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Use of the Internal Mammary Artery for Myocardial Revascularization in a Patient With Radiation-Induced Coronary Artery Disease
s
eport
Use of the Internal Mammary Artery for Myocardial Revascularization in a Patient With Radiation-Induced Coronary Artery Disease
FARID GHARAGOZLOO, M.D.,* Division of Thoracic and Cardiovascular Surgery; IAN P. CLEMENTS, M.D., Division of Cardiovascular Diseases and Internal Medicine; CHARLES J. MULLANY, M.B., M.S., Division of Thoracic and Cardiovascular Surgery
A 9-year-old boy with clinical stage IIA Hodgkin's disease underwent radiotherapy to the neck and mediastinum. Twenty-two years later, he sought medical attention because of angina pectoris. Cardiac catheterization revealed proximally located high-grade stenoses of the left main, left anterior descending, circumflex, and right coronary arteries. He underwent coronary artery bypass grafting with use of the left internal mammary artery to the left anterior descending coronary artery and reversed saphenous vein grafts to the circumflex and right coronary arteries. The postoperative course was uncomplicated. Previous radiotherapy to the mediastinum should be considered a risk factor for the development of premature coronary artery disease. Surgical revascularization is the preferred method of management. A combination of an internal mammary artery graft and a saphenous vein graft should be used in young patients.
The spectrum of radiation-induced heart disease includes pericarditis,' pancarditis.' cardiomyopathy, 2 conduction abnormalities,' valvular dysfunction,' and coronary artery disease." Until recently, reports of the development of coronary artery disease after radiation therapy have been based mainly on postmortem studies. Recognition of the relationship between radiotherapy and coronary artery disease has led to early diagnosis and timely intervention. Herein we describe a young man with presumed radiation-induced coronary artery disease. This case report illustrates the peculiar factors inherent to this type of coronary artery disease that usually necessitates surgical myocardial revascularization. REPORT OF CASE In 1969, a 9-year-old boy was found to have nodular sclerosing Hodgkin's disease that involved the right cervical *Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. C. J. Mullany, Division of Thoracic andCardiovascular Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 67: 1081-1084, 1992
lymph nodes. Findings on chest radiography, lymphangiography, and examination of bone marrow were normal. Clinical stage I1A Hodgkin's disease was diagnosed. With use of a cobalt-60 machine, the patient received a total dose of 2,700 rad to the right cervical region and 4,200 rad to the neck and mediastinum. After a dose of 2,500 rad, the heart was shielded with a subcarinal block; however, the base of the heart still received 4,200 rad. After completion of the treatment, the patient underwent follow-up annually. He has remained in complete remission with no evidence of recurrent Hodgkin's disease. In 1974, hypothyroidism was diagnosed, and thyroid replacement therapy was begun. In 1983, bilateral asymptomatic carotid bruits were detected; however, they were not investigated at that time. In 1985, the patient began experiencing dysphagia. Upper gastrointestinal endoscopy revealed a distal esophageal band, with characteristics of a Schatzki ring. Biopsy specimens were consistent with fibrous tissue. In 1989 and 1991, pneumatic dilation was required for relief of symptomatic dysphagia. In 1991, 22 years after the completion of mantle radiotherapy, the patient experienced the onset of typical 1081
1082 RADIATION-INDUCED CORONARY ARTERY DISEASE
exertional angina pectoris associated with shortness of breath. Physical examination revealed atrophy of the muscles of the right side of the neck and the right shoulder. Results of a cardiac examination were normal. Bilateral carotid bruits were detected, but no other murmurs were noted. Electrocardiographic and chest roentgenographic findings were interpreted as normal. The patient underwent exercise thallium-201 myocardial scintigraphy, which showed no perfusion defects. Results of the exercise electrocardiogram, however, were strongly positive for ischemia. A coronary angiogram (Fig. 1) disclosed focal stenoses in the proximal coronary arteries: 90% in the left main coronary artery, 70% in the proximal right coronary artery, 60% in the proximal left anterior descending coronary artery, and 80% in the proximal circumflex coronary artery. The distal coronary arteries were of normal caliber with no angiographic evidence of disease. Angiographic findings of both internal mammary arteries were