Reprinted from CIRCULATION
Vol. XXIII, No. 1, January, 1961
Printed in U.S.A.

Surgical Treatment of Angina Pectoris

By Micuareu E. Dr Bakery, M.D., anp Wa.TeR 8S. HENLy, M.D.

INCE Heberden’s classic description! of
the syndrome of angina pectoris in 1768,
considerable effort by medical investigators
has been directed toward this problem. Al-
though these studies have enriched the litera-
ture and have added to greater knowledge
and better understanding of the various as-
pects of coronary artery disease, the surgical
approach to the condition has remained in-
conclusive and controversial. A number of
factors probably account for this disputed
and uneertain status of the surgical treat-
ment of coronary artery disease. Among these,
perhaps the most important is the fact that
the natural course of the disease is often so
highly variable, not only among different
patients but even in the same patient at dif-
_ ferent periods, and may be greatly influenced
by many factors, both intrinsic and extrinsic,
as well as by medical therapy. It has long
been recognized, for example, that significant
coronary artery disease could be present at
necropsy with little disturbance of cardiac
activity during life. On the other hand, Sir
William Osler? made the observation more
than fifty years ago that in some fatal cases
of angina pectoris there was little alteration
in the heart or coronary arteries. Because of
these and other variables and the consequent
inability to provide a properly controlled
study, precise and accurate evaluation of the
clinical results of surgical therapy has been
extremely difficult.
The basic pathologic lesion in coronary
artery disease is atherosclerosis, which leads

ultimately to narrowing or occlusion of the

 

From the Cora and Webb Mading Department of
Surgery, Baylor University College of Medicine,
Houston, Texas.

Supported in part by grants from the American
Heart Association, Texas Heart Association, and
Houston Heart Association, and grants H-3137 and
HTS-5387 from the National Institutes of Health,
U. S. Pubhe Health Serviee. ?

Dr. Henly is an Established Investigator of the
American Heart Association.

Circulation, Volume XXIII, January 1961

lumen by progressive intimal thickening,
intimal ulceration, hemorrhage, or superim-
posed thrombosis. As a result of this occlusive
process, the myocardial circulation is reduced
to a variable degree, depending upon the na-
ture and extent of the lesion and the degree
to which interecoronary collateral vessel de-
velopment takes place. Serious disturbances
occur when the latter compensatory mecha-
nism fails to meet the ischemic changes pro-
duced by the atherosclerotic process. One or
more of the following effects may then take
place: angina pectoris, myocardial infarction,
or mechanism failure. Myocardial damage
leads to fibrosis, congestive failure, aneurysm
formation, ventricular septal defects, or ex-
ternal rupture.? These disturbances ultimately
lead to variable degrees of disability, invalid-
ism, and death.

Accordingly, surgical treatment of coro-
nary artery disease has been directed toward
relief of these adverse effects of coronary
arterial insufficiency. A number of different
methods and procedures have been proposed
and applied for this purpose, but in general
they may be classified as follows: (1) dener-
vation of the heart for the relief of angina
pectoris; (2) decreasing metabolic demands
on coronary circulation by thyroidectomy ;
and (3) improvement of arterial circulation
to the myocardium.

More than fifty years have elapsed since
the first surgical attack was made on angina
pectoris. This consisted in interruption of
eardiosensory and motor pathways to the
heart by sympathectomy, a procedure which
was originally suggested by Francois-Frank*
in 1899, and successfully performed by Jon-
nesco,® in 1916. While many experimental and
clinical investigations have since provided a
better understanding of the underlying ana-
tomie and physiologic principles of this
method of attack, its clinical value remains
uncertain. Anatomic and physiologic studies
have demonstrated that the sensory nerve
112

endings of the heart and aorta are present in
the myocardium, endocardium, and epicar-
dium, and in the adventitia of the coronary
arteries. The neurons to these sensory end-
ings converge in the periarterial plexus of
the coronary arteries, traverse the superficial
and deep cardiac plexuses, and course in the
middle and inferior cardiac nerves, which
join the corresponding cervical ganglia of
the sympathetic chain. Practically all of these
outbound fibers then descend to the upper
thoracic ganglia and finally reach their cells
in the spinal ganglia by passing through the
white rami communicantes into the central
portions of the first thoracic and upper four
or five intercostal nerves. The vasomotor
efferent or accelerator impulses to the heart
and coronary arteries differ from the sensory,
and their actions and pathways are not so
well understood. These pathways involve both
vagal and sympathetic nerves, but the exact
mechanism of their action in producing vaso-
constriction and vasodilatation has been diffi-
cult to determine precisely.

