surgical treatment angina pectoris - semantic …...angina pectoris have been reported in about 75...

Surgical Treatment of Angina PectorisBy MICHAEL E. DE BAKEY, 1\J.D., AND ANALTER S. HENLY, M.D.

S INCE Heberden 's classic description' ofthe syndrome of angina pectoris in 1768,

considerable effort by medical investigatorshas been directed toward this problem. Al-though these studies have enriched the litera-ture and have added to greater knowledgeand better understanding of the various as-l)ects of coronary artery disease, the surgi('alapproach to the condition has remained in-conclusive and controversial. A number offactors probably account for this disputedand uncertain status of the sulgical treat-ment of coronary artery disease. Among these?l)erhaps the most important is the fact thatthe natural course of the disease is often sohigrhly variable, not only among (liflerenitl)atients but even inl the same patient at dif-fe enAt p)eriods, and may be greatly influencedby many factors, both intrinsic and extriinsic.as well as by medical therapy. It has longlebeen recognized, for example, that significantcoronary artery disease could be present atiiecropsv with little disturbance of cardiacactivity during life. On the other hand, SirW\Tilliam Osler2 made the observation morethan fifty years ago that in some fatal cases,of angina pectoris there was little alterationin the heart or coronary arteries. Because ofthese and other variables and the consequentinability to provide a properly, controlledstudy, precise and accurate evaluation of theclinical results of surgical therapy has beenextremely difficult.The basic pathologic lesion in coronar-

artery disease is atherosclerosis, which leadsultimately to narrowing or occlusion of the

From the Cora and Webb Mading Department ofSurgery, Baylor Uniiiversity College of Mledicinie,Houston, Texas.Supported in part by grants frlomii the Amnerican

heart Association, Texas Hea rt Association, andlHouston Heart Association, and grants H-3137 andHTS-5387 fromn the Nationa.il Instittites of Heailth,UJ. S. Public Health Service.

Dr. Henly is an Established fllvestigator of theAmnerican Heart Association.

Iinmen by progressive intimal thickenhing,intimal ulceration, hemorrhage, or superim-posed thrombosis. As a result of this occlusiveprocess, the myocardial circulation is reducedto a variable degree, depending upon the na-ture and extent of the lesion and the degreeto which intercoronary collateral vessel dle-velopmeiit takes place. Serious disturbancesoccur when the latter compensatory mecha-iism fails to meet the ischemic changes pro-dluced by the atherosclerotic process. One ormore of the following effects may then takeI)lace: angina pectoris, myocardial infarction,or mechanism failuire. Myocardial damageleads to fibrosis, congYestive failure, aneurysmformation, ventricular septal defects, or ex-ternal rupture.3 These disturbances ultimatelylead to variable degrees of disability, invalid-ism, and death.

Accordilngly, surgical treatment of coro-nary artery disease has been directed towardrelief of these adverse effects of coronaryarterial insufficiency. A number of differentmethods and procedures have been proposedanod applied for this purpose, but in generalthey mav be classified as follows: (1) dener-vation of the heart for the relief of anginal)ectoris; (2) decreasing metabolic demandson coronary circulation by thyroidectomy;and (3) improvement of arterial circulationto the myocardium.More than fifty years hcave elapsed since

the first surgical attack was made on anginapectoris. This consisted in interruption ofcardiosensorv and motor pathways to theheart by symlipathectomy, a procedure whichwas originally suggested by Francois-Frank4ill 1899, and successfully performed by Jon-nesco,5 in 1916. While many experimental andclinical investigations have since provided abetter understanding of the underlying ana-tomic and physiologic principles of thismethod of attack, its clinical value remainsuncertain. Anatomic and physiologic studieshave demonstrated that the sensory nerve

Circulation, Vollume XXIII, January 1961 ill

by guest on October 4, 2017

http://circ.ahajournals.org/D

ownloaded from

http://circ.ahajournals.org/

DEBAKEY, HENLY

endings of the heart and aorta are present inthe myocardium, endocardium, and epicar-dium, and in the adventitia of the coronaryarteries. The neurons to these sensory end-ings converge in the periarterial plexus ofthe coronary arteries, traverse the superficialand deep cardiac plexuses, and course in themiddle and inferior cardiac nerves, whichjoin the corresponding cervical ganglia ofthe sympathetic chain. Practically all of theseoutbound fibers then descend to the upperthoracic ganglia and finally reach their cellsin the spinal ganglia by passing through thewhite rami communicantes into the centralportions of the first thoracic and upper fouror five intercostal nerves. The vasomotorefferent or accelerator impulses to the heartand coronary arteries differ from the sensory,and their actions and pathways are not sowell understood. These pathways involve bothvagal and sympathetic nerves, but the exactmechanism of their action in producing vaso-constriction and vasodilatation has been diffi-cult to determine precisely.