normal. Because of the high-grade proximal lesions, especially in the left main coronary artery, myocardial revascularization was undertaken. At operation, the pericardium was free of adhesions; however, the epicardium seemed thickened. The left internal mammary artery was grossly normal and had excellent blood flow. The patient underwent coronary artery bypass grafting with the left internal mammary artery to the left anterior descending coronary artery and saphenous vein grafts to the right posterior descending coronary artery and the marginal branch of the circumflex coronary artery. The postoperative recovery was uneventful, and the patient was free of symptoms 2 months after the procedure. Subsequent ultrasonography of the carotid arteries showed diffuse narrowing of the left common carotid artery and 50% stenosis of the right common carotid artery; no treatment regimen has been initiated. DISCUSSION Although concerns about the possible harmful effects of irradiation on the heart were expressed by Seguy and Quenisset? in 1897, for many years, the heart was considered highly radioresistant. In 1924, Davis" first described the nature of pericardial and myocardial damage associated with radiation therapy. Investigators now generally accept that irradiation damages all three layers of the heart," The literature contains numerous descriptions of myocardial infarction or other coronary events occurring in young patients who were previously exposed to radiation therapy to the mediastinum and lacked other risk factors." In addition, because irradiation has been reported to induce carotid artery" and subclavian artery'? occlusive disease, our patient's stenoses of the carotid arteries were likely related to the previous radiation therapy.
Mayo Clio Proc, November 1992, Vol 67
Fig. I. Right anterior oblique angiogram of left coronary system in man who had undergone radiotherapy 22 years earlier. Note ostial lesion in left main coronary artery.
In 1981 in a postmortem study, Brosius and associates' described radiation-induced changes in the epicardial coronary arteries. The narrowing of the epicardial arteries in patients who had received irradiation to the mediastinum was significantly greater than that in a matched group of control subjects. The proximal portion of the arteries had significantly more narrowing than did the distal portions. Furthermore, the plaques were primarily composed of fibrous tissue. In a study of patients whose coronary artery disease after radiation therapy was confirmed by angiography, McEniery and colleagues" found lesions of the left main trunk in more than 50% of cases and ostial lesions of the right coronary artery in 25%. They also noted that these lesions developed after a latency period of 10 or more years. Modem techniques of radiation therapy, including the use of linear accelerators, mediastinal blocks, and equally weighted anterior and posterior portals, have decreased the overall amount of irradiation delivered to the heart. In a recent review, Com and co-workers" estimated that with the current techniques, only 4% of the heart receives radiation doses of more than 4,000 rad in comparison with 65% with the techniques used before 1970. Of importance, although the total area of exposure of the myocardium to irradiation is less with modem techniques, shielding does not protect the proximal portion of the coronary arteries, the area where most of the lesions have been noted. The incidence of coronary artery disease in patients who have received radiation therapy to the mediastinum and who have survived at least 10 years ranges from 6 to 19%.6 This percentage substantially exceeds the incidence of coronary
Mayo Clio Proc, November 1992, Vol 67
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1083
artery disease in young age-groups ofthe general population. increased risk of sternal infection in patients who received In fact, Annest and co-workers" proposed that radiation bilateral internal mammary artery grafts in comparison with therapy to the mediastinum should be considered a new risk those who received single internal mammary artery grafts. factor for the development of coronary artery disease. Although revascularization with other arterial conduits, such Successful treatment of radiation-induced coronary artery as the gastroepiploic artery or the inferior epigastric artery, disease with angioplasty" and bypass grafting" has been could have been performed, the long-term results with use of reported. Iqbal and associates'? first used the saphenous vein these grafts, particularly in comparison with a combination to revascularize a proximally occluded left anterior descend- of one internal mammary artery and one saphenous vein, ing coronary