Interventions in RIMA
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Interventions in RIMA On the Web |
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American Roentgen Ray Society Images of Interventions in RIMA |
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Directions to Hospitals Treating Percutaneous Coronary Intervention |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Anum Ijaz M.B.B.S., M.D.[2]
Overview
Percutaneous coronary intervention (PCI) of the right internal mammary artery (RIMA) graft is an uncommon procedure, performed in patients who have undergone coronary artery bypass grafting (CABG) with bilateral internal mammary artery grafting. The RIMA may be used in situ, as a free graft, or as part of a composite arterial configuration, and the configuration determines how the graft is reached and engaged. Arterial graft interventions carry an early mortality similar to vein graft interventions and higher than native vessel interventions, so the threshold for RIMA graft PCI is high: PCI of a suitable native vessel is preferred, and RIMA graft PCI is reserved for focal graft disease supplying an ischemic territory when the native vessel cannot be treated. Randomized data comparing native vessel and graft PCI exist only for saphenous vein grafts and do not favor the native vessel, so the native-first approach for arterial grafts rests on observational data. Diffuse involution of the graft (the string sign) reflects competitive flow from an insufficiently stenosed native vessel rather than focal disease. Lesions cluster at the distal anastomosis, are less common in the graft body and are rare at the ostium. Computed tomography angiography, assessment of the subclavian inflow to an in situ RIMA, radial access from the right radial artery, soft guidewires, short guides and cautious use of guide extension catheters are central to procedural planning. In the bare-metal stent era, balloon angioplasty of the anastomosis was followed by less repeat revascularization than stenting, and data on drug-eluting stents at this site are mixed; the optimal device has not been established. Embolic protection has no role in arterial graft PCI. Tortuosity and small caliber make arterial grafts prone to catheter- and wire-induced dissection, vasospasm and pseudolesions, whereas no-reflow and overall periprocedural complications are more frequent with vein graft PCI. Evidence specific to the RIMA is sparse, and most practice is extrapolated from internal mammary artery graft series dominated by left internal mammary artery interventions.
Right Internal Mammary Artery Graft Configurations
- The right internal mammary artery can be used in situ, arising from its native origin, or as a free graft; in situ grafts are directed predominantly to the right coronary artery system, whereas free grafts are divided between the right and left coronary systems.[1]
- Free RIMA grafts have long-term patency comparable to the left internal mammary artery and superior to saphenous vein grafts.[1]
- Internal mammary artery grafts may be constructed as composite grafts to each other, provided that one of them remains in situ.[2]
- RIMA grafts perform best when placed on the left coronary system and on native vessels with high-grade stenosis, and concern about inferior long-term patency has discouraged grafting an internal mammary artery to the right coronary artery.[3][2]
- When the RIMA is directed to the right coronary system, it is placed on the posterior descending artery rather than on the main right coronary artery near the acute margin, because atherosclerosis progresses at the right coronary bifurcation; arterial grafting of the right coronary artery is generally reserved for stenosis of 90% or more.[4][5]
Epidemiology and Demographics
- Patients with prior CABG account for roughly one in six percutaneous coronary intervention procedures, and an arterial graft is the target vessel in about 2.5% of these procedures.[6]
- The RIMA is used as a conduit in only a small minority of coronary bypass operations, so RIMA graft interventions are rare.[1]
Patient Selection
- When the native coronary artery supplying the ischemic territory is amenable to PCI, native vessel PCI should be preferred to bypass graft PCI.[7][6]
- In-hospital mortality after arterial graft PCI is similar to that after saphenous vein graft PCI and higher than after native coronary artery PCI.[6]
- The evidence for a native-first strategy is observational. The only randomized comparison of native vessel and graft PCI enrolled patients with saphenous vein graft failure and did not favor native vessel PCI; no randomized data exist for arterial grafts.[8]
- The threshold for PCI of an internal mammary artery graft should be high, because of the risk of ischemia and complications during the procedure; redo CABG is generally avoided when a patent internal mammary artery graft to the left anterior descending artery is present.[7]
- Diffuse involution of an internal mammary artery graft (the string sign) is associated with competitive flow from a native vessel whose stenosis is not severe, most often because the native lesion was overestimated at the time of surgery.[9][10]
