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Right internal thoracic artery (RITA) bifurcating in 4th intercostal space (ICS) while left internal thoracic artery (LITA) bifurcating in 6th ICS.
Source publication
Introduction
Predictable intrathoracic course, anatomical proximity to heart and long-term patency has made Internal thoracic artery (ITA) a conduit of choice in coronary artery bypass grafting (CABG). Its frequent bilateral use has necessitated the need to have a comparative knowledge of surgical anatomy of ITA on both sides.
Methods
A random stud...
Contexts in source publication
Context 1
... ITA terminated in left 6th intercostal space (ICS) in 52% cases and in right 6th ICS in 54% in the remaining specimens it terminated at variable levels ranging from 4th ICS (2%, both on right side - Fig 2) to 7th ICS (Table 1). When compared on both sides only 38 cases had arterial termination at the same level on both sides, among these 28 specimens had artery terminating in 6th ICS bilaterally while 8 were showing termination at the level of 6th rib and 2 at the level of 7th ICS. ...
Context 2
... arteries bifurcating in an upper intercostal space were significantly shorter than those terminating in 6th ICS in same individuals. Such arteries are usually not long enough to reach the target coronary therefore can be considered for a Y graft for two closely placed coronary arteries (Fig.2) 10 or Y graft with proximal anastamosis of shorter ITA on other ITA. ...
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Abstract
Background: Internal thoracic artery became the cornerstone graft in coronary artery bypass grafting. This study aimed to investigate sternal healing and wound infection in patients undergoing coronary artery bypass graft (CABG) surgery using skeletonized versus pedicled internal thoracic artery.
Methods: 100 patients who underwent isolate...
This second report in the series on coronary artery bypass presents the authors experience and personal views on the internal thoracic artery (ITA) which date to 1966. There has been a very gradual evolution in the acceptance of this conduit which was initially compared with the saphenous vein and viewed as an improbable alternative to it. As is co...
Background:
Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revasculari...
Background There remains uncertainty regarding the second-best conduit after the
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compared the clinical results of the radial artery ( RA ), right internal
thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta-analysis has
compared these 3 strategies. M...
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Citations
... Moreover, the ribs also receive blood flow from a branch of the internal thoracic artery (Knudsen et al. 1993). Anatomically, the main trunk of the internal thoracic artery terminates mostly near the 6th ribs and then bifurcate in the intercostal space (Puri et al. 2007). In previous reports of salmonella osteomyelitis, the 6th rib was involved, as also noted in this case (Table 1). ...
Salmonella infection predominantly causes four clinical syndromes: enteric fever, gastroenteritis, bacteremia, and asymptomatic carrier state. Salmonella osteomyelitis is an extremely rare manifestation of salmonella infection except in children with hemoglobinopathies. Salmonella osteomyelitis has been reported to mostly affect the diaphysis of long bones and lumbar spine. Here, we describe a case of salmonella osteomyelitis of the right 6th rib in a 74-year-old woman who presented with breast pain, swelling, high fever and local heat. Her medical history showed myocardial infarction; namely, at the age of 71, the patient had undergone the drug-eluting stent placement in the left anterior descending artery. A computed tomography (CT) scan at the first visit to another hospital showed a mass in the chest that invaded the ribs. 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging showed a lesion suspected to be a mammary malignant tumor. A needle biopsy revealed mesenchymal cells and suspected mammary sarcoma. However, the osteomyelitis of the rib was diagnosed when pyogenic tissue was observed during an open biopsy. The bacterial culture examination identified Salmonella enterica. Surgical drainage and antibiotic treatment were performed. Importantly, there was no evidence for any underlying disease that could lead to an immunocompromised status of the patient. To our knowledge, this is the first report of salmonella osteomyelitis of the rib presenting in an older female that required differentiation from a mammary tumor. Clinicians should consider rib osteomyelitis when they find swelling and local heat in the female’s breast tissue and detect no cancerous tissue.
... The length of the IMAs varies from 13.2 to 26 cm, with a mean of 20.4 ± 2.1 cm, where the LIMA is slightly longer [1,10], whilst some reports the mean length of the IMA on each side between origin and termination are as follows: 18.05 and 18.09 cm for the RIMA and LIMA, respectively [13]. Similar results are also seen with another study, with LIMA lengths varying from 13.2 to 24.5 cm (mean length of 19.25 ± 2.30 cm) and RIMA lengths varying from 15.7 to 25.1 cm (mean length of 19.54 ± 2.24 cm) [14]. ...
... Another study reported similar results regarding the crossing of phrenic nerves with the IMA [14]. Fifty-two percentage of cases had their phrenic nerve on both sides across the IMAs anteriorly, 14% of cases had their phrenic nerve on both sides cross the IMAs posteriorly, whilst 20% of cases had the LPN cross anteriorly, RPN cross posteriorly, and 14% of cases had the reverse relationship [14]. ...
... Another study reported similar results regarding the crossing of phrenic nerves with the IMA [14]. Fifty-two percentage of cases had their phrenic nerve on both sides across the IMAs anteriorly, 14% of cases had their phrenic nerve on both sides cross the IMAs posteriorly, whilst 20% of cases had the LPN cross anteriorly, RPN cross posteriorly, and 14% of cases had the reverse relationship [14]. ...