artery in a patient who had received radio- have not been reported." therapy. To our knowledge, use of the internal mammary artery has been described in only one previous report of a CONCLUSION patient with radiation-induced coronary artery disease. Previous radiation therapy to the mediastinum should be Revascularization was done in a 33-year-old woman in considered a risk factor for the development of coronary whom coronary artery disease had developed 14 years after artery disease. In a young patient who has chest pain 10 to she had received radiotherapy because of stage IIA 20 years after receiving such radiotherapy, life-threatening Hodgkin's disease." The right internal mammary artery was coronary artery disease and possible stenosis of the left main grafted to the right coronary artery, and the left internal coronary artery should be suspected. The patient should mammary artery was grafted to the circumflex coronary undergo coronary angiography and angiography of both artery. Surgical revascularization may be preferred for the mammary arteries. Coronary artery bypass grafting is the management of such patients." The lesions are multiple, preferred method for myocardial revascularization in such fibrotic, and ostial or proximal in the coronary arteries. Fur- patients. A single internal mammary artery should be used if thermore, the concomitant presence of fibrous pericarditis in all other contraindications have been excluded; however, some patients may be a relative contraindication for because of the risk of possible sternal nonunion and subseangioplasty, if urgent surgical revascularization becomes quent mediastinal infection, we caution against using the internal mammary artery if extensive radiation-induced necessary. In our patient who had previously undergone irradiation changes are noted on the skin overlying the sternum. to the mediastinum, we were concerned about the integrity of the internal mammary arteries and the postoperative healing of the sternal wound. Preoperatively, no radiation-induced REFERENCES changes were noted in the skin overlying the sternum, and an 1. Haas JM: Symptomatic constrictivepericarditis developing angiogram revealed normal bilateral mammary arteries. Af45 years after radiationtherapy to the mediastinum: a review ter being dissected from the chest wall, the left internal of radiation pericarditis. Am Heart J 77:89-95, 1969 2. Gottdiener JS, Katin MJ, Borer JS, Bacharach SL, Green mammary artery was qualitatively satisfactory and had exMV: Late cardiac effects of therapeutic mediastinal irradiacellent blood flow. Consequently, because of the patient's tion: assessment by echocardiography and radionuc1ide young age, the left internal mammary artery was used as the angiography. N Engl J Med 308:569-572, 1983 conduit for the anterior descending coronary artery-in view 3. Totterman KJ, Pesonen E, Siltanen P: Radiation-related of the associated significantly improved 10- to 15-year surchronic heart disease. Chest 83:875-878, 1983 4. Carlson RG, Mayfield WR, Normann S, AlexanderJA: Ravival, decrease in late myocardial infarction, and less need diation-associated valvulardisease. Chest 99:538-545,1991 for reoperation with use of this graft in comparison with only 5. Fajardo LF: Radiation-induced coronaryartery disease (edisaphenous vein grafts. 18 In addition, patency of the left torial). Chest 71:563-564, 1977 anterior descending coronary artery, independent of the left 6. Annest LS, Anderson RP, Li W, HafermannMD: Coronary main coronary artery, has been demonstrated to be the most artery disease following mediastinal radiation therapy. J Thorac Cardiovasc Surg 85:257-262,1983 important coronary artery patency in predicting long-term 7. Seguy G, QuenissetF: Actiondes rayonsX sur Iecoeur. C R survival. 19 Acad Sci 124:790, 1897 Because of the history of irradiation in our patient, we 8. Davis KS: Intrathoracicchanges following x-ray treatment: were especially concerned about a possible increased risk of a clinical and experimental study. Radiology 3:301-322, nonhealing and infection of the sternum. Thus, we decided 1924 9. Arsenian MA: Cardiovascular sequelae of therapeutic thoto use one internal mammary artery for revascularization racic radiation. Prog CardiovascDis 33:299-311, 1991 because we believed that sternal complications were consid10. StewartJR, FajardoLF: Radiation-induced heart disease: an erably less likely with use of one internal mammary artery update. Prog Cardiovasc Dis 27:173-194, 1984 than with use of bilateral internal mammary arteries. A 11. Silverberg GD, Britt RH, Goffinet DR: Radiation-induced recent report by Grossi and colleagues" clearly showed an carotid artery disease. Cancer 41:130-137,1978
1084
12. 13.
14.
15. 16.
