IJCM  Vol.5 No.5 , March 2014
Management of Internal Mammary Artery Spasm

The article is dedicated to the management of internal mammary artery spasm intra- and postoperatively based on the accumulated evidence in the literature. It provides a stepwise decision algorithm for safely resolving the spasm and prevention of relapse.

Cite this paper
Ziadinov, E. , Al-Kemyani, N. and Al-Sabti, H. (2014) Management of Internal Mammary Artery Spasm. International Journal of Clinical Medicine, 5, 284-291. doi: 10.4236/ijcm.2014.55042.
[1]   Tector, A.J., Schmahl, T.M. and Canino, V.R. (1983) The Internal Mammary Artery Graft: The Best Choice for Bypass of the Diseased Left Anterior Descending Coronary Artery. Circulation, 68, II214-II217.

[2]   Stone, G.W. and Hartzler, G.O. (1989) Spontaneous Reversible Spasm in an Internal Mammary Artery Graft Causing Acute Myocardial Infarction. American Journal of Cardiology, 64, 822-823.

[3]   Lorusso, R., Crudeli, E., Lucà, F., De Cicco, G., Vizzardi, E., D’Aloia, A. and Gelsomino, S. (2012) Refractory Spasm of Coronary Arteries and Grafted Conduits after Isolated Coronary Artery Bypass Surgery. Annals of Thoracic Surgery, 93, 545-551. http://dx.doi.org/10.1016/j.athoracsur.2011.09.078

[4]   Sarabu, M.R., McClung, J.A., Fass, A. and Reed, G.E. (1987) Early Postoperative Spasm in Left Internal Mammary Artery Bypass Grafts. Annals of Thoracic Surgery, 44, 199-200. http://dx.doi.org/10.1016/S0003-4975(10)62041-3

[5]   Kong, B., Kopelman, H., Segal, B.L. and Iskandrian, A.S. (1988) Angiographic Demonstration of Spasm in a Left Internal Mammary Artery Used as a Bypass to the Left Anterior Descending Coronary Artery. American Journal of Cardiology, 61, 1363. http://dx.doi.org/10.1016/0002-9149(88)91191-5

[6]   Mills, N.L. and Ochsner, J.L. (1975) Preparations of Internal Mammary Arteries for Coronary Bypass with Intraluminal Papaverine. Journal of Cardiovascular Surgery (Torino), 16, 632-633.

[7]   Green, G.E. (1971) Rate of Blood Flow from the Internal Mammary Artery. Surgery, 70, 809-813.

[8]   Battaloglu, B., Nisanoglu, V., Erdil, N., Ozgur, B., Eroglu, T., Aydin, N., Kaynak, M. and Secici, S. (2007) Effects of Pretreatment with Different Topical Vasodilators on Blood Flow in the Internal Mammary Artery: A Prospective Randomized Study. Heart Surgery Forum, 10, E136-E140. http://dx.doi.org/10.1532/HSF98.20061166

[9]   Sasson, L., Cohen, A.J., Hauptman, E. and Schachner, A. (1995) Effect of Topical Vasodilators on Internal Mammary Arteries. Annals of Thoracic Surgery, 59, 494-496. http://dx.doi.org/10.1016/0003-4975(94)00896-F

[10]   Nili, M., Stamler, A., Sulkes, J. and Vidne, B.A. (1999) Preparation of the Internal Thoracic Artery by Vasodilator Drugs: Is It Really Necessary? A Randomized Double-Blind Placebo-Controlled Clinical Study. European Journal Cardio-Thoracic Surgery, 16, 560-563. http://dx.doi.org/10.1016/S1010-7940(99)00308-5

[11]   Formica, F., Ferro, O., Brustia, M., Corti, F., Colagrande, L., Bosisio, E. and Paolini, G. (2006) Effects of Papaverine and Glycerylnitrate-Verapamil Solution as Topical and Intraluminal Vasodilators for Internal Thoracic Artery. Annals of Thoracic Surgery, 81, 120-124. http://dx.doi.org/10.1016/j.athoracsur.2005.06.037

[12]   Yildiz, O., Ciçek, S., Ay, I., Demirkiliç, U. and Tuncer, M. (1996) Hypertension Increases the Contractions to Sumatriptan in the Human Internal Mammary Artery. Annals of Thoracic Surgery, 62, 1392-1395; Discussion 1396.