Three general methods have been employedclinically to denervate the heart: (1) cervico-thoracic ganglionectomy; (2) posterior rhiz-otomy; and (3) paravertebral chemical(alcohol) block of the upper four or five sym-pathetic ganglia. A more accurate and lastingeffect is obtained by the first two procedures;they require a major operation, however, andare associated with an operative mortality ofabout 8 to 10 per cent.6 Good results in termsof relief of pain, increase in work capacity,and improvement of general condition havebeen reported in 70 to 75 per cent of casesfollowing all these methods, but there is nogood evidence that survival expectancy is in-creased. It should be recalled that destructionof cardiosensory nerves and the protectivealarm mechanism occurs concomitantly.The procedure of total thyroidectomy to

decrease'the metabolic demands of the bodyfor the treatment of coronary insufficiency isnow only of historical interest.7 It is of in-terest to observe that in 1937 Parsons andPurks,8 following a collection of tabulateddata from various sources, found that in a

series of 133 cases in which thyroidectomywas performed for angina pectoris excellentresults were obtained in 55 per cent and that28 per cent were moderately improved. Theoperative mortality was almost 4 per cent.Hypothyroidism may be induced more easilyand safely by the administration of radio-active iodine.9 Good results in relief of severeangina pectoris have been reported in about75 per cent of cases.10, 11 Final evaluation ofthis therapeutic approach in terms of workcapacity and longevity remains to be deter-mined.

Direct and indirect surgical methods de-signed to improve the arterial circulation ofthe myoeardium have been developed follow-ing a better understanding of the factorsunderlying myocardial ischemia. Certainphysiologic principles and pathologic changesconcerning coronary arteries are of consider-able surgical importance. Functionally thecoronary arteries are largely "end arteries."Although intereoronary communication mayexist, collateral circulation from this sourceis usually not sufficient to maintain viabilityof the myocardium following sudden occlu-sion of a major branch of a coronary artery.In a slowly developing occlusive lesion, pro-gressive increase in intercoronary collateralchannels may take place and provide someprotection to the ischemic segment of myo-cardium. Although arteriosclerotic changemay be generalized, it commonly is segmen-talb Atheromata may occur anywhere in thecoronary arterial tree, but points of vesselbifurcation are sites of predilection. Fre-quently the occluding lesion is segmental' innature, is less-than 5 mm.' in' length, and 'oftenlies in ''the proximal larger arteries.2 13Distally, a thrombus 'may or may not bepresent.On the basis of these observations, investi-

gators have been encouraged to develop sur-gical procedures designed to augment arterialbloodflow to the myocardium through increasein intercoronary collateral circulation or byrestoring circulation in the involved coronaryartery. These various surgical methods maythus be classified into two broad categories,

Circulation, Volume XXIII, January 1961

112



ownloaded from


SYMPOSIUM ON CORONARY HEART DISEASE

namely, indirect and direct approaches.Among the former, a number of different

procedures have been devised and employedboth experimentally and clinically to increasecoronary collateral circulation. These vary incomplexity from the simple placement of an

irritant such as talc or asbestos in the peri-cardium14 or ligation of the internal mam-

mary arteries15-17 to the grafting of variousvascular structures such as the pericardium,18omentum,19 pectoral muscles,20 lung,5 21.22

and intestines23 to the myocardium; the im-plantation of a systemic artery such as theinternal mammary artery into a tunnel inthe myocardium ;24 and arterialization of thecoronary sinus.25 Perhaps the most popularof these procedures is the Beck I operation,or some modification of it, consisting inabrasion of the epicardium by mechanicalor chemical (phenol) means, partial ligationof the coronary sinus, the use of asbestos or

talc poudrage, and mediastinopexy. In a

series of 347 patients in which this type ofprocedure was employed during a period ofapproximately 4 years, Beck26 reported an

operative mortality of 6 per cent and a totalmortality after discharge from the hospitalof 9.2 per cent. Of the 295 patients whowere still living at the end of this period,32 per cent were classified as having an

excellent result and 62 per cent a good result.Using a somewhat similar procedure on 57patients, Thompson and Plachta2 reported

an operative mortality of 12 per cent withresults classified as 90 per cent improvedin 50 per cent of the cases and 75 per centimproved in; 40 per cent of the cases. -Advo-

cates of this procedure have been able todemonstrate that it provides an increase in

the survival rate of dogs following ligationof the anterior descending coronary arteryand have contended that this is due to in-crease in intercoronary anastomoses. On theother hand Gage and his associates,28 usingan experimental procedure that producedgradual occlusion of the circumflex and ante-rior descending branches of the left coronary

artery, were unable to demonstrate any bene-ficial effects of poudrage in terms of a de-Cirrcufation, Volume XXIII. January 1961

crease or delay in mortality or a reductionin incidence of gross infarction.