Mayo CIiD Proc, November 1992, Vol 67
RADIATION-INDUCED CORONARY ARTERY DISEASE
Levinson SA, Close MB, Ehrenfeld WK, Stoney RJ: Carotid artery occlusive disease following external cervical irradiation. Arch Surg 107:395-397, 1973 Brosius FC III, Waller BF, Roberts WC: Radiation heart disease: analysis of 16 young (aged 15 to 33 years) necropsy patients who received over 3,500 rads to the heart. Am J Med 70:519-530, 1981 McEniery PT, Dorosti K, Schiavone WA, Pedrick TJ, Sheldon WC: Clinical and angiographic features of coronary artery disease after chest irradiation. Am J Cardiol 60: 10201024, 1987 Corn BW, Trock BJ, Goodman RL: Irradiation-related ischemic heart disease. J Clin Oncol 8:741-750,1990 Nakhjavan FK, Yazdanfar S, Friedman A: Percutaneous transluminal coronary angioplasty for stenosis of the ostium of the right coronary artery after irradiation for Hodgkin's disease. Am J Cardiol 53:341-342, 1984
17.
Iqbal SM, Hanson EL, Gensini GG: Bypass graft for coronary arterial stenosis following radiation therapy. Chest 71:664-666, 1977 18. Cameron A, Kemp HG Jr, Green GE: Bypass surgery with the internal mammary artery graft: 15 year follow-up. Circulation 74 (SuppI3):1II30-1II36, 1986 19. Klein LW, WeintraubWS, Argarwal JB, Schneider RM, Seelaus PA, Katz RI, Helfant RH: Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery. Am J Cardiol 58:42-46,1986 20. Grossi EA, Esposito R, Harris LJ, Crooke GA, Galloway AC, Colvin SB, Culliford AT, Baumann FG, Yao K, Spencer FC: Sternal wound infections and use of internal mammary artery grafts. J Thorac.Cardiovasc Surg 102:342-346, 1991 21. Harverich A, Borst HG: Arterial grafts. In Annual of Cardiac Surgery. Edited by M Jacoub, J Pepper. London, Current Science, 1990-1991, pp 121-125
eport
Use of the Internal Mammary Artery for Myocardial Revascularization in a Patient With Radiation-Induced Coronary Artery Disease
FARID GHARAGOZLOO, M.D.,* Division of Thoracic and Cardiovascular Surgery; IAN P. CLEMENTS, M.D., Division of Cardiovascular Diseases and Internal Medicine; CHARLES J. MULLANY, M.B., M.S., Division of Thoracic and Cardiovascular Surgery
A 9-year-old boy with clinical stage IIA Hodgkin's disease underwent radiotherapy to the neck and mediastinum. Twenty-two years later, he sought medical attention because of angina pectoris. Cardiac catheterization revealed proximally located high-grade stenoses of the left main, left anterior descending, circumflex, and right coronary arteries. He underwent coronary artery bypass grafting with use of the left internal mammary artery to the left anterior descending coronary artery and reversed saphenous vein grafts to the circumflex and right coronary arteries. The postoperative course was uncomplicated. Previous radiotherapy to the mediastinum should be considered a risk factor for the development of premature coronary artery disease. Surgical revascularization is the preferred method of management. A combination of an internal mammary artery graft and a saphenous vein graft should be used in young patients.