Internal mammary artery, by far, is the gold standard and first conduit for surgical revascularization especially when it comes to bypassing a lesion in the left anterior descending coronary artery. Several factors behind using this artery have been established, including but not limited to, the anatomical location, the course and flow, the elastic nature of the artery as well as the physiological characteristics that make this conduit to yield excellent long-term patency rates. This review aims to thoroughly examine current literature and establish the facts behind using this conduit in our daily surgical revascularization practice.
... Origin from third part on either side is rare and represents < 1% of cases. IMA commonly arises as a single artery in 96% of subjects, while may arise as a part of a common trunk with other branches of the subclavian artery (thyrocervical trunk, suprascapular and inferior thyroid arteries) in about 4% of the population [13]. ...
... The length of IMA varies from 13-26 cm, with LIMA being slightly longer than the right side. IMA most frequently terminated on the 6 th rib or the corresponding intercostal space (60% of LIMA and 76.7% of RIMA), also, it can terminate anywhere between 5 th rib & 7 th intercostal space [13]. It ends in 93% of the cases by bifurcating into superior epigastric and musculophrenic arteries, and in 7% as a trifurcation; with an additional diaphragmatic branch [15]. ...
... Pericardial branches: small branches arise from the back of the IMA to supply the pericardium. Thymic branch: small branch to supply the thymic gland remnants [13]. ...
Coronary artery bypass grafting (CABG) surgery is a widely accepted option for surgical treatment of coronary artery diseases (CAD). Although various conduits have been used in CABG, the left internal mammary artery (LIMA) has become the gold standard conduit for grafting the left anterior descending (LAD) coronary artery [1]. This is due to its higher patency rates at ≥10 years with little or no atherosclerotic changes [2].
The LIMA influence in clinical practice can be diverse, with variation being introduced by different harvesting techniques. Universally, there are two well established harvesting methods: pedicled and skeletonized methods. The pedicled technique dissects the artery away from the chest wall with its accompanying veins, fascia, adipose tissue, and lymphatics, while skeletonization involves the dissection of the LIMA solely away from the chest wall [3].
The preferential harvesting technique has been periodically debated, as each technique is associated with its own respective advantages and disadvantages. Skeletonization can provide some advantages, compared to pedicled LIMA, ranging from having a longer conduit with superior free flow to a reduced chest wall pain [4]. On the contrary, skeletonization is technically more demanding, and theoretically, harvesting the vessel without the niche may reduce its long- term resistance as it is subjected to a more direct contact with more pronounced surgical trauma [5].
The selection of the harvesting technique must incorporate consideration of its complication profile with a great concern to the potential sternal wound infections (SWI). It has been suggested that the pedicled technique results in an increase in SWI owing to the reduced sternal vascularization [6]. At this point, skeletonization emerged as a preferable solution, presenting better preservation of sternal micro-circulation that might be a protective factor against SWI [5].
SWI is one of the most serious complication following myocardial revascularization although CABG is also vitiated with other complications [7]. SWI leads to significant burden on patient prognosis as well as augmented health care budgets [8]. Mediastinitis or deep sternal wound infection (DSWI) is the most devastating manifestation of SWI which occurs in about 1–2 % of CABG operations. Also, there are the more common, superficial sternal wound infections (SSWI), that range between 5–12 % after CABG [9].
There are a number of a well-known patient-related, preoperative, intraoperative and postoperative risk factors that is associated with a higher risk of developing SWI after CABG. Accordingly, major attempts have been focused to reduce the incidence of SWI at all levels, beginning from the clinic, to the operating theatre up to the postoperative period [10].
The management of SWI, particularly DSWI, has evolved through prolonged clinical experience although there has been no general consensus regarding the appropriate management. The Commonly adopted strategies for treatment include surgical revision with primary closure, surgical revision with open dressings or closed irrigation, reconstruction with muscle or omental flaps, and application of negative pressure wound therapy (NPWT).
The aim of the present study was to evaluate and compare the impact of the LIMA harvesting technique, either pedicled or skeletonized techniques, in terms of SWI in patients underwent CABG surgery.
... Usually, the LIMA bifurcates at the level of the sixth rib or the sixth ICS, and very rarely it bifurcates earlier, at the level of fifth rib or the fifth ICS, according to the literature. [1][2][3][4] In our case, the bifurcation of the LIMA occurred at the level of the third ICS. ...
The left internal mammary artery is the most accepted and widely used conduit in coronary artery bypass grafting. This report presents a rare case of very early bifurcation of the left internal mammary artery at the level of the third intercostal space.
... In recent years, Internal thoracic artery is being widely used for CABG. It has gained importance in CABG because of long term patency [9,10] and survival rate [11,12] and improvement in post-operative quality of life [13], when compared with the results of saphenous vein grafts. Secondly, because of its adequate size and intrathoracic course it is also used as recipient vessels in breast reconstruction [14]. ...