Particularly important in this connectionand in the critical evaluation of these indirectrevascularization procedures as emphasizedby these authors as well as by Gregg andSabiston29 is the concept of whether or notthey can produce an increase in collateralcirculation above that produced by the dis-ease itself.Second to the Beck I operation in clinical

popularity has been the bilateral ligation ofthe internal mammary arteries, frequentlycombined with poudrage or retrosternalneurolysis. This procedure was first suggestedby Fieschi in Italy in 193915 and employedin a number of patients with coronary insuffi-ciency by De Marchi, Battezzati, and Tag-liaferro.16 The pericardiophrenic arteriesarising from the internal mammary arteriessupply a significant quantity of blood tothe pericardium and give origin to smallvessels to the posterior wall of the leftatrium. In necropsy preparations vascularcommunications are demonstrable betweenthe internal mammary artery and the coro-nary circulation. In this country Glover andhis associates1T' 30 employed this technic inthe treatment of coronary arterial disease,reporting relief of angina in 68 per cent ofpatients with an operative mortality of 7per cent. The simplicity of the procedure,the variable course of the disease, and therelatively low associated operative mortalityundoubtedly account for the widespreadacceptance of this procedure prior to ade-quate clinical or experimental evidence thatthis operation significantly altered myocardialblood flow. Sabiston and Blalock31 and nu-merous other investigators in experimentalstudies have demonstrated no evidence of valuein internal mammary ligation. Even underspecial laboratory conditions permitting an

increase in flow in the ligated mammary arte-ries,* no; significant increase in retrogradecoronary flow nor protection of the heartagainst coronary arterial occlusion could bedemonstrated. The clinical results followingsham operations, i.e., transection of the

113



ownloaded from


DEBAKEY, JIENLY

sternunm without mammlary ligation, are asgood as those receiving the ligation.32

In 1946 Vineberg3 first proposed, and laterhe and other investigators demonstrated, thatif a systemic arters such as the carotid, sub-clavian, or internal mammary artery wereimplanted in a myocardial tunnel, the arterywould eventually form atiastomoses with theterminal branches of the coronary arteries.These arteriolar communications tend toocclude by intimial and medial thickeninog inlthe normal heart; these obliterative changes,however, do not take place iii an ischemieventricle. Although these vascular channelsr'eiiiaini patent and undoubtedly conduct some1)lood, flowv stu(lies have shown this iiiagniitudeof flow to be disappointingly small.34 :Vinieberg:3" ill 1958 reported the results ofthis procedure ill 59 patients. In 17 patientswsith angina pectoris at rest the operativemortality was 59 )per ecut. In 40 patientswitli less severe svlIptomns the operative mor-tality was 5 per cent, with 78 per ceiitmarkedly improved after surgery. The un-Iaredictable augmentation of myocardial bloodflows combined with the technical problemsassociated wN!ith a successful operation hasI)revented wide acceptance of this procedurefor the present.

It should be noted that, experimentally.arterialization of the coronary sinus (the Beck11 operation) affords the most effective pro-tectioni against ventricular fibrillation follow-inig acute coronary occlusioll.26 The anasto-mlosis of a systemic artery to the coronarysinus is, however, fraught with many tech-nical difficulties, requires a second procedureto ligate the coronary sinus partially, andclinically has had an operative mortality of15 to 20 per cent. The resulting beneficialheniodynamic changes are usually lost within6 mouths after operation.Numerous investigators have attempted to

graft richly vascularized tissues upon thesurface of the heart. At present it has been(ifficult to demonstrate conclusively a signifi-('ant flows of blood from the graft to the heartwall. Each worker has stressed the importanceof the epicardial barrier to these revasculari-

zation procedures. Removal of the epicardiumby mechanical or chemical means allows forbetter surface revaseularization.37 There isno strong evidence that any of these vascularpedicles significantly improves the myocardialcirculation. Attempts to revascularize themyocardium from within the ventricularchamber by means of small plastic T tubesimplanted within the wall of the ventriclehave not justified clinical application.38 3'More recently, still another procedure has

been introduced by Day and Lillehei,40 con-sisting in the creation of a right-to-left shuntby anastoinosis between the pulmonary arteryand left atrium to lower arterial oxygen sat-uration and thins utilize the stimulation ofhypoxia in the development of intereoronarva iiastomosis. Experimentally they were ableto demonstrate a significant increase in inter-(oronlary anastomnosis within 1 month afteroperation and reported dramatic improvementin one patient in which this procedure wasused.The direct surgical approach is aimed at

incereasing arterial inflow through the coro-nlary arteries by removal of the occlusive le-sion or by anastomosis of a systemic arteryto the coronary arteries distal to the occlu-sioin. This approach is based upon the dem-oiistration that patients with angina pectorisnot infrequently have partial or completeocclusion of a major coronary artery in theproximal portions of the vessel, which is seg-mental in character with a relatively normaldistal arterial bed.12 In light of this evidenceand the fact that effective methods have beendeveloped for the treatment of similar seg-mental occlusive lesions in peripheral vascu-lar disease, it was only natural to considerapplication of these procedures, such as re-section and graft replacement, endarterec-tomy, the bypass graft, and the patch graftto segniiental coronary occlusive disease. Thefeasibility of utilizing these procedures hasbeen well demomnstrated by aim inereasinignuber of immvestigators in clinical studies as\vell as in experinmental animals.41-53 In theclinical application of these procedures par-ticular interest has been devoted to endarter-