The spectrum of radiation-induced heart disease includes pericarditis,' pancarditis.' cardiomyopathy, 2 conduction abnormalities,' valvular dysfunction,' and coronary artery disease." Until recently, reports of the development of coronary artery disease after radiation therapy have been based mainly on postmortem studies. Recognition of the relationship between radiotherapy and coronary artery disease has led to early diagnosis and timely intervention. Herein we describe a young man with presumed radiation-induced coronary artery disease. This case report illustrates the peculiar factors inherent to this type of coronary artery disease that usually necessitates surgical myocardial revascularization. REPORT OF CASE In 1969, a 9-year-old boy was found to have nodular sclerosing Hodgkin's disease that involved the right cervical *Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. C. J. Mullany, Division of Thoracic andCardiovascular Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 67: 1081-1084, 1992
lymph nodes. Findings on chest radiography, lymphangiography, and examination of bone marrow were normal. Clinical stage I1A Hodgkin's disease was diagnosed. With use of a cobalt-60 machine, the patient received a total dose of 2,700 rad to the right cervical region and 4,200 rad to the neck and mediastinum. After a dose of 2,500 rad, the heart was shielded with a subcarinal block; however, the base of the heart still received 4,200 rad. After completion of the treatment, the patient underwent follow-up annually. He has remained in complete remission with no evidence of recurrent Hodgkin's disease. In 1974, hypothyroidism was diagnosed, and thyroid replacement therapy was begun. In 1983, bilateral asymptomatic carotid bruits were detected; however, they were not investigated at that time. In 1985, the patient began experiencing dysphagia. Upper gastrointestinal endoscopy revealed a distal esophageal band, with characteristics of a Schatzki ring. Biopsy specimens were consistent with fibrous tissue. In 1989 and 1991, pneumatic dilation was required for relief of symptomatic dysphagia. In 1991, 22 years after the completion of mantle radiotherapy, the patient experienced the onset of typical 1081
1082 RADIATION-INDUCED CORONARY ARTERY DISEASE
exertional angina pectoris associated with shortness of breath. Physical examination revealed atrophy of the muscles of the right side of the neck and the right shoulder. Results of a cardiac examination were normal. Bilateral carotid bruits were detected, but no other murmurs were noted. Electrocardiographic and chest roentgenographic findings were interpreted as normal. The patient underwent exercise thallium-201 myocardial scintigraphy, which showed no perfusion defects. Results of the exercise electrocardiogram, however, were strongly positive for ischemia. A coronary angiogram (Fig. 1) disclosed focal stenoses in the proximal coronary arteries: 90% in the left main coronary artery, 70% in the proximal right coronary artery, 60% in the proximal left anterior descending coronary artery, and 80% in the proximal circumflex coronary artery. The distal coronary arteries were of normal caliber with no angiographic evidence of disease. Angiographic findings of both internal mammary arteries were normal. Because of the high-grade proximal lesions, especially in the left main coronary artery, myocardial revascularization was undertaken. At operation, the pericardium was free of adhesions; however, the epicardium seemed thickened. The left internal mammary artery was grossly normal and had excellent blood flow. The patient underwent coronary artery bypass grafting with the left internal mammary artery to the left anterior descending coronary artery and saphenous vein grafts to the right posterior descending coronary artery and the marginal branch of the circumflex coronary artery. The postoperative recovery was uneventful, and the patient was free of symptoms 2 months after the procedure. Subsequent ultrasonography of the carotid arteries showed diffuse narrowing of the left common carotid artery and 50% stenosis of the right common carotid artery; no treatment regimen has been initiated. DISCUSSION Although concerns about the possible harmful effects of irradiation on the heart were expressed by Seguy and Quenisset? in 1897, for many years, the heart was considered highly radioresistant. In 1924, Davis" first described the nature of pericardial and myocardial damage associated with radiation therapy. Investigators now generally accept that irradiation damages all three layers of the heart," The literature contains numerous descriptions of myocardial infarction or other coronary events occurring in young patients who were previously exposed to radiation therapy to the mediastinum and lacked other risk factors." In addition, because irradiation has been reported to induce carotid artery" and subclavian artery'? occlusive disease, our patient's stenoses of the carotid arteries were likely related to the previous radiation therapy.
Mayo Clio Proc, November 1992, Vol 67
Fig. I. Right anterior oblique angiogram of left coronary system in man who had undergone radiotherapy 22 years earlier. Note ostial lesion in left main coronary artery.