... A study reveals that 1% of right ITA originates from right thyrocervical trunk [6]. Nidhi Puri et al. reported in their study that a common trunk gives rise to ITA with other branches of subclavian artery in 12% on right side and 4% on left side [7]. A study on pattern of ramification of the subclavian artery in 56 cadavers (112 sides) reported that subclavian artery lying in front of the scalenus anterior muscle (3.5%) and also stated that the ITA originated from the TCT in 11.8 % of cases [8]. ...
... Now a day's unilateral / bilateral pedicle, sequential or free graft of ITA will be used in CABG surgery because of long term patency and event free survival. Now studies have shown that skeletonised bilateral internal thoracic artery grafting can provide better event free survival than single internal thoracic artery grafting in selected group of patients [3]. In autologous breast reconstruction internal thoracic vessels are widely used as recipient vessels. ...
The internal thoracic artery (ITA) is the largest artery of the thoracic wall. ITA has become a conduit of choice for coronary artery bypass graft surgery because of its predictable intrathoracic course, anatomical proximity to the heart and excellent long-term patency. The rare and unexpected occurrence of anomalies of the internal thoracic artery such as the one reported here may complicate the entire procedure of revascularization of the myocardium. We conclude that knowledge of variation of internal thoracic artery is necessary during surgical procedures that involve thoracic region. DOI: http://dx.doi.org/10.3126/jbs.v2i1.13032 Journal of Biomedical Sciences 2015 Mar.; 2(1): 7-9
... It is widely utilized for coronary artery bypass grafting (CABG) surgery. The ITA's anatomic characteristics, such as distinct intrathoracic course and anatomical vicinity with the heart [1], its long-term patency [1][2][3][4], the long-term survival rate [2,4] and post-operative quality of life [5] render it as an excellent arterial graft for myocardial revascularization. ...
... It is widely utilized for coronary artery bypass grafting (CABG) surgery. The ITA's anatomic characteristics, such as distinct intrathoracic course and anatomical vicinity with the heart [1], its long-term patency [1][2][3][4], the long-term survival rate [2,4] and post-operative quality of life [5] render it as an excellent arterial graft for myocardial revascularization. ...
... Inside the thorax, ITA provides mediastinal, sternal, pericardial, perforating and anterior intercostals branches [13][14][15]. Although the termination level ranges between the third and seventh rib [3], ITA commonly terminates at the level of the sixth intercostal space, dividing into its terminal branches [1,3,16]. Henriquez-Pino et al. [16] encountered the presence of a third terminal, diaphragmatic ITA branch in 7 % of the cases, whereas trifurcation of the artery was also found in 12.5 % [17]-61.3 % [18], including a xiphoid branch. ...
An unusual case of left internal thoracic artery (ITA) origin from the thyrocervical trunk (TCT) was detected during routine cadaver dissection. The variability of origin and course of ITA has less or more frequently been documented in the literature. However, the ITA origin from the TCT on the left side has been detected less commonly, making its dissection and preparation during coronary artery bypass grafting surgery more difficult. We discuss the ITA origin and course variability as well as clinical significance of the present variant, reviewing the relative literature. The objective of our study is to exhibit a rare ITA origin in order to provide a more accurate knowledge of such variations.
The application of stainless-steel wire is still the "standard of care" and is believed to be the "gold standard" after trans-sternal thoracotomy. To overcome postoperative instability and surgical wound infection there had been the development of a variety of circumferential, Hemi-circular, and surface on-lay implant designs to enhance bone healing of the sternum particularly in compromised patients. This fundamental descriptive theoretical research study probes into biology and effects of mechanical environment on fracture healing in general and various types of ossifications that may occur during healing of the sternum. Following surgical anatomy of the sternum, the biology of fracture (osteotomy) healing, an update on the conventional and newer biomaterials, and role of 3D printing in custom additive manufacturing of the surgical implants have been discussed in detail. There is discussion on design principles and structural optimization in-line with patient-specific and patient-appropriate osteosynthesis. In support, the Teorija Rezhenija Izobretatelskikh Zadatch engineering principles have been applied to improve implant design in the face of the current strategies to relieve some of the recalcitrant deficiencies underlying the mechanics of the most favored implant for the reconstruction of the sternum. Several scientific domains of the engineering design principles and fracture healing processes have been connected leading to four newly conceptualized prototype designs for the reconstruction of the sternum. In conclusion, despite increased knowledge of the fracture healing process there are limited means to mitigate the adverse mechanical environment experienced by the healing sternum. There are uncertainties how to transfer the well-known facts of tissue strain during healing from the experimental platform to the operating table at the time of fracture fixation and reconstruction of the sternum for its optimal healing.
The use of internal mammary artery (IMA) grafts for coronary artery bypass may devascularize the sternum. We performed a literature review by searching the PubMed database for studies that assessed sternal perfusion after IMA harvesting. The majority of papers describe various techniques and compared (1) IMA harvest versus no IMA harvest, (2) single versus bilateral, and (3) skeletonized versus pedicled. Evidence is inconclusive as to whether single harvesting causes significant devascularisation and whether this is increased with bilateral harvesting. Sternal ischemia may also be a transient phenomenon. However, skeletonization may preserve perfusion more than pedicled harvesting, particularly in diabetic patients.