Circulation, Volume XXIII, Jarnuary 1961

1-14



ownloaded from



Figure 1Photograph showing bypass Dacron graft betweenaforta and left circumflex coronary artery in dogthat maintained coronary flow satisfactorily fol-lowing ligation of left main coronary artery.

ectomy following the original report of Baileyand associates54 on its successful employmentin 2 patients. More recently Kattus and hisassociates '6 56 have reported their observa-tions on a series of 11 patients suffering fromincapacitating angina pectoris in which coro-nary endarterectomy was performed. Amongthe 5 patients surviving operation, resultswere considered excellent in 2, good in 1, andfair in 2.

Efforts to utilize the bypass graft principleby some form of systemic-to-coronary arteryanastomosis have been predominantly, if notcompletely, experimental in nature. Some ofthe earliest attempts of this kind were re-ported by Murray and his associates,50 whoutilized the carotid artery as a free graftfrom the aorta to the left anterior descendingcoronary artery. Among 17 dogs in which thisprocedure was performed, 5 survived 21½qhours to 8 days without infarction. A higherrate of successful results was more recentlyreported by Thal and associates,53 who anas-tomosed the left internal mammary artery tothe left circumflex coronary artery over aglass cannula to permit blood flow during theanastomosis. Fifty per cent of the animalsCirculation, Volume XXIII, January 1961

Figure 2Coronary arteriogram made 24 hours after instal-lation of bypass graft between aorta and leftcircumflex coronary artery demonstrating patencyof anastomosis and filling of distal branches ofcircumflex artery.

survived the operation and the anastomnoseswere found to be patent 2 to 6 months laterin 41 per cent. Somewhat similar results havebeen obtained in our laboratory with use ofa knitted Dacron graft 3 to 5 mm. in diameterattached proximally by end-to-side anastomo-sis to the ascending aorta and distally by asimilar anastomosis to the left circumflexcoronary artery or the left anterior descend-ing coronary artery with the use of a teni-porary internal shunt (figs. 1-3). Followingcompletion of the anastomoses, the left maincoronary artery is ligated, leaving the leftventricle dependent on the graft for its bloodsupply. These grafts have functioned in about50 per cent of the cases.Another procedure that has been studied

experimentally in our laboratory is concerned

115



ownloaded from


DEBAKEY, HENLY

Figure 3Diagrams depicting (a) aorta-to-coronary artery bypass graft showing relationshipto heart and aorta; (b-d) technic of insertion of internal polyethylene shunt and itswithdrawal upon completion of anastomosis and (e) maintenance of entire coronarycirculation by means of a trifurcated bypass graft.

with the use of the patch graft.57 We haveused this procedure extensively in the sur-gical treatment of other forms of well-local-ized atherosclerotic occlusive disease with orwithout endarterectomy, and it has beenfound particularly valuable in lesions involv-ing smaller arteries such as the internalcarotid, vertebral, and popliteal arteries.These small patches of autogenous or syn-thetic graft material provide replacement ofa sufficient part of the circumference of theartery to permit restoration of a normal lu-men following arteriotomy. Successful appli-cation of this procedure to the coronaryartery of dogs has been demonstrated in ourlaboratory (figs. 4-6). On this basis and fromour clinical experience with its use in othersmall arteries, the patch graft would seem tohave some advantages in the treatment of cer-tain forms of well-localized coronary arteryocclusive lesions.

It is thus apparent that a wide variety ofsurgical procedures has been devised andadvocated for the purpose of improving myo-cardial circulation. Extensive investigationshave also been done to evaluate the resultsof these procedures. In general the experi-mental design of most of these studies hasemployed one or more of the following cri-teria of benefit: (1) reduction in the amount'of myocardial damage or in mortality rate inthe group of animals having the experimental"protective" operation as compared with thecontrols following occlusion of a test artery,such as ligation of the left anterior descend-ing coronary artery; (2) increase in retro-grade coronary backflow in the experimen-tally treated animals as compared with thecontrols; and (3) morphologic evidence ofnew vessel formation following the experi-mental procedure. Evaluation of results ofclinical application of these various proce-


116



ownloaded from



Figure 4Photographs illustrating (a) arteriotomy of leftcircumflex coronary artery with internal polyethyl-ene shunt in place.

dures has been based largely upon such cri-teria as survival rate, symptomatic improve-ment, and increased work or exercise capacity,with the patient serving as his own control. Awide range of operative mortality has beenreported for these various surgical approachesfrom less than 5 per cent for the simpler pro-cedures to over 50 per cent for the moreextensive operations.

