isonly capable of supplying sufficient blood tomaintain the health of the left ventricle. This wasbrought to our attention in 1956 when a patientwho had undergone internal mammary artery im-plantation four years previously died of a rupturedright ventricular aneurysm. A study of this patient'sheart revealed that the only patent artery in theheart was the internal mammary artery and thatthe left ventricular muscle appeared to 'be healthy.This and other cases led us to seek additionalmeans of relieving myocardial ischemia caused byright coronary artery disease.The results of Ivalon sponge operations on

animals were encouraging but we found that it wasimpossible to suture the sponge to the posteriorsurfaces of the right and left ventricles and to theanterior surface of the right ventricle. In additionto the fact that the internal mammary artery wasnot sufficiently large to supply the entire heart inthe presence of progressive coronary artery occlu-sion, a certain percentage of implanted internalmammary arteries, both in the animal and inhumans, became obstructed or narrowed.

In 1960 we developed the free omental graftor omental graft without pedicle; the experimentaldata upon which this operation is based have beenpublished elsewhere.'6 The graft deprived of itsown blood supply seeks a new blood supply andwithin eight days forms arteriolar connections withsurrounding tissue, namely those of the chest wall,ascending aorta, pericardium and the coronaryarteries themselves.

In the lower half of Table IV the results of thecombined free omental graft operation and internalmammary artery implantation are listed in a groupof 31 patients who have been followed up for fromsix to 16 months. These patients have shown re-markable and very rapid improvement. It seemsthat internal mammary artery implantation com-bined with the detached omental graft is veryvaluable in the treatment of patients with far-advanced coronary artery disease. Twenty-four ofthe 29 surviving patients are working and 26(84%) are improved in spite of severe "triple"coronary artery occlusion.

Prior to the use of cine coronary arteriographythe only proof of internal mammary artery patencywas that found in postmortem studies of the im-planted arteries. Eighteen implanted arteries havebeen studied up to four years after surgery and14 (78%) of these were shown to be completelypatent (Table V). A description of the pathologicalstudies of the implanted human artery has beenpublished.'3 In the past three years some of our

Fig. 7.-Photograph taken from cine coronary arterlo-graphy made of an implanted internal mammary artery 7 .years after surgery. In this patient the implanted internalmammary artery was filled with radiopaque dye that floweddown the implanted artery to perfuse the vessels lying inthe left ventricular myocardium.

332 VINEBERG: CORONARY ARTERY INSUFFICIENCY Canad. Med. Ass. 3.Feb. 13, 1965, vol. 92

TABLE V.-POSTMORTEM STUDY OF IMPLANTED INTERNALMAMMARY ARTERIES

No. of Condition of implantcases Blocked Patent

Time after operation:8 hours to 6 months.... 10 2 864years 8 2 6

Total.18 4 14 (78%)Causes of death include right ventricular aneurysm, right

ventricular infarctions, left ventricular failure, chronicempyema (two cases), cancer of the pancreas, and deathfollowing a fight.

internal mammary artery implants have beenstudied by cine coronary arteriography. In Decem-ber 1960, one such patient who had been operatedupon seven and one-half years previously had cinecoronary arteriography elsewhere* and the internalmammary artery was shown to be widely patent,perfusing the left ventricle. Marked disease of theright coronary artery and the left coronary systemwas also demonstrated. A reproduction from thiscine is shown in Fig. 7. Since that time we haveused this technique to examine 11 internal mam-mary arteries, and eight (73%) of these arteries'vere patent (Table VI; Fig. 8).

