Post-coronary artery bypass graft (CABG) surgery, chylothorax is a rare, but a serious, complication. We report a case of 49-year-old female who underwent CABG, and developed pleural effusion on post-operative day 2 which was milky in nature. Chylothorax was confirmed based on the biochemical analysis of the pleural fluid. As the medical line of management failed, video-assisted thoracoscopic surgery (VATS) was done and thoracic duct clipped on the right side. Close to the proximal portion of the left internal thoracic artery, disrupted tributaries of thoracic duct were noted and clipped. Rarity of the case and management is highlighted.

BACKGROUND: The left internal mammary artery (LIMA) is protected from developing atherosclerosis. Perivascular inflammation, which is closely associated with atherosclerosis, can be measured by perivascular adipose tissue attenuation on computed tomography angiography. Whether the absence of atherosclerosis in LIMA is related to the lower level of perivascular inflammation is unknown. This study was performed to compare the level of perivascular inflammation between LIMA in situ and native coronary arteries in patients with coronary artery disease.
RESULTS: A total of 573 patients who underwent both computed tomography angiography and optical coherence tomography imaging were included. The level of perivascular adipose tissue attenuation between LIMA in situ and coronary arteries was compared. Perivascular adipose tissue attenuation around LIMA in situ was significantly lower around the 3 coronary arteries (-82.9 [-87.3 to -78.0] versus -70.8 [-75.9 to -65.9]; P<0.001), irrespective of the level of pericoronary inflammation or the number of vulnerable features on optical coherence tomography. When patients were divided into high and low pericoronary inflammation groups, those in the high inflammation group had more target vessel failure (hazard ratio, 2.97 [95% CI, 1.16-7.59]; P=0.017).
CONCLUSIONS: The current study demonstrated that perivascular adipose tissue attenuation was significantly lower around LIMA in situ than around native coronary arteries. The lower level of perivascular inflammation may be related to the low prevalence of atherosclerosis in LIMA.
BACKGROUND: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04523194.

OBJECTIVE: It is uncertain whether Thunderbeat has a place in harvesting the left internal mammary artery (LIMA) and whether skeletonization is superior to pedicle-harvested LIMA. Some investigations have shown improved flowrates in the skeletonized graft. The aim of this study was to compare 3 groups of harvesting techniques: Pedicled, surgical skeletonized and skeletonized with Thunderbeat in terms of flow rates in the LIMA and postoperative in-hospital outcomes.
METHODS: Patients undergoing coronary artery bypass grafting with the LIMA to the anterior descending artery were randomized to pedicled (n = 56), surgical skeletonized (n = 55) and skeletonized with Thunderbeat (n = 54). Main outcomes were blood flow and pulsatility index in the graft.
RESULTS: No statistical difference between groups regarding flow in LIMA or pulsatility index. Similarly, no difference in postoperative bleeding or days of hospitalization. The duration of harvesting was faster for the pedicled technique compared with surgical skeletonized and skeletonized with Thunderbeat [mean total min: pedicled 20.2 min standard deviation (SD) ± 5.4; surgical skeletonized 28.6 min SD ± 8.7; skeletonized with Thunderbeat 28.3 min SD ± 9.11, P < 0.001]. No grafts discarded due to faulty harvesting and there was no graft failure within hospital stay.
CONCLUSIONS: We found no difference between the harvesting methods except for a significantly faster harvesting time with the pedicled technique. However, non-touch skeletonized LIMA harvesting with Thunderbeat seems to be an effective alternative to traditional surgical skeletonized LIMA. The future will reveal whether patency is harvesting dependent.
BACKGROUND: ClinicalTrials.gov Identifier: NCT05562908.

Guide-catheter-induced ostial coronary artery dissection is a feared complication of percutaneous coronary intervention, but thankfully the incidence is low. We describe a case of catheter-induced ostial dissection of the left internal mammary artery (LIMA) with multiple radial jump grafts during percutaneous coronary intervention of radial graft bifurcation disease via the LIMA. The dissection led to loss of flow and profound haemodynamic compromise and cardiac arrest as the LIMA supplied the majority of the myocardium in this patient. Intravascular ultrasound was not immediately available, so an Export AP thrombus aspiration catheter (Medtronic) was used over the coronary wire in place to allow the injection of contrast while simultaneously pulling back on the catheter to delineate the extent of the dissection and guide accurate drug-eluting stent placement. The report is a cautionary tale to the reader to treat the LIMA with respect and think long and hard before considering any interventional procedure that uses the LIMA as a conduit.

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UNASSIGNED: This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries.
UNASSIGNED: This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries.
UNASSIGNED: The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05).
UNASSIGNED: The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.

There is a variety of conduits utilized as vascular grafts in coronary artery bypass grafting (CABG). Post-CABG graft rate of failure varies depending on the type of conduit used, with the highest failure rates seen in saphenous vein grafts (SVG). Patency rates of SVG are reported to be about 75% at 12-18 months. Left internal mammary artery (LIMA) grafts have shown higher long-term patency rates when compared to other arterial and venous grafts; however, LIMA occlusions occur, most commonly in the early postoperative period. Percutaneous coronary intervention (PCI) of LIMA graft can be challenging based on the location, the length of the lesion, as well as other factors such as vessel tortuosity. Here we present a case of a complex intervention for osteal and proximal LIMA chronic total occlusion (CTO) in a symptomatic patient. Long stent delivery is usually a challenge in LIMA intervention; however, it was successfully achieved here by placing two overlapping stents. This intervention was also complicated by the tortuosity of the lesion, as well as the difficult cannulation of the left subclavian artery requiring a longer sheath for guide support.

BACKGROUND: The fractional flow reserve (FFR) has made the treatment of coronary heart disease more precise. However, there are few reports on the measurement of FFR via the left internal mammary artery (LIMA). Herein, we described the determination of further treatments by measuring FFR via the LIMA in 2 cases after coronary artery bypass grafting (CABG).
METHODS: Case 1 was a 66-year-old male who was admitted due to \"chest tightness after CABG.\" The patient underwent CABG 7 years prior due to coronary heart disease. Coronary artery angiography showed complete occlusion of the left anterior descending artery (LAD), and subtotal occlusion of the third segment of the right coronary artery. On arterial angiography, there was 85% stenosis at the distal end of the anastomosis of the LIMA-LAD graft. FFR via LIMA was determined at 0.75. Thus, balloon dilation was performed in Case 1. FFR after balloon dilation was 0.94. Case 2 was a 60-year-old male who was admitted due to \"chest tightness after CABG.\" The patient underwent CABG 6 years prior due to coronary heart disease. There was 60% segmental stenosis in the middle segment of LAD and 75% anastomotic stenosis. FFR measured via LIMA was 0.83 (negative); thus the intervention was not performed. Case 2 was given drug treatments. At the 3-mo follow-up, there was no recurrence of chest tightness or shortness of breath in both cases. They are currently under continual follow-up.
CONCLUSIONS: We provided evidence that FFR measurement via grafted blood vessels, especially LIMA, after CABG is a good method to determine the intervention course.

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