Efforts to assess the relative value of thesevarious methods of surgical treatment ofcoronary insufficiency are fraught with manydifficulties. As indicated previously, these aredue in large measure to the highly variablecourse of the disease and to lack of preciseand accurate criteria of benefit. Particularlystriking is the remarkable similarity in theclinical results following these widely varyingmethods as reported by their respective ad-vocates. This would suggest that they allpossess some common factor or mechanismother than improvement in coronary circula-tion. This is well exemplified by the subse-quent demonstration in well-controlled stud-ies that certain procedures, such as ligationof the internal mammary artery, do not in-Circulation, Volume XXIII, January 1961

Figure 5Appearance of vessel (fig. 4) after closure of ar-tery with use of Dacron patch graft to avoidconstriction of lumen.

CL.~~~~~C

Figure 6Diagrams (a-d) depicting technical aspects ofarterial repair of circumflex coronary artery withaid of internal shunt and small Dacron patch graft.

crease circulation.58 Obviously the majordifficulty in the critical evaluation of thesemethods of surgical treatment clinically liesin the lack of precise and accurate methods ofdemonstrating increased myocardial flow.59' 60

Despite these considerations there are rea-sons to believe that the surgical approach tothis problem offers some promise.8' Certainlyfor the relief of intractable pain uncontrolledby medical means, surgical methods by oneof the simpler procedures, such as neurectomy

117



ownloaded from


DEBAKEY, HENLY

or chemical or mechanical de-epicardializa-tion, may be employed with a low operativerisk and high incidence of relief of pain. Themost meaningful surgical approach to thisproblem, however, would seem to lie in thoseprocedures designed to restore normal bloodflow in the obstructed segment of the coro-nary arterial tree by methods, such as endar-terectomy, bypass graft, or patch graft, thathave proved so effective elsewhere. Bettergeneral acceptance and more widespread clin-ical application of these methods, however,await further developments along certainlines including particularly proper selectionof patients for this purpose, diminution inthe risk of operation, and good evidence oflonig-terni maintenance of restored circula-tiol. Precise and accurate localization of thelesioin is probably the most important factorin proper selection of patients for operation.While certain tests may be of indicative valuein this regard, in the final analysis angiog-raphy is absolutely essential for this pur-pose.62-64 For this reason recent developmentsproviding safer and improved methods ofcoronary arteriography are most encourag-ing.65 -71 Ready application of coronary arte-riography will not only be of great value inthe preoperative selection of patients foroperation but will also provide more preciseand accurate evaluation of the operative pro-cedure by subsequent visualization of thecoronary arterial tree. Progressive develop-ments along these lines and increasing experi-enice gained with application of these surgicallrocedures in segmental occlusive lesions inother small arteries should permit furtherrefinements ill technic and improvements insurgical management which would lower theoperative risk to acceptable levels. There aresufficiently encouraging reasons to believe,therefore, that more intensive investigationsof this approach toward relief of coronaryo(clusive disease are fully justified.

References1. HEBERDEN, W.: Some account of a disorder of the

breast. M. Tr. College Physicians 2: 59, 1768.

2. OSLER, W.: The Lumleian lectures on anginapectoris. Lancet p. 8R39, 1910.

3. COOLEY, D. A., HENLY, W. S., AMAD, K. H., ANDCHAPMAN, D. W.: Ventricular aneurysm fol-lowing myocardial infarction: Results of sur-gical treatment. Ann. Surg. 150: 595, 1959.

4. FRANVOIS-FRANK, C. E.: Signification physio-logique de la resection du symnpathique dansla maladie de Basedow, 1 'epilepsie, l 'idiotieet le glaucome. Bull. Acad. de med., Paris, 3Serie, 41: 565, 1899.

5. JONNESCO, T.: Traitenment ehirurgical de 1 'anginede poitrine par la resection du sympathiquecervico-thoracie. Bull. Acad. de med. 84: 93,1920.

6. OCHSNER, A., AND DEBAKEY, M. E.: The surgicaltreatment of coronary disease. Surgery 2: 478,1937.

7. BLUMGART, H. L., LEVINE, S. A., AND BERLIN,D. D.: Congestive heart failure and anginapectoris. The therapeutic effect of thyroidec-tomy on patients without clinical or pathologicevidence of thyroid activity. Arch. Int. 'Med.51: 866, 1933.

8. PARSONS, W., AND PURKS, W. K.: Total thy-roidectomy for heart disease. Ann. Surg. 105:722, 1937.

9. BLUMGART, H. L., FREEDBERG, A. S., AND BUKA,R. B.: Treatment of euthyroid cardiac patients;by producing myxedema with radioactiveiodine. Proc. Soc. Exper. Biol. & Med. 67:190, 1948.

