A classification is presented of anomalies involving the coronary sinus. These anomalies are classified into four anatomic groups on the basis of (1) enlargement of the coronary sinus, (2) absence of the coronary sinus, (3) atresia of the right atrial coronary sinus ostium, and (4) hypoplasia of the coronary sinus. Anomalies involving the coronary sinus often are associated with other venous anomalies, either of the systemic or the pulmonary circulation. In some there is no basic disturbance of the circulation. Those conditions involving the coronary sinus which are of major functional significance participate in shunts, either left-to-right or right-to-left in nature. Enlargement of the coronary sinus in the absence of a shunt usually indicates that a systemic venous channel joins the coronary sinus anomalously.
We studied the patency of saphenous vein aortocoronary bypass grafts in nonconsecutive and consecutive subgroups of our first 600 patients. The patency rates were 87-93% within 1 month and 74-85% approximately 1 year after surgery. The attrition rate of grafts averaged 2.2% per year between 1 and 6 years. Early occlusion was due to thrombosis; occlusion at 1 year was caused by fibrous intimal proliferation of grafts, which also led to variable reduction in caliber and to significant (greater than 50%) segmental stenoses in 5-15% of patent grafts. The most important determinant of graft patency at 1 year was the runoff capacity of the recipient arteries, followed by the quality of the surgical techniques. Late occlusion was related to atherosclerosis that became manifest only after at least 2 years. Coronary atherosclerosis progressed in more than 50% of proximal segments of grafted arteries during the first year, but little additional deterioration occurred between 1 and 6 years. During the first year, only 10% of preexisting stenoses in nongrafted arteries showed progression of disease; progression in these vessels increased to 46% at 6 years and was no longer different, for preexisting lesions greater than 50%, from that of grafted arteries. A close correlation was observed between changes in grafts and in coronary arteries and long-term survival or relief of angina. Ninety-four percent of patients with all grafts patent and 98% with an optimal correction were alive at 6 years compared with 70% of patients without patent grafts or surgical correction. Changes in grafts or coronary arteries were observed in two-thirds of patients in whom functional deterioration occurred between 1 and 6 years, compared with 18% in whom improvement persisted after surgery.
In 28 consecutive patients who died following coronary artery grafting and within 30 days of a previous coronary cineangiogram, a study was undertaken to compare the findings at autopsy and those at angiography. In five instances, such a comparison could not be made: in one instance, no postmortem examination was obtained, and in four additional cases, the quality of the cineangiographic document (three instances) or the pathological specimen (one instance) did not permit a reliable comparison. In the remaining 23 cases, there were nine specimens in which an appreciable difference (≥ 25%) was noted in the severity of the coronary artery lesions. In four of these nine cases, failure of cineangiography to assess the degree of coronary arterial narrowing led to incomplete myocardial revascularization and contributed, in retrospect, to the surgical failure. Most discrepancies occurred in the left coronary artery system, despite the fact that in all instances, four projections had been obtained of the left coronary artery in the transverse plane. Because of the particular orientation of the initial portion of the left coronary artery and its major divisions, it is recommended that additional projections in the sagittal plane be included to eliminate angiographic superimposition of multiple branches, which often cannot be properly separated in the standard transverse plane.
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