- Internal mammary artery grafts placed on native vessels with less than 50% diameter stenosis have a high rate of failure.[11]
- Before a string sign is attributed to graft disease, the native stenosis should be assessed physiologically; fractional flow reserve frequently shows the native lesion to be hemodynamically non-significant.[9]
Lesion Assessment
- Computed tomography angiography before invasive angiography should be considered in patients with prior CABG, as it shortens the invasive procedure and reduces contrast-induced nephropathy and procedural complications.[12]
- The subclavian artery proximal to an in situ internal mammary artery graft should be assessed, since stenosis at this level causes coronary–subclavian steal in up to about 3.4% of patients with internal mammary artery grafts and is treated with subclavian stenting; for the in situ RIMA this means assessing the right subclavian and brachiocephalic inflow.[5][7]
- About two-thirds of internal mammary artery graft lesions are located at the distal anastomosis, fewer than one in ten at the ostium, and the remainder in the body of the graft.[13][14][15]
- Ostial lesions of internal mammary artery grafts are rare and their pathophysiology is uncertain.[16]
Treatment
Antithrombotic Therapy and Adjunctive Devices
- Peri-procedural antithrombotic therapy follows standard PCI practice, with aspirin, a P2Y12 inhibitor and weight-adjusted unfractionated heparin; no regimen specific to arterial graft PCI has been studied.[17]
- Embolic protection devices apply to saphenous vein graft intervention and have no role in PCI of arterial grafts such as the RIMA.[17]
Vascular Access and Graft Engagement
- Radial access in patients with prior CABG is associated with fewer access-site complications and lower contrast volume than femoral access, at the cost of more frequent crossover to another access site.[18]
- Selective angiography of both internal mammary artery grafts is feasible from the right radial approach, which gives ipsilateral access to the in situ RIMA.[19]
- Shorter guide catheters of about 90 cm and internal mammary-shaped curves are preferred, and deep intubation of the graft should be avoided.[5][7]
- A soft, floppy guidewire should be used, because moderate- and extra-support wires straighten the tortuous conduit and provoke the accordion effect.[5][7]
- Engagement of an internal mammary artery graft from the contralateral radial artery is technically difficult; advancing a coronary guidewire into the graft and tracking a guide extension catheter over it to the graft ostium permits selective angiography, and injecting with the wire in place limits subintimal injection.[20]
- Transradial PCI of mammary grafts is limited by coaxial engagement, lesion visualization, backup support and reach to distal lesions; where no guide catheter will engage the RIMA, a guide extension catheter can be used to deliver equipment into the graft.[21]
- Deep intubation and guide extension use increase the risk of graft dissection and perforation, so guide extensions should be advanced with care and only as far as needed.[5][7]
- Free arterial conduits are prone to vasospasm during intervention, which can impede device delivery.[5]
Lesion-Specific Treatment
- Anastomotic lesions of internal mammary artery grafts have predominantly been treated with balloon angioplasty, whereas ostial lesions have more often been treated with stents.[13]
- In bare-metal stent era series, stenting of the internal mammary artery anastomosis was followed by substantially more target lesion revascularization than balloon angioplasty alone.[13][14]
- Whether drug-eluting stents overcome this is unsettled. At the internal mammary artery anastomosis, drug-eluting stents have been associated with more repeat revascularization than bare-metal stents in one series and with no difference in another, and repeat revascularization after drug-eluting stenting of internal mammary grafts was low in a third; all of these data are observational, and the optimal device for the anastomosis has not been established.[22][23][24][15]
- Ostial lesions can be treated percutaneously, but data are limited to small series and restenosis has been reported during follow-up.[16]
- Long drug-eluting stent implantation has been used for a diffusely diseased RIMA graft, but only case-level evidence exists.[25]
Management Algorithm
- The algorithm below summarizes the management approach described in this chapter.[12][5][7][6][9][19][17][20][21][13][14][22][23][24][16][25]
Prior CABG with suspected RIMA graft failure ❑ Consider computed tomography angiography before invasive angiography ❑ In situ RIMA: assess the right subclavian and brachiocephalic inflow ❑ Inflow stenosis causing coronary–subclavian steal: subclavian stenting | |||||||||||||||||||||||||||||||||
Is the native vessel supplying the ischemic territory amenable to PCI? | |||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||
Native vessel PCI | Diffuse involution of the RIMA (string sign) with a moderate native stenosis? | ||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||