[13]   Tanaka, N. (2009) Pharmacological Studies on Responsiveness of 5-Hydroxytryptamine in Overcoming Perioperative Spasm of Coronary Artery Bypass Graft. Yakugaku Zasshi, 129, 1049-1053.

[14]   Grapow, M.T., Reineke, D.C., Kern, T., Müller-Schweinitzer, E., Carrel, T. and Eckstein, F.S. (2009) Human Internal Thoracic Arteries from Diabetic Patients Are Resistant to Endothelial Dysfunction. Fundamental & Clinical Pharmacology, 23, 567-572. http://dx.doi.org/10.1111/j.1472-8206.2009.00707.x

[15]   Turoni, C.M., de Bruno, M.P., Coviello, A., Marañón, R.O., Herrera, R.N., Muntaner, J. and Proto, V. (2007) Internal Mammary Artery Grafts Reactivity in Hypertensive Patients: Role of Stretching in Extraendothelial Nitric Oxide. Clinical and Experimental Hypertension, 29, 327-344. http://dx.doi.org/10.1080/10641960701500570

[16]   He, G.W., Fan, K.Y., Chiu, S.W. and Chow, W.H. (2000) Injection of Vasodilators into Arterial Grafts through Cardiac Catheter to Relieve Spasm. Annals of Thoracic Surgery, 69, 625-628.

[17]   Janelle, G.M., Urdaneta, F., Martin, T.D. and Lobato, E.B. (2000) Effects of Calcium Chloride on Grafted Internal Mammary Artery Flow after Cardiopulmonary Bypass. Journal of Cardiothoracic and Vascular Anesthesia, 14, 4-8.

[18]   Cantürk, E., Arslan, C., Altinok, A., &OUMLzyazgan, S., Besirli, K., Bozkurt, A.K. and Akkan, G. (2010) The in vitro Effects of Iloprost with Other Vasodilators on the Human Internal Thoracic Artery. Annals of Thoracic and Cardiovascular Surgery, 16, 78-84.

[19]   Akar, F., Manavbasi, Y., Parlar, A.I., Ulus, A.T. and Katircioglu, S.F. (2007) The Gender Differences in the Relaxation to Levosimendan of Human Internal Mammary Artery. Cardiovascular Drugs and Therapy, 21, 331-338.

[20]   Deja, M.A., Golba, K.S., Malinowski, M., Wos, S., Kolowca, M., Biernat, J., Kajor, M. and Spyt, T.J. (2005) Skeletonization of Internal Thoracic Artery Affects Its Innervation and Reactivity. European Journal of Cardio-Thoracic Surgery, 28, 551-557. http://dx.doi.org/10.1016/j.ejcts.2005.06.037

[21]   Tanaka, K.A., Szlam, F., Katori, N., Tsuda, A. and Levy, J.H. (2004) In Vitro Effects of Antihypertensive Drugs on Thromboxane Agonist (U46619)-Induced Vasoconstriction in Human Internal Mammary Artery. British Journal of Anaesthesia, 93, 257-262. http://dx.doi.org/10.1093/bja/aeh189

[22]   Harskamp, R.E., McNeil, J.D., van Ginkel, M.W., Bastos, R.B., Baisden, C.E. and Calhoon, J.H. (2008) Postoperative Internal Thoracic Artery Spasm after Coronary Artery Bypass Grafting. Annals of Thoracic Surgery, 85, 647-649.

[23]   Tarhan, A., Kehlibar, T., Yapici, F., Yilmaz, M., Arslan, Y., Yapici, N. and Ozler, A. (2006) Role of Physiological State ‘Normothermia’ in Internal Thoracic Artery Spasm after Harvesting. European Journal Cardio-Thoracic Surgery, 30, 749-752. http://dx.doi.org/10.1016/j.ejcts.2006.09.001

[24]   Choi, J.B. and Lee, S.Y. (1996) Skeletonized and Pedicled Internal Thoracic Artery Grafts: Effect on Free Flow during Bypass. Annals of Thoracic Surgery, 61, 909-913. http://dx.doi.org/10.1016/0003-4975(95)01171-4

[25]   Massa, G., Johansson, S., Kimblad, P.O., SjÖberg, T. and Steen, S. (1991) Might Free Arterial Grafts Fail Due to Spasm? Annals of Thoracic Surgery, 51, 94-101. http://dx.doi.org/10.1016/0003-4975(91)90458-3