10. BLIUMGART, H. L., FREEDBERG, A. S., AND KUR-

LAND, G. S.: Hypothyroidism produced byradioactive iodine (Im) in the treatment of

euthyroid patients with angina pectoris andcongestive heart failure. Circulation 1: 1105,1950.

11. BLUMGART, H. L., FREEDBERG, A. S., AND KUR-LAND, G. S.: Treatment of incapacitated euthy-roid cardiac patients with radioactive iodine.

J.A.M.A. 157: 1, 1955.12. BLiTMGART, H. L., SCHLESSINGER, M. J., ANI

DAVIS, D.: Studies on relation of clinical miani-festations of angina pectoris, coronary throm-

hosis, and myocardial infaretion to pathologicfindings, with particular reference to signifi-cance of collateral circulation. Am. Heart J.19: 1, 1940.

13. SZILAGYI, D. E., MCDONALD, R. T., AND FRANCE,L. C.: The applicability of angioplastic pro-

cedures in coronary atherosclerosis: An esti-mate through postmortem injection studeies.Ann. Surg. 148: 447, 1958.

14. THOMPSON, S. A.: Development of cardio-peri-cardial adhesions following the use of talc.Proc. Soc. Exper. Biol. & Med. 40: 260, 1939.

15. BATTEZZATI, M., TAGLIAFERRO, A., AND DE MARCHI,G.: The ligature of the two internal mammary

Circulation, Voluime XXIII, January 1.961

118



ownloaded from



arteries in disorders of vascularization of themyocardium. Minerva med. 46: 1173, 1955.

16. DE MARCHI, G., BATTEZZATI, M., AND TAGLIAFERRO,A.: Influenze della legature delle arterie mam-marie interne sulla insufficienza miocardia.Minerva med. 47: 1184, 1956.

17. GLOVER, R. P., DAVILA, J. C., KYLE, R. H.,BEARD, J. C., TROUT, R. A., AND KITCHELL,J. R.: Ligation of the internal mammaryarteries as a means of increasing blood supplyto the myoeardium. J. Thoracic Surg. 34:661, 1957.

18. THOMPSON, S. A., AND RAISBECK, M. J.: Cardio-pericardiopexy; the surgical treatment ofcoronary arterial disease by the establishmentof adhesive pericarditis. Ann. Int. Med. 16:495, 1942.

19. O 'SHAUGHNESSY, L., SLOME, D., AND WATSON,F.: Surgical revascularization of the heart;experi'aental basis. Lancet 1: 617, 1939.

20. BAKST, A. A., BOLEY, S. J., MORSE, W., ANDLOEWE, L.: Experimental surgical treatmentof pedicled pectoral muscle grafts. Angiology8: 308, 1957.

21. KLINE, J. L., STERN, H., BLOOMER, W. E., ANDLIEBow, A. A.: The application of an inducedbronchial collateral circulation to the coronaryarteries by cardiopneumopexy. I. Anatomicalobservations. Am. J. Path. 32: 663, 1956.

22. GARAMELLA, J. J., GEORGE, V. P., ANDERSEN,J. G., DITMANSON, M. L., AND HAY, L. J.:Modified cardiopneumopexy employing pul-monary segmental resection: A mortality-infaret study. Ann. Surg. 146: 864, 1957.

23. KEY, J. A., KERGIN, F. G., MARTINEAU, Y., ANDLECKEY, R. G.: A method of supplementingthe coronary circulation by a jejunal pediclegraft. J. Thoracic Surg. 28: 320, 1954.

24. VINEBERG, A., AND WALKER, J.: Six months' tosix years' experience with coronary arteryinsufficiency treated by internal mammaryimplantation. Am. Heart J. 54: 851, 1957.

25. BECK, C. S., AND LEIGHNINGER, D. S.: Operationsfor coronary artery disease. J.A.M.A. 156:1226, 1954.

26. -: Coronary heart disease after twenty-fiveyears. J. Thoracic Surg. 36: 329, 1958.

27. THOMPSON, S. A., AND PLACHTA, H.: Fourteenyears' experience with cardiopexy in the treat-ment of coronary artery disease. J. ThoracicSurg. 27: 64, 1951.

28. GAGE, A. A., OLSON, K. C., AND CHARDACK,W. M.: Cardiopericardiopexy. An experimentalevaluation. Ann. Surg. 147: 289, 1958.

29. GREGG, D. E., AND SABISTON, D. C., JR.: Currentresearch and problems of the coronary circu-lation. Circulation 13: 916, 1956.


30. KITCHELL, J. R., GLOVER, R. P., AND KYLE, R. H.:Bilateral internal mammary artery ligation forangina pectoris. Am. J. Cardiol. 1: 46, 1958.

