[HSF] Another on vs off pump question, dilatation of IMA......

Fri Jun 8 06:59:51 EDT 2007

I can vouch for what Don says.  When I operated on a 78 year old female who had previous sequential LIMA to Diag and LAD, and radial T-graft to OMB and PDA by a well known anaortic, arterial surgeon, those skeletonized totally occluded arterial conduits were very easy to find.ED Bender, MD

---- Donald Ross <donross at bigpond.com> wrote: 
> It doesn't actually jump up and say "Hi!" like Mr Hanky but it  
> remains as a discrete easily identifiable entity, particularly within  
> the pericardium.
> Don
> On 08/06/2007, at 12:39 PM, Mitch Lirtzman wrote:
> 
> > Don,
> > It sits up even when dropped down into the mediastinum and the lung  
> > gloms over it? M.At 07:51 PM 6/7/2007, you wrote:
> >> Mitch,
> >> You must have done a re-do with a patent ima and found the artery to
> >> be imbedded in the scared remnants of the peri-arterial  tissue
> >> including the veins making  it difficult to locate and dissect ,
> >> particularly if you need to gain length to rotate the heart.
> >> If the ima has been skeletonised there is no such scaring and the ima
> >> sits up prettily like an undiseased SVG.
> >> Don
> >>
> >> On 08/06/2007, at 10:25 AM, Mitch Lirtzman wrote:
> >>
> >>> Frankly, I can't as I can honestly say I haven't had the occasion
> >>> to do so. However, the fortunately exceptionally few I've had to
> >>> take back shortly after surgery seem to have been quite viable. To
> >>> be honest, for those re-explorations I have done, I just look to
> >>> see there's no bleeding from the vessel and that's all that's
> >>> necessary. I doubt anyone in that situation would evacuate the
> >>> clot, identify any source(s) of bleeding, wash things out quickly
> >>> and then look closely enough to say "AHA, those little veins are
> >>> thrombosed!" before closing as expeditiously as possible. I don't
> >>> mean to sound flip about it. I've just never checked.
> >>> MitchAt 12:49 AM 6/7/2007, you wrote:
> >>>> Mitch,
> >>>> How do you explain the fact that the ima veins are always  
> >>>> thrombosed
> >>>> if you, unfortunately,  have an opportunity  to inspect  them next
> >>>> day?
> >>>> Don
> >>>>
> >>>> On 07/06/2007, at 2:54 PM, Mitch Lirtzman wrote:
> >>>>
> >>>>> John, I would respectfully disagree with part of the last posting.
> >>>>> As one of the "wrappers and extraluminal injectors", in well over
> >>>>> two decades, dark blood has never come out of the LIMA at the time
> >>>>> of unclamping for grafting. I'm one of the leave-it-on-the-pedicle
> >>>>> guys with accompanying veins. As stated, I don't skeletonize and
> >>>>> have never had problems with graft length. My guess is that the
> >>>>> vasa vasorum remain intact...or whatever circulation others have
> >>>>> postulated, and the vessel remains a living organ. BRB across the
> >>>>> table.
> >>>>> Mitch LirtzmanAt 08:45 PM 6/6/2007, you wrote:
> >>>>>> Don, you and others have said that you clamp and divide the IMA
> >>>>>> and lay it
> >>>>>> aside until time for the anastomosis, some with it wrapped in a
> >>>>>> sponge soaked
> >>>>>> with papaverine and/or verapamil, some after injecting the same
> >>>>>> drugs into the
> >>>>>>  lumen, and later found the IMA to be plump and pulsating.  
> >>>>>> Perhaps
> >>>>>> there is
> >>>>>> another explanation. When you open the IMA after it has been
> >>>>>> clamped for some
> >>>>>> time, the blood in the lumen is dark, desaturated, meaning that
> >>>>>> the oxygen
> >>>>>> has  been extracted, which must mean that the vessel wall has  
> >>>>>> been
> >>>>>> ischemic.
> >>>>>> Could it  be that when the smooth muscle cells become ischemic,
> >>>>>> they lose there
> >>>>>> capacity  to contract and the vessel wall relaxes and dilates and
> >>>>>> the drugs
> >>>>>> have nothing  to do with it? John Flege
> >>>>>>
> >>>>>>
> >>>>>>
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