[26]   Tabel, Y., Hepaguslar, H., Erdal, C., Catalyürek, H., Acikel, U., Elar, Z. and Aslan, O. (2004) Diltiazem Provides Higher Internal Mammary Artery Flow than Nitroglycerin during Coronary Artery Bypass Grafting Surgery. European Journal Cardio-Thoracic Surgery, 25, 553-559. http://dx.doi.org/10.1016/j.ejcts.2004.01.004

[27]   Gaudiani, V.A., Buch, W.S., Chin, A.K., Ayres, L.J. and Fogarty, T.J. (1988) An Improved Technique for the Internal Mammary Artery Coronary Bypass Graft Procedure. Journal of Cardiac Surgery, 3, 467-473.

[28]   Jeanmart, H., Perrault, L.P., Desjardins, N., Chavanon, O., Carrier, M. and Fonger, J.D. (2001) Arterial Balloon Catheter: A New Atraumatic Device for Dilating Arterial Grafts. Annals of Thoracic Surgery, 72, 810-815, Discussion 816.

[29]   Abad, C., Valerón, M.E., Cáceres, J.J. and Avalos, O. (2001) Preparation of the Internal Mammary Artery with the IMAG Fogarty Balloon Catheter. Minerva cardioangiologica, 49, 263-266.

[30]   Minami, T., Suzuki, S., Isomatsu, Y., Kasama, K., Matsuki, Y. and Masuda, M. (2010) Usefulness of Photo Dynamic Eye System for Detection of Graft Spasm in Off-Pump Coronary Artery Bypass Grafting. Kyobu Geka, 63, 809-812.

[31]   Bertona, R., De Candia, G., Boccuzzi, G., Ribichini, F., Agostini, M. and Vassanelli, C. (2004) Left Internal Mammary Artery Graft Stenosis. Atherosclerosis, Spasm or Kinking? Italian Heart Journal. Supplement, 5, 53-58.

[32]   Fakiolas, C.N., Adamopoulou, E.N., Kouvaras, G.A., Olympios, C.D. and Foussas, S.G. (1995) Systolic Segmental Disappearance of Internal Mammary Artery Graft. Correlation with Prolonged Spasm of the Graft. Acta Cardiologica, 50, 71-77.

[33]   Sanders, L.H. and Newman, M.A. (2005) Intractable Postoperative Internal Thoracic Artery Spasm Managed with Angiographic Intraluminal Papaverine. Journal of Thoracic and Cardiovascular Surgery, 130, 938-940.

[34]   Kitamura, H., Nakayama, K. and Kitano, T. (2001) A Case of Refractory Spasm of Multiple Coronary Arteries and Left Internal Thoracic Artery Graft Following Off-Pump CABG. Kyobu Geka, 54, 1103-1106.

[35]   Kollar, A., Simonton, C.A., Thomley, A.M. and Selle, J.G. (1996) Balloon Angioplasty of the Internal Mammary Artery Trunk for Early Postoperative Ischemia: A Case Report. Catheterization and Cardiovascular Diagnosis, 37, 49-51.

[36]   Pratt, G.F., Erickson, M., Provenzano, S., Mews, G. and Edwards, M. (2008) Intractable LIMA Spasm in the Postoperative Period Treated by Placement of ‘Bridging’ Stent. Annals of Thoracic Surgery, 86, 1985-1987.

[37]   Vogt, P.R., Hess, O. and Turina, M.I. (1996) Internal Mammary Artery Spasm Immediately after Grafting to the Left Anterior Descending Artery: Diagnosis and Treatment. European Heart Journal, 17, 804.

[38]   Arnaudov, D., Cohen, A.J., Zabeeda, D., Hauptman, E., Sasson, L., Schachner, A. and Ezra, S. (1996) Effect of Systemic Vasodilators on Internal Mammary Flow during Coronary Bypass Grafting. Annals of Thoracic Surgery, 62, 1816-1819. http://dx.doi.org/10.1016/S0003-4975(96)00741-2

[39]   Polvani, G., Marino, M.R., Roberto, M., Dainese, L., Parolari, A., Pompilio, G., Di Matteo, S., Fumero, A., Cannata, A., Barili, F. and Biglioli, P. (2002) Acute Effects of 17β-Estradiol on Left Internal Mammary Graft after Coronary Artery Bypass Grafting. Annals of Thoracic Surgery, 74, 695-699. http://dx.doi.org/10.1016/S0003-4975(02)03742-6

[40]   Kelsall, C.J., Chester, A.H., Amrani, M. and Singer, D.R. (2005) C-Type Natriuretic Peptide Relaxes Human Coronary Artery Bypass Grafts Preconstricted by Endothelin-1. Annals of Thoracic Surgery, 80, 1347-1351.

