History of internal thoracic artery grafting and alternative arterial grafts

Abstract

The early successful treatment of injuries to the heart at the end of last century provided evidence beyond doubt that it was possible to operate successfully on the heart. Dr. Ludwig Rehn of Frankfurt is generally accredited with performing the first successful heart operation in August 1897 on a 22-year-old gardener who was stabbed in the heart and collapsed. He entered the chest through the left fourth intercostal space to find a massive collection of blood in the pleural cavity and continuous bleeding from a hole in the pericardium. Rehn enlarged this hole to expose the heart and a gaping 1.5-cm right ventricular wound. Using a small intestinal needle and silk he sutured the wound during diastole managing to control all bleeding. He went on prophetically to state: 'This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigation regarding surgery of the heart. This may save many lives.' [1]. RudolphMatas [2], who successfully repaired arterial aneurysms, was first to prove that it was possible to repair a diseased segment of an artery. Subsequent surgical therapies mostly developed incrementally by new generations of surgeons building on the knowledge and experience of their predecessors. The progress of openheart surgery and arterial grafting is a story of delay, frustration and perseverance marked by flashes of brilliance from the visionaries and innovators. Carrel [3] andGibbon [4]were suchmen pioneering the development of coronary artery grafting techniques and techniques involving slowing or arresting the heart respectively. Early attempts to improve the coronary artery circulation to boost the supply of blood to the myocardium were indirect. Cervical sympathectomy was championed by Charles Emile Francois-Frank [5] and performed by Charles Mayo and his father to denervate the heart and therefore reduce the rate of contractility. In 1901 Kocher [6] observed that a patient with angina became asymptomatic after a total thyroidectomy. While improving anginal symptoms thyroidectomy left patients hypothyroid. It was Elliott Cutler who performed the first subtotal thyroidectomy with the specific objective of relieving angina [7]. Although his patient was improved symptomatically, the widespread use of this operation was not popular because of the risk of recurrent laryngeal nerve injury and airway obstruction. Beck [8] and O'Shaughnessy [9] promoted the collateral circulation to the myocardium from the epicardium by a number or procedures, including artificial pericarditis, and muscle or omental flaps. Obstruction of coronary venous drainage was shown to relieve symptoms and was associated with a reduction of angina clinically and also experimentally in dogs [10]. Beck went on to develop two operations combining the development of collateral circulation with techniques of coronary venous ligation (Beck I Procedure). Subsequently, he added a brachial arterial graft between the descending thoracic aorta and the coronary sinus, followed by partial ligation of the coronary sinus at a later date. This procedure was known as the Beck II Procedure [11] and was designed to increase the supply of arterial blood to the coronary sinus, a procedure which fell into disrepute because of the high perioperative mortality. Vineberg postulated that anastomoses could develop between the coronary arteries and the transplanted internal thoracic artery (ITA) as early as 1941 atMcGill University [12]. He mobilized the left ITA, leaving the side branches, and ligated the vessel distally. The ITA was subsequently implanted into a tunnel in the left ventricular muscle alongside the left anterior descending coronary artery (LAD) (Fig. 10.1). By 1962, Vineberg [13] had reported 140 operations with an initial mortality of 33%, which subsequently fell to 2% in the decade between 1954 and 1963. These patients had no, or only slight, angina and showed marked clinical improvement. When coronary angiography was developed at the Cleveland Clinic, significant anastomoses were demonstrated in approximately 80% of these patients. This operation continued to be used until about 1970, when direct aortocoronary bypass techniques were introduced. © Springer-Verlag Berlin Heidelberg 2006.