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This 66 year old white man had had an inferior myocardial infarction and coronary artery bypass surgery (CABG) in 1980. He underwent five vessel CABG in 1980 for refractory angina with severe three vessel coronary artery disease. He received several saphenous vein grafts. The left internal mammary artery (LIMA) was sutured directly into the posterior left ventricular wall using the Vineberg technique.
He had been angina free since surgery in 1980; however, a decrease in exercise tolerance prompted exercise echocardiographic stress testing in 1999. The resting echocardiogram showed mild inferior hypokinesis. He exercised for 6 minutes 47 seconds on the standard Bruce protocol, stopping for fatigue. There were no ECG changes suggestive of ischaemia. Echocardiography following exercise showed inferior dyskinesis and anteroseptal hypokinesis with normal function of the posterolateral wall.
Coronary angiography demonstrated a 60% distal left main stenosis and occlusions of the proximal left anterior descending (LAD), left circumflex, and right coronary arteries. The saphenous vein graft to the obtuse marginal branch of the circumflex was occluded. The saphenous vein grafts to the LAD, diagonal, and posterior descending branch of the right coronary artery (PDA) were patent. There was high grade disease of the saphenous vein graft to the PDA. The LIMA to the myocardium was patent (A). A magnified view during LIMA angiography (B) showed collateral filling of the obtuse marginals (curved arrow) and PDA (straight arrow).
Promulgated by the Canadian surgeon Arthur Vineberg, implantation of the LIMA directly into the myocardial wall was performed in the 1960s. With the introduction of LIMA to coronary artery anastomosis toward the end of the decade, the Vineberg procedure was largely abandoned. This case demonstrates that 19 years following the Vineberg procedure, this patient still had a patent LIMA graft providing brisk collateral filling of the obtuse marginal and PDA. This graft is performing well, providing adequate blood flow to the posterolateral wall. The patient is currently feeling well continuing his antianginal medical regimen.