31. SABISTON, D. C., JR., AND BLALOCK, A.: Experi-mental ligation of the internal mammary arteryand its effect on coronary occlusion. Surgery43: 9, 1958.

32. DIMOND, E. G., KITTLE, C. F., CROCKETT, J. E.,AND RODRIGUEZ, L. M.: A clinical study ofinternal mammary ligation for angina pectoriswith sham operations. Presented at SeventhAnnual Meeting, American College of Cardi-ology, St. Louis, Missouri, May 22, 1958.

33. VINEBERG, A. M.: Development of anastomosisbetween coronary vessels and transplantedinternal mammary artery. Canad. M.A.J. 55:117, 1946.

34. BAKST, A. A., MANIGLIA, B., ADAM, A., AXNDBAILEY, C. P.: The physiologic and pathologicevaluation of the implantation of the internalmammary artery into the left ventricular myo-cardium for the treatment of coronary arterydisease. Surgery 38: 349, 1955.

35. SABISTON, D. C., JR., FAUTEUX, J. P., ANDBLALOCK, A.: An experimental study of thefate of arterial implants in the left ventricularmyocardium. Ann. Surg. 145: 927, 1957.

36. VINEBERG, A. M.: Coronary vascular anastomosisby internal mammary artery implantation.Canad. M.A.J. 78: 871, 1958.

37. HARKEN, D. E., BLACK, H., DICKSON, J. F., III,AND WILSON, H. E., III: De-epicardialization:Simple, effective surgical treatment for anginapectoris. Circulation 12: 955, 1955.

38. GOLDMAN, A., GREENSTONE, S .M., PREUSS, F. S.,STRAUSS. S. H., AND CHANG, EN-SHU: Experi-mental methods for producing a collateralcirculation to the left heart directly from theleft ventricle. J. Thoracic Surg. 31: 364, 1956.

39. MASSIMO, C., AND BOFFI, L.: Myocardial revas-cularization by a new method of carrying blooddirectly from the left ventricular cavity intothe coronary circulation. J. Thoracic Surg.34: 257, 1957.

40. DAY, S. B., AND LILLEHEI, C. W.: Experimentalbasis for a new operation for coronary arterydisease; a left atiial-pulmonary artery shuntto encourage the development of interarterialintercoronary anastomoses. Surgery 45: 487,1959.

41. ABSOLON, K. B., AUST, J. B., VAkRCO, R. L., ANDLILLEHEI, C. W.: Surgical treatment of occlu-sive coronary artery disease by endarterectomyor anastomotic replacement. Surg., Gynec. &Obst. 103: 180, 1956.

42. BAKER, N. H., AND GRINDLAY, J. H.: Technic ofexperimental systemic-to-coronary-artery anas-

119



ownloaded from


DEBAKEY, HENIJY

tomosis. Proc. Staff Meet., Mayo Clin. 34:497, 1959.

43. CANNON, J. A., LONGMIRE, W. P., AND KATTUS,A. A.: Considerations of the rationale andtechnique of coronary endarterectomy forangina pectoris. Surgery 46: 197, 1959.

44. CARTER, E. L., AND ROTH, E. J.: Direct non-suturecoronary artery anastomosis in the dog. Ann.Surg. 148: 212, 1958.

45. GOTTESMAN, L.: Direct surgical relief of coronaryartery occlusion. Am. J. Cardiol. 2: 315, 1958.

46. HAEGER, K.: Collateral coronary circulationproduced by plastic prosthesis. An experimentalstudy. Acta chir. scandinav. 16: 196, 1959.

47. LONGMIRE, W. P., JR., CANNON, J. A., ANDKATTUS, A. A.: The surgical treatment ofangina pectoris. Arch. Int. Med. 104: 886,1959.

48. MAY, A. M., AND BAILEY, C. P.: Coronary en-darterectomy. J. Internat. Coll. Surg. 29: 160,1958.

49. MOORE, T. C., AND RIBERI, A.: Maintenance ofcoronary circulation during systemic-to-coronaryartery anastomosis. Surgery 43: 245, 1958.

50. MURRAY, G.: Resection of atheromatous segmentsof coronary arteries and graft replacement.Read before Congress of International Collegeof Angiology, Lisbon, Portugal, September1953.

51. MURRAY, G., PORCHERON, R., HILARIO, J.,AND ROSCHLAU, W.: Anastomosis of a systemicartery to the coronary. Canad. M.A.J. 71: 594,1954.

52. SABISTON, D. C., JR.: Coronary endarterectomy.Am. Surg. 26: 219, 1960.

5:3. THAL, A. P., PERRY, J. F., JR., MILLER, F. A.,AND WANGENSTEEN, 0. H.: Direct sutureanastomosis of the coronary arteries in thedog. Surgery 40: 1023, 1956.

