The Fate of the Internal Mammary Artery Implant in the Ischaemic Human Heart  Arthur Vineberg, M.D., F.C.C.P., G.C. Mcmillan, M.D.  Diseases of the Chest  Volume 33, Issue 1, Pages 64-85 (January 1958) DOI: 10.1378/chest.33.1.64 Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 1A Digestion cast of implanted internal mammary artery made 12 days after implantation. Observe the fine arterial buds in tunnel. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 1B Digestion cast of implanted internal mammary artery made 7 months after implantation, and 5½ months after ligation of anterior descending branch left coronary artery (128B4). Measurement of diameter of casted mammary artery and arterial lumina by dissecting microscope: Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 2 Reproduction of drawing published by Bakst et al and Bailey, of internal mammary artery implant. Note how direction of tunnel is placed in different plane to internal mammary artery on chest wall, which favours angulation, narrowing, and final obliteration of implanted vessel. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 3A Microphotograph of animal No. 306, section 32 of internal mammary artery left in normal canine heart 2 years 5 months. Lumen 18% open, measuring approximately 0.4 mm. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 3B Microphotograph of animal No. 356, section 78 of internal mammary artery left in normal canine heart 1 year 8½ months. Artery lumen 25% open, measuring approximately 0.5 mm. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 3C Microphotograph of animal No. 6, 13 months after implantation into normal heart. Note 40% arterial lumen, measuring approximately 0.6 mm. at entrance to heart. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 4 Digestion cast of internal mammary artery made 5 months after implantation and 4 months after anterior descending branch ligation. Measurements by dissecting microscope showed lumina as follows: Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 5 Method of placing internal mammary artery in tunnel. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 6 Technique of pericardial fat pad graft. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 7 Microphotograph of human internal mammary artery lying within the myocardium 62 hours after implantation. Note open arterial lumen and absence of haematoma. There is little reaction surrounding the vessel other than a small zone of muscle necrosis. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 8 Microphotograph of human internal mammary artery 60 hours after implantation with second vessel alongside of it—presumably the 6th intercostal artery. Again there is no haematoma, and there is a small area of muscle necrosis about the implant. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 9 Standard method of injecting internal mammary artery through cannula in internal mammary artery. Injection mass returns through cannula placed in left coronary artery. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 10A Internal mammary artery in myocardium of human case of angina decubitus. This patient died 82 hours after implantation, from intractable bronchial spasm following penicillin injection. At autopsy, the internal mammary artery was injected with India ink. Note the slit in the arterial wall, with India ink in the space surrounding the vessel. There is no haematoma. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 10B Note India ink filling the arterioles within the myocardium distant to the implant. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 10C Same patient as in Figure 10A and B. C, note how the India ink is lying in large spaces between muscle bundle groups. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 10D These may be myocardial sinusoids filled with India ink. D, note how the India ink injected through the internal mammary artery has reached the capillaries which lie between muscle fibres. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 11 Microphotograph of internal mammary artery 96 hours after implantation into ischaemic heart. Note patent internal mammary artery containing India ink mixed with blood in its lumen. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 12 The above sketch indicates how the elevated left diaphragm tilts the apex of the heart, causing angulation of the implanted internal mammary artery. Angulation of artery resulted in thrombosis of vessel. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 13 Microphotograph of human internal mammary artery 10 days after implantation, with 6 day old thrombus (estimated age) occluding its lumen. Note relationship between peak of paralytic ileus 4 days post-operative and estimated 6 day age of thrombus. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 14 Microphotograph of section made through intramyocardial portion of same artery shown in Figure 13. Note artery in Figure 13 outside heart is thrombosed due to angulation, whereas same artery lying in heart shown above is patent. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15A Microphotographs of serial sections taken through implanted human internal mammary artery 18 months after implantation. Before tunnel. Here the internal mammary artery is seen lying on the surface of the left ventricular myocardium. It is flattened due to deep-freeze packaging which resulted in flattening of the entire specimen. It is widely open and shows little or no intimal proliferation, and the lumen contains India ink which was injected through the circumflex artery. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15B Entrance to Tunnel. The artery is seen at the beginning of the tunnel, widely open, with India ink in another myocardial vessel. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15C First 1/4 of tunnel. Shows artery branching within the myocardium. The branches contain India ink. Again there is no evidence of intimai proliferation. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15D First 1/3 of tunnel. In this area the artery breaks up into arteriolar branches and many almost cavernous-like cavities containing India ink. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15E Centre of tunnel. The artery can no longer be identified. It has broken up into numerous branches containing India ink, and two vessel complexes one of which slowly disappears when followed through the tunnel. The other continues branching and eventually reconstitutes itself as an artery. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15F Last quarter of tunnel. Here one sees the artery after reconstitution. It is open, still branching, and shows no evidence of intimai proliferation. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 15G End of tunnel. The artery is still open, and branching at the very end of the tunnel. It contains India ink which was injected, retrograde, through the circumflex artery. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions

Figure 16 Microphotograph of pericardial fat pad graft showing injection of vessels with India ink from retrograde circumflex artery injection. Diseases of the Chest 1958 33, 64-85DOI: (10.1378/chest.33.1.64) Copyright © 1958 The American College of Chest Physicians Terms and Conditions