In 1981 in a postmortem study, Brosius and associates' described radiation-induced changes in the epicardial coronary arteries. The narrowing of the epicardial arteries in patients who had received irradiation to the mediastinum was significantly greater than that in a matched group of control subjects. The proximal portion of the arteries had significantly more narrowing than did the distal portions. Furthermore, the plaques were primarily composed of fibrous tissue. In a study of patients whose coronary artery disease after radiation therapy was confirmed by angiography, McEniery and colleagues" found lesions of the left main trunk in more than 50% of cases and ostial lesions of the right coronary artery in 25%. They also noted that these lesions developed after a latency period of 10 or more years. Modem techniques of radiation therapy, including the use of linear accelerators, mediastinal blocks, and equally weighted anterior and posterior portals, have decreased the overall amount of irradiation delivered to the heart. In a recent review, Com and co-workers" estimated that with the current techniques, only 4% of the heart receives radiation doses of more than 4,000 rad in comparison with 65% with the techniques used before 1970. Of importance, although the total area of exposure of the myocardium to irradiation is less with modem techniques, shielding does not protect the proximal portion of the coronary arteries, the area where most of the lesions have been noted. The incidence of coronary artery disease in patients who have received radiation therapy to the mediastinum and who have survived at least 10 years ranges from 6 to 19%.6 This percentage substantially exceeds the incidence of coronary
Mayo Clio Proc, November 1992, Vol 67
RADIATION-INDUCED CORONARY ARTERY DISEASE
1083
artery disease in young age-groups ofthe general population. increased risk of sternal infection in patients who received In fact, Annest and co-workers" proposed that radiation bilateral internal mammary artery grafts in comparison with therapy to the mediastinum should be considered a new risk those who received single internal mammary artery grafts. factor for the development of coronary artery disease. Although revascularization with other arterial conduits, such Successful treatment of radiation-induced coronary artery as the gastroepiploic artery or the inferior epigastric artery, disease with angioplasty" and bypass grafting" has been could have been performed, the long-term results with use of reported. Iqbal and associates'? first used the saphenous vein these grafts, particularly in comparison with a combination to revascularize a proximally occluded left anterior descend- of one internal mammary artery and one saphenous vein, ing coronary artery in a patient who had received radio- have not been reported." therapy. To our knowledge, use of the internal mammary artery has been described in only one previous report of a CONCLUSION patient with radiation-induced coronary artery disease. Previous radiation therapy to the mediastinum should be Revascularization was done in a 33-year-old woman in considered a risk factor for the development of coronary whom coronary artery disease had developed 14 years after artery disease. In a young patient who has chest pain 10 to she had received radiotherapy because of stage IIA 20 years after receiving such radiotherapy, life-threatening Hodgkin's disease." The right internal mammary artery was coronary artery disease and possible stenosis of the left main grafted to the right coronary artery, and the left internal coronary artery should be suspected. The patient should mammary artery was grafted to the circumflex coronary undergo coronary angiography and angiography of both artery. Surgical revascularization may be preferred for the mammary arteries. Coronary artery bypass grafting is the management of such patients." The lesions are multiple, preferred method for myocardial revascularization in such fibrotic, and ostial or proximal in the coronary arteries. Fur- patients. A single internal mammary artery should be used if thermore, the concomitant presence of fibrous pericarditis in all other contraindications have been excluded; however, some patients may be a relative contraindication for because of the risk of possible sternal nonunion and subseangioplasty, if urgent surgical revascularization becomes quent mediastinal infection, we caution against using the internal mammary artery if extensive radiation-induced necessary. In our patient who had previously undergone irradiation changes are noted on the skin overlying the sternum. to the