54. BAILEY, C. P., MAY, A., AND LEMMON, W. M.:Survival after coronary endarterectomy in man.J.A.M.A. 164: 641, 1957.

55. KATTUS, A. A., LONGMIRE, W. P., JR., CANNON,J. A., WINFIELD, M. E., AND DAVIS, J. H.:Diagnostic and functional evaluation of candi-dates for coronary endarterectomy. Arch. Int.Med. 104: 870, 1959.

56. LONGMIRE, W. P., JR., CANNON, J. A., AND

KATTUS, A. A.: Direct-vision coronary endar-terectomy for angina pectoris. New EnglandJ. Med. 259: 993, 1958.

57. CRAWFORD, E. S., BEALL, A. C., JR., ELLIS, P. R.,JR., AND DEBAKEY, M. E.: A technic per-mitting operation upon small arteries. Surg.Forum, Am. Coll. Surg. 10: 671, 1960.

58. ADAMS, R.: Internal mammary artery ligationfor coronary insufficiency. New England J.Med. 258: 113, 1958.

59. ECKENHOFF, J. E., HAPKENSCHIEL, J. H., HAR-MEL, M. E., GOODALE, W. T., LUBIN, M., BING,R. J., AND KETY, S. S.: Measurement of coro-nary blood flow by the nitrous oxide method.Am. J. Physiol. 152: 356, 1948.

60. SEVELIUS, G., AND JOHNSON, P. C.: Myocardialblood flow determined by surface counting andratio formula. J. Lab. & Clin. Med. 54: 669,1959.

61. BLALOCK, A., AND SABISTON, D. C., JR.: Thecoronary artery disease problem. Western J.Surg., Obst. & Gynec. 67: 18, 1959.

62. Hoyos, J. M., AND DEL CAMPO, C. G.: Angiog-raphy of the thoracic aorta and coronaryvessels, with direct injection of an opaquesolution into the aorta. Radiology 50: 211,1948.

63. JONSSON, G.: Visualization of the coronaryarteries. Acta radiol. 29: 536, 1948.

64. RADNER, S.: An attempt at the roentgenologicvisualization of the coronary blood vessels inman. Acta radiol. 26: 497, 1945.

65. DI GUGLIELMO, L., AND GUTTADAURO, M.: Aroentgenologic study of the coronary arteriesin the living. Acta radiol., Suppl., 97: 1, 1952.

66. HELMSWORTH, J. A., MCGuIRE, J., AND FELSON,B.: Arteriography of the aorta and its branchesby means of the polyethylene catheter. Am.J. Roentgenol. 64: 196, 1950.

67. MILLER, E. W., KOLFF, W. J., AND HUGHES, C. R.:Angiography of the coronary arteries in dogs.III. During perfusion with a heart-lung ma-chine in combination with cardiac arrest incoronary artery surgery. Cleveland Clin. Quart.24: 123, 1957.

68. SONES, F. M., JR., SHIREY, E. K., PROUDFIT,W. L., AND WESTCOTT, R. N.: Cine-coronaryarteriography. Proceedings of the 32nd Scien-tifi Sessions, American Heart Association.Philadelphia, 1959, p. 773.

69. THAL, A. P., LESTER, R., RICHARDS, L. S., AND

MURRAY, J.: Coronary arteriography in arterio-sclerotic disease of the heart. Surg., Gynec.& Obst. 105: 457, 1957.

70. THAL, A. P., RICHARDS, L. S., GREENSPAN, R.,AND MURRAY, M. J.: Arteriographic studies ofthe coronary arteries in ischemic heart disease.J.A.M.A. 168: 2104, 1958.

71. WEST, J. W., AND GUzMAN, S. V.: Coronarydilatation and constriction visualized by selec-tive arteriography. Circulation Research 7:527, 1959.


120



ownloaded from


MICHAEL E. DE BAKEY and WALTER S. HENLYSurgical Treatment of Angina Pectoris

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1961 American Heart Association, Inc. All rights reserved.

75231is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TXCirculation

doi: 10.1161/01.CIR.23.1.1111961;23:111-120Circulation.

http://circ.ahajournals.org/content/23/1/111.citationlocated on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://circ.ahajournals.org//subscriptions/

is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer

of the Web page under Services. Further information about this process is available in thewhich permission is being requested is located, click Request Permissions in the middle columnClearance Center, not the Editorial Office. Once the online version of the published article for

can be obtained via RightsLink, a service of the CopyrightCirculationoriginally published in Requests for permissions to reproduce figures, tables, or portions of articlesPermissions:



ownloaded from

http://circ.ahajournals.org/content/23/1/111.citation

http://www.ahajournals.org/site/rights/

http://www.lww.com/reprints

http://circ.ahajournals.org//subscriptions/


surgical treatment angina pectoris - semantic …...angina pectoris have been reported in about 75...

Documents