❑ Assess the native stenosis with fractional flow reserve ❑ Involution reflects competitive flow, not focal graft disease | Focal RIMA lesion supplying an ischemic territory ❑ Proceed to RIMA graft PCI, accepting a high threshold for intervention | ||||||||||||||||||||||||||||||||
Access, equipment and adjunctive therapy ❑ In situ RIMA or bilateral internal mammary grafts: right radial access ❑ Short (about 90 cm) internal mammary-shaped guide catheter ❑ Soft, floppy guidewire to avoid the accordion effect ❑ Avoid deep intubation of the graft ❑ No embolic protection ❑ Aspirin, a P2Y12 inhibitor and weight-adjusted unfractionated heparin ❑ Contralateral access or graft not engaged: guidewire into the graft, then a guide extension catheter, advanced with care | |||||||||||||||||||||||||||||||||
Where is the lesion? | |||||||||||||||||||||||||||||||||
| Distal anastomosis | Ostium | Diffuse graft disease | |||||||||||||||||||||||||||||||
❑ Balloon angioplasty has been the predominant strategy ❑ Bare-metal stenting was followed by more repeat revascularization ❑ Drug-eluting stent data are mixed; optimal device not established | ❑ Stenting has been the predominant strategy ❑ Data limited to small series; restenosis reported | ❑ Long drug-eluting stent implantation ❑ Case-level evidence only | |||||||||||||||||||||||||||||||
Before concluding the procedure ❑ New narrowing after wiring a tortuous graft: consider a pseudolesion ❑ Withdraw the stiff wire; use intravascular ultrasound to exclude dissection or thrombus | |||||||||||||||||||||||||||||||||
Outcomes
- Internal mammary artery graft PCI achieves high procedural success with low rates of in-hospital death, myocardial infarction and emergency CABG.[13]
- Compared with saphenous vein graft PCI, PCI of internal mammary artery grafts to the left anterior descending artery achieves similar procedural success and in-hospital mortality, with fewer myocardial infarctions and repeat revascularizations at one year.[26]
- Registry data are not uniform: in-hospital mortality after arterial graft PCI has matched that of vein graft PCI in one national registry, whereas another found fewer periprocedural complications with internal mammary artery graft PCI than with vein graft PCI.[6][27]
Complications
- Tortuosity and small caliber make arterial grafts prone to catheter- and wire-induced dissection and perforation.[5][7]
- Dissection is more frequent in internal mammary artery graft interventions than in saphenous vein graft interventions, and arterial grafts other than the left internal mammary artery, including the RIMA, share this excess risk.[26]
- Conversely, no-reflow, perforation and overall periprocedural complications are more frequent with saphenous vein graft PCI than with internal mammary artery graft PCI.[27]
- Abrupt closure and graft perforation are rare but can result in death or emergency CABG.[13]
- Internal mammary artery graft perforation can be sealed with polytetrafluoroethylene-covered stents.[28]
- Straightening of a tortuous graft by the guidewire can create artifactual narrowings (pseudolesions) in the internal mammary artery graft and the native vessel that mimic thrombus and dissection.[29]
- Guidewire-induced pseudolesions resolve when the stiff wire is withdrawn; intravascular ultrasound can exclude dissection or thrombus before the wire is removed.[30]
References
- ↑ 1.0 1.1 1.2 Assi R, Youssef SJ, Almarzooq Z, Al-Raweshidy Y, Hashim PW, Geirsson A; et al. (2014). "The "free" right internal thoracic artery: a versatile and durable conduit". Journal of Cardiac Surgery. 29 (5): 609–615. doi:10.1111/jocs.12396.
|access-date=requires|url=(help) - ↑ 2.0 2.1 Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U; et al. (2016). "Randomized trial of bilateral versus single internal-thoracic-artery grafts". New England Journal of Medicine. 375 (26): 2540–2549. doi:10.1056/NEJMoa1610021.
|access-date=requires|url=(help) - ↑ Buxton BF, Ruengsakulrach P, Fuller J, Rosalion A, Reid CM, Tatoulis J (2000). "The right internal thoracic artery graft—benefits of grafting the left coronary system and native vessels with a high grade stenosis". European Journal of Cardio-Thoracic Surgery. 18 (3): 255–261. doi:10.1016/S1010-7940(00)00527-3.
|access-date=requires|url=(help) - ↑ Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Journal of the American College of Cardiology. 58 (24): e123–e210. doi:10.1016/j.jacc.2011.08.009.
|access-date=requires|url=(help) - ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Beerkens FJ, Claessen BE, Mahan M, Gaudino MFL, Tam DY, Henriques JPS; et al. (2022). "Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization". Nature Reviews Cardiology. 19 (3): 195–208. doi:10.1038/s41569-021-00612-6.
|access-date=requires|url=(help) - ↑ 6.0 6.1 6.2 6.3 6.4 Brilakis ES, Rao SV, Banerjee S, Goldman S, Shunk KA, Holmes DR; et al. (2011). "Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry". JACC: Cardiovascular Interventions. 4 (8): 844–850. doi:10.1016/j.jcin.2011.03.018. PMID 21851896.