[41]   Buzun, L., Kleszczewski, T., Kostrzewska, A., Lisowski, P., Oleksza, P., Jackowski, R., Pedzińska, A. and Hirnle, T. (2004) Influence of Low Molecular Weight Heparin Preparations on Human Internal Thoracic Artery Contraction. European Journal of Cardio-Thoracic Surgery, 26, 951-955.

[42]   Coskun, B., Soylemez, S., Parlar, A.I., Tulga Ulus, A., Fehmi Katircioglu, S. and Akar, F. (2006) Effect of Resveratrol on Nitrate Tolerance in Isolated Human Internal Mammary Artery. Journal of Cardiovascular Pharmacology, 47, 437-445.

[43]   Ege, T., Gur, O., Karadag, C.H. and Duran, E. (2010) Evaluation of Iloprost to Prevent Vasospasm in Coronary Artery Bypass Grafts. Journal of International Medical Research, 38, 1759-1763.

[44]   Watanabe, G., Noda, Y., Takagi, T., Tomita, S., Yamaguchi, S. and Kiuchi, R. (2013) Fasudil Is a Superior Vasodilator for the Internal Thoracic Artery in Coronary Surgery. Annals of Thoracic Surgery, 96, 543-547.

[45]   Cracowski, J.L., Chavanon, O., Durand, M., Borrel, E., Devillier, P., Mallion, J.M. and Blin, D. (1997) Effect of Low-Dose Positive Inotropic Drugs on Human Internal Mammary Artery Flow. Annals of Thoracic Surgery, 64, 1742-1746.

[46]   Usta, C., Eksert, B., GÖlbasi, I., Bigat, Z. and Ozdem, S.S. (2006) The Role of Potassium Channels in the Vasodilatory Effect of Levosimendan in Human Internal Thoracic Arteries. European Journal of Cardio-Thoracic Surgery, 30, 329-332. http://dx.doi.org/10.1016/j.ejcts.2006.05.019

[47]   Akar, F., Manavbasi, Y., Parlar, A.I., Ulus, A.T. and Katircioglu, S.F. (2007) The Gender Differences in the Relaxation to Levosimendan of Human Internal Mammary Artery. Cardiovascular Drugs and Therapy, 21, 331-338.

[48]   Mirkhani, H., Shafa, M. and Khazraei, H. (2009) Comparison of the Effects of Levosimendan and Papaverine on Human Internal Mammary Artery and Saphenous Vein. Cardiovascular Drugs and Therapy, 23, 355-359.

[49]   Liu, J.J., Doolan, L.A., Xie, B., Chen, J.R. and Buxton, B.F. (1997) Direct Vasodilator Effect of Milrinone, an Inotropic Drug, on Arterial Coronary Bypass Grafts. FANZCA. Journal of Thoracic and Cardiovascular Surgery, 113, 108-113. http://dx.doi.org/10.1016/S0022-5223(97)70405-7

[50]   Lobato, E.B., Janelle, G.M., Urdaneta, F. and Martin, T.D. (2001) Comparison of Milrinone versus Nitroglycerin, Alone and in Combination, on Grafted Internal Mammary Artery Flow after Cardiopulmonary Bypass: Effects of αAdrenergic Stimulation. Journal of Cardiothoracic and Vascular Anesthesia, 15, 723-727.

[51]   Mollhoff, T., Schmidt, C., Van Aken, H., et al. (2002) Myocardial Ischaemia in Patients with Impaired Left Ventricular Function Undergoing Coronary Artery Bypass Grafting-Milrinone versus Nifedipine. European Journal of Anaesthesiology, 19, 796-802.

[52]   Irat, A.M., Aslamaci, S., Karasu, C. and Ari, N. (2006) Alteration of Vascular Reactivity in Diabetic Human Mammary Artery and the Effects of Thiazolidinediones. Journal of Pharmacy and Pharmacology, 58, 1647-1653.