mediastinum, we were concerned about the integrity of the internal mammary arteries and the postoperative healing of the sternal wound. Preoperatively, no radiation-induced REFERENCES changes were noted in the skin overlying the sternum, and an 1. Haas JM: Symptomatic constrictivepericarditis developing angiogram revealed normal bilateral mammary arteries. Af45 years after radiationtherapy to the mediastinum: a review ter being dissected from the chest wall, the left internal of radiation pericarditis. Am Heart J 77:89-95, 1969 2. Gottdiener JS, Katin MJ, Borer JS, Bacharach SL, Green mammary artery was qualitatively satisfactory and had exMV: Late cardiac effects of therapeutic mediastinal irradiacellent blood flow. Consequently, because of the patient's tion: assessment by echocardiography and radionuc1ide young age, the left internal mammary artery was used as the angiography. N Engl J Med 308:569-572, 1983 conduit for the anterior descending coronary artery-in view 3. Totterman KJ, Pesonen E, Siltanen P: Radiation-related of the associated significantly improved 10- to 15-year surchronic heart disease. Chest 83:875-878, 1983 4. Carlson RG, Mayfield WR, Normann S, AlexanderJA: Ravival, decrease in late myocardial infarction, and less need diation-associated valvulardisease. Chest 99:538-545,1991 for reoperation with use of this graft in comparison with only 5. Fajardo LF: Radiation-induced coronaryartery disease (edisaphenous vein grafts. 18 In addition, patency of the left torial). Chest 71:563-564, 1977 anterior descending coronary artery, independent of the left 6. Annest LS, Anderson RP, Li W, HafermannMD: Coronary main coronary artery, has been demonstrated to be the most artery disease following mediastinal radiation therapy. J Thorac Cardiovasc Surg 85:257-262,1983 important coronary artery patency in predicting long-term 7. Seguy G, QuenissetF: Actiondes rayonsX sur Iecoeur. C R survival. 19 Acad Sci 124:790, 1897 Because of the history of irradiation in our patient, we 8. Davis KS: Intrathoracicchanges following x-ray treatment: were especially concerned about a possible increased risk of a clinical and experimental study. Radiology 3:301-322, nonhealing and infection of the sternum. Thus, we decided 1924 9. Arsenian MA: Cardiovascular sequelae of therapeutic thoto use one internal mammary artery for revascularization racic radiation. Prog CardiovascDis 33:299-311, 1991 because we believed that sternal complications were consid10. StewartJR, FajardoLF: Radiation-induced heart disease: an erably less likely with use of one internal mammary artery update. Prog Cardiovasc Dis 27:173-194, 1984 than with use of bilateral internal mammary arteries. A 11. Silverberg GD, Britt RH, Goffinet DR: Radiation-induced recent report by Grossi and colleagues" clearly showed an carotid artery disease. Cancer 41:130-137,1978
1084
12. 13.
14.
15. 16.
Mayo CIiD Proc, November 1992, Vol 67
RADIATION-INDUCED CORONARY ARTERY DISEASE
Levinson SA, Close MB, Ehrenfeld WK, Stoney RJ: Carotid artery occlusive disease following external cervical irradiation. Arch Surg 107:395-397, 1973 Brosius FC III, Waller BF, Roberts WC: Radiation heart disease: analysis of 16 young (aged 15 to 33 years) necropsy patients who received over 3,500 rads to the heart. Am J Med 70:519-530, 1981 McEniery PT, Dorosti K, Schiavone WA, Pedrick TJ, Sheldon WC: Clinical and angiographic features of coronary artery disease after chest irradiation. Am J Cardiol 60: 10201024, 1987 Corn BW, Trock BJ, Goodman RL: Irradiation-related ischemic heart disease. J Clin Oncol 8:741-750,1990 Nakhjavan FK, Yazdanfar S, Friedman A: Percutaneous transluminal coronary angioplasty for stenosis of the ostium of the right coronary artery after irradiation for Hodgkin's disease. Am J Cardiol 53:341-342, 1984
17.
Iqbal SM, Hanson EL, Gensini GG: Bypass graft for coronary arterial stenosis following radiation therapy. Chest 71:664-666, 1977 18. Cameron A, Kemp HG Jr, Green GE: Bypass surgery with the internal mammary artery graft: 15 year follow-up. Circulation 74 (SuppI3):1II30-1II36, 1986 19. Klein LW, WeintraubWS, Argarwal JB, Schneider RM, Seelaus PA, Katz RI, Helfant RH: Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery. Am J Cardiol 58:42-46,1986 20. Grossi EA, Esposito R, Harris LJ, Crooke GA, Galloway AC, Colvin SB, Culliford AT, Baumann FG, Yao K, Spencer FC: Sternal wound infections and use of internal mammary artery grafts. J Thorac.Cardiovasc Surg 102:342-346, 1991 21. Harverich A, Borst HG: Arterial grafts. In Annual of Cardiac Surgery. Edited by M Jacoub, J Pepper. London, Current Science, 1990-1991, pp 121-125