|access-date=requires|url=(help) - ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Xenogiannis I, Tajti P, Hall AB, Alaswad K, Rinfret S, Nicholson W; et al. (2019). "Update on cardiac catheterization in patients with prior coronary artery bypass graft surgery". JACC: Cardiovascular Interventions. 12 (17): 1635–1649. doi:10.1016/j.jcin.2019.04.051. PMID 31422085.
|access-date=requires|url=(help) - ↑ de Winter RW, Hoek R, Walsh SJ, Hanratty CG, Sprengers RW, Twisk JWR; et al. (2026). "PCI of native coronary artery vs saphenous vein graft after prior bypass surgery: a multicenter, randomized trial". Journal of the American College of Cardiology. 87 (3): 269–282. doi:10.1016/j.jacc.2025.09.1577. PMID 41159978 Check
|pmid=value (help).|access-date=requires|url=(help) - ↑ 9.0 9.1 9.2 Kolozsvari R, Galajda Z, Ungvari T, Szabo G, Racz I, Szerafin T; et al. (2012). "Various clinical scenarios leading to development of the string sign of the internal thoracic artery after coronary bypass surgery: the role of competitive flow, a case series". Journal of Cardiothoracic Surgery. 7: 12. doi:10.1186/1749-8090-7-12. PMID 22289632.
|access-date=requires|url=(help) - ↑ Siebenmann R, Egloff L, Hirzel H, Rothlin M, Studer M, Tartini R (1993). "The internal mammary artery 'string phenomenon': analysis of 10 cases". European Journal of Cardio-Thoracic Surgery. 7 (5): 235–238. doi:10.1016/1010-7940(93)90210-3.
|access-date=requires|url=(help) - ↑ Berger A, MacCarthy PA, Siebert U, Carlier S, Wijns W, Heyndrickx G; et al. (2004). "Long-term patency of internal mammary artery bypass grafts: relationship with preoperative severity of the native coronary artery stenosis". Circulation. 110 (11 Suppl 1). doi:10.1161/01.CIR.0000141256.05740.69.
|access-date=requires|url=(help) - ↑ 12.0 12.1 Jones DA, Beirne AM, Kelham M, Rathod KS, Andiapen M, Wynne L; et al. (2023). "Computed tomography cardiac angiography before invasive coronary angiography in patients with previous bypass surgery: the BYPASS-CTCA trial". Circulation. 148 (18): 1371–1380. doi:10.1161/CIRCULATIONAHA.123.064465.
|access-date=requires|url=(help) - ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Gruberg L, Dangas G, Mehran R, Hong MK, Waksman R, Mintz GS; et al. (2000). "Percutaneous revascularization of the internal mammary artery graft: short- and long-term outcomes". Journal of the American College of Cardiology. 35 (4): 944–948. doi:10.1016/S0735-1097(99)00652-X. PMID 10732892.
|access-date=requires|url=(help) - ↑ 14.0 14.1 14.2 Sharma AK, McGlynn S, Apple S, Pinnow E, Canos DA, Gevorkian N; et al. (2003). "Clinical outcomes following stent implantation in internal mammary artery grafts". Catheterization and Cardiovascular Interventions. 59 (4): 436–441. doi:10.1002/ccd.10580.
|access-date=requires|url=(help) - ↑ 15.0 15.1 Badr S, Dvir D, Waksman R (2013). "Distal anastomotic lesions after coronary artery bypass surgery: incidence, pathogenesis, and treatment approach". Catheterization and Cardiovascular Interventions. 81 (7): 1162–1168. doi:10.1002/ccd.24582.
|access-date=requires|url=(help) - ↑ 16.0 16.1 16.2 Jacq L, Lancelin B, Brenot P, Caussin C (2001). "Percutaneous transluminal angioplasty of ostial lesions of internal mammary artery grafts". Catheterization and Cardiovascular Interventions. 52 (3): 368–372. doi:10.1002/ccd.1084. PMID 11246255.
|access-date=requires|url=(help) - ↑ 17.0 17.1 17.2 Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM; et al. (2022). "2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check
|pmid=value (help).|access-date=requires|url=(help) - ↑ Nikolakopoulos I, Vemmou E, Xenogiannis I, Karacsonyi J, Rao SV, Romagnoli E; et al. (2022). "Radial versus femoral access in patients with coronary artery bypass surgery: frequentist and Bayesian meta-analysis". Catheterization and Cardiovascular Interventions. 99 (2): 462–471. doi:10.1002/ccd.30010. PMID 34779096 Check
|pmid=value (help).|access-date=requires|url=(help) - ↑ 19.0 19.1 Kim MH, Cha KS, Kim HJ, Kim JS (2001). "Bilateral selective internal mammary artery angiography via right radial approach: clinical experience with newly designed Yumiko catheter". Catheterization and Cardiovascular Interventions. 54 (1): 19–24. doi:10.1002/ccd.1232.