TABLE VI.-EVALUATION OF INTERNAL MAMMARY ARTERYPATENCY IN LIVING PATIENTS

TimeNo. of after Condition of internalcases operation mammary artery

Re-operation 3 2 - 9 yr. 3 - soft and pulsatingCine angiography. 8 2 - 9 yr. 5 - widely patent

Total. 11 8 (73%)

Fig. 8 A patient studied four years after operation.Cineangiography demonstrated a widely patent internalmammary artery carrying dye into the left ventricularmyocardium and filling the anterior descending artery in aretrograde manner up to its point of occlusion near itsorigin. Note calcium at point of occlusion in anterior descend-ing vessel

Sones, M The first demonstration by cine of a patentinternal mammary artery in man

CONCLUSION

In the course of 14 years' experience we haveaccumulated both laboratory and clinical evidencewhich shows that an internal mammary artery im-plant introduces systemic blood into an ischemicmyocardium by bypassing the points of proximalcoronary artery occlusion. Likewise we have shownthat epicardiectomy stimulates the development ofcollateral arterioles and that ischemia of bothventricles can be successfully treated by the addi-tion of the omental graft without pedicle to theinternal mammary implant procedure.

REFERENCES

1. SCHLESINGER, M. J. AND ZoLL, P. M.: Arch. Path.(Chicago), 32: 178, 1941.

2. VINEBERO, A. M. et al.: Canad. Med. Ass. J., 90: 717, 1964.3. MALLORY, G. K., ZOLL, P. M. AND LIEBOW, A.: Personal

communication.4. LITVAK, J., SIDERIDES, L. E. AND VINEBERG, A. M.: Amer.

Heart ,J., 53: 505, 1957.5. LITYAK, J. AND VINEBERO, A.: Surgery, 46: 953, 1959.6. V:NEBERG, A. M., MAHANTI, B. AND LITYAK, J.: Ibid., 47:

765, 1960.7. VINEBERO, A. M.: Ann. Surg., 159: 185, 1964.8. VINEBERG, A. M., BECERRA, A. AND CHARI, R. S.: Canad.

Med. Ass. J., 85: 1075, 1961.9. VINEBERO, A. M., DELIYANNIS, T. AND PABLO, G.: Ibid.,

80: 948, 1959.10. RAGHEB, S. AND VINEBERG, A.: Surgery, 55: 293, 1964.11. VINEBERO, A. M. et al.: Canad. Med. Ass. J., 87: 1074,

1962.12. VINEBERO, A. M., PIFARRE, R. AND KATO, Y: Ibid., 88:

499, 1963.13. VINEBERG, A. M. AND MCMILLAN, G. C.: Dis. Chest, 33:

64, 1958.14. SONES, M.: Personal communication.15. VINEBERG, A. M. AND WALKER, J.: Dis. Chest, 45: 190,

1964.16. VINEBERO, A., PIFARRE, H. AND MERCIER, C.: Canad. Med.

Ass. J., 86: 1116, 1962.

PAGES OUT OF THE PAST: FROM

THE JOURNAL OF FIFTY YEARS AGO

"A HORRIBLE REPROACH"

Cancer of the stomach to-day presents itself as a horriblereproach to the medical profession. Many thousands aredying annually of this disease, and it still continues to bethe most deplorable condition of the digestive tract, inspite of our wonderful modern surgery, and in spite ofthe refinements of physical diagnosis.

It is recognized to-day that the only hope for the futurelies in surgery applied early enough before there is muchlocal extension, and before there are any metastases. Timeand time again we have heard the late Maurice Richardsonmake the statement that 85 per cent of his inoperable casesof gastric cancer might have been cured by operation ifit had only been done early enough. Early operation,however, means early diagnosis; and here is where thedifficulty lies. The ability to use our modem surgery effec-tively depends entirely upon pushing the present limits ofdiagnosis farther back.The old criteria upon which the diagnosis of cancer of

the stomach was based, namely, twenty-four hour food stasis,blood, and a palpable tumour, are quite worthless so faras the effective application of surgery is concerned. Thecancer here is practically inoperable-at least all that canbe done is to relieve symptoms of obstruction by a palliativeoperation; or in some extremely favourable cases partialresection may stay the progress of the disease for a while.

Even with more refined clinical diagnosis with the recog-nition of micro-retention, decrease in acidity, presence oflactic acid and Oppler-Boas bacilli, and occult blood in thestools,-when all these are found, the clinical diagnosis isperhaps early but the cancer is not. By the time it isrecognizable by these methods, it is already late, and thequestion of radical cure is very doubtful-A. W. Georgeand I. Gerber, Caned. Med. Ass. J., 5: 197, 1915.