|access-date=requires|url=(help) - ↑ 20.0 20.1 Osler B, Fischman DL, Savage MP (2026). "Simplified technique for internal mammary artery bypass graft angiography from contralateral radial access using a guide extension catheter: a case series". Journal of the Society for Cardiovascular Angiography & Interventions. 5 (5): 105327. doi:10.1016/j.jscai.2026.105327.
|access-date=requires|url=(help) - ↑ 21.0 21.1 Vishnevsky A, Savage MP, Fischman DL (2018). "GuideLiner as guide catheter extension for the unreachable mammary bypass graft". Catheterization and Cardiovascular Interventions. 92 (6): 1138–1140. doi:10.1002/ccd.27592.
|access-date=requires|url=(help) - ↑ 22.0 22.1 Freixa X, Carpen M, Kotowycz MA, Ho KW, Krimly A, Osten MD; et al. (2012). "Long-term outcomes after percutaneous intervention of the internal thoracic artery anastomosis: the use of drug-eluting stents is associated with a higher need of repeat revascularization". Canadian Journal of Cardiology. 28 (4): 458–463. doi:10.1016/j.cjca.2012.01.020. PMID 22521296.
|access-date=requires|url=(help) - ↑ 23.0 23.1 Zavalloni D, Rossi ML, Scatturin M, Morenghi E, Soregaroli D, Municino A; et al. (2007). "Drug-eluting stents for the percutaneous treatment of the anastomosis of the left internal mammary graft to left anterior descending artery". Coronary Artery Disease. 18 (6): 495–500. doi:10.1097/MCA.0b013e3282cf4ba9. PMID 17700223.
|access-date=requires|url=(help) - ↑ 24.0 24.1 Buch AN, Xue Z, Gevorkian N, Torguson R, Fournadjieva J, Deible R; et al. (2006). "Comparison of outcomes between bare metal stents and drug-eluting stents for percutaneous revascularization of internal mammary grafts". American Journal of Cardiology. 98 (6): 722–724. doi:10.1016/j.amjcard.2006.03.058.
|access-date=requires|url=(help) - ↑ 25.0 25.1 Niccoli G, Biscione C, Conte M, Crea F (2007). "Long drug-eluting stent implantation for a diffusely diseased right internal mammary artery". Journal of Cardiovascular Medicine. 8 (5): 381–383. doi:10.2459/01.JCM.0000268129.82037.95. PMID 17443108.
|access-date=requires|url=(help) - ↑ 26.0 26.1 Yeo KK, Azarbal F, Zakroysky P, Dai D, Roe M, Wojdyla D; et al. (2020). "Differential longitudinal outcomes following percutaneous coronary intervention to the left internal mammary artery and other bypass grafts of the LAD: findings from the NCDR". Journal of Invasive Cardiology. 32 (6): E143–E150. doi:10.25270/jic/19.00486.
|access-date=requires|url=(help) - ↑ 27.0 27.1 Januszek RA, Dziewierz A, Siudak Z, Rakowski T, Dudek D, Bartuś S (2019). "Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts". Cardiology Journal. 26 (6): 633–644. doi:10.5603/CJ.a2018.0044.
|access-date=requires|url=(help) - ↑ Albiero R, Nishida T, Corvaja N, Vaghetti M, Di Mario C, Colombo A (2000). "Left internal mammary artery graft perforation repair using polytetrafluoroethylene-covered stents". Catheterization and Cardiovascular Interventions. 51 (1): 78–82.
|access-date=requires|url=(help) - ↑ Zanchetta M, Pedon L, Rigatelli G, Olivari Z, Zennaro M, Maiolino P (2004). "Pseudo-lesion of internal mammary artery graft and left anterior descending artery during percutaneous transluminal angioplasty". Angiology. 55 (4): 459–462. doi:10.1177/000331970405500415.
|access-date=requires|url=(help) - ↑ Gavrielatos G, Pappas LK, Anthopoulos P, Salachas A, Ifantis G, Antonellis I (2008). "Severe accordion effect: myocardial ischemia due to wire complication during percutaneous coronary intervention: a case report". Cases Journal. 1: 138. doi:10.1186/1757-1626-1-138.
|access-date=requires|url=(help)