Three general methods have been employed
clinically to denervate the heart: (1) cervico-
thoracic ganglionectomy; (2) posterior rhiz-
otomy; and (3) paravertebral chemical
(aleohol) block of the upper four or five sym-
pathetic ganglia. A more accurate and lasting
effect is obtained by the first two procedures:
they require a major operation, however, and
are associated with an operative mortality of
about 8 to 10 per cent.® Good results in terms
of relief of pain, increase in work capacity,
and improvement of general condition have
been reported in 70 to 75 per cent of cases
fol'owing all these methods, but there is no
good evidence that survival expectancy is in-
ereased. It should be recalled that destruction
of cardiosensory nerves and the protective
alarm mechanism occurs concomitantly.

The procedure of total thyroidectomy to
decrease the metabolic demands of the body
for the treatment of coronary insufficiency is
now only of historical interest.’ It is of in-
terest to observe that in 1937 Parsons and
Purks,’ following a collection of tabulated
data from various sources, found that in a

DEBAKEY, HENLY

series of 133 cases in which thyroidectomy
was performed for angina pectoris excellent
results were obtained in 55 per cent and that
28 per cent were moderately improved. The
operative morta!ity was almost 4 per cent.
Hypothyroidism may be induced more easily
aud safely by the administration of radio-
active iodine.® Good results in relief of severe
angina pectoris have been reported in about
75 per cent of cases.!° 11 Final evaluation of
this therapeutic approach in terms of work
capacity and longevity remains to be deter-
mined,

Direct and indirect surgical methods de-
signed to improve the arterial circulation of
the myocardium have been developed follow-
ing a better understanding of the factors
underlying myocardial ‘ischemia. Certain
physiologic principles and pathologie changes
concerning coronary arteries are of consider-
able surgical importance. Functionally the
coronary arteries are largely ‘‘end arteries.’’
Although intercoronary communication may

- exist, collateral circulation from this source

is usually not sufficient to maintain viability
of the myocardium following sudden occlu-
sion of a major branch of a coronary artery.
In a slowly developing occlusive lesion, pro-
gressive increase in intercoronary collateral
channels may take place and provide some
protection to the ischemic segment of myo-
eardium. Although arteriosclerotic change
may be generalized, it commonly is segmen-
tal. Atheromata may occur anywhere in the
coronary arterial tree, but points of vessel
bifureation are sites of predilection. Fre-
quently the occluding lesion is segmental in
nature, is less than 5 mm. in length, and often
lies in the proximal larger arteries,12: 13
Distal'y, a thrombus may or may not be
present.

On the basis of these observations, investi-
gators have been encouraged to develop sur-
gical procedures designed to augment arterial
bloodfiow to the myocardium through increase
in intereoronary collateral circulation or by
restoring circulation in the involved coronary
artery. These various surgical methods may
thus be classified into two broad categories,

Circulation, Volume XXIII, January 1961
SYMPOSIUM ON CORONARY HEART DISEASE 113

namely, indirect and direct approaches.
Among the former, a number of different
procedures have been devised and employed
both experimentally and clinically to increase
coronary collateral circulation. These vary in
complexity from the simple placement of an
irritant such as tale or asbestos in the peri-
cardium’* or ligation of the internal mam-
mary arteries!®-!" to the grafting of various
vascular structures such as the pericardium,!®
omentum,’ pectoral muscles,2° lung,» 21: 22
and intestines*® to the myocardium; the im-
plantation of a systemic artery such as the
internal mammary artery into a tunnel in
the myocardium ;*4 and arterialization of the
coronary sinus.”° Perhaps the most popular
of these procedures is the Beck I operation,
or some modification of it, consisting in
abrasion of the epicardium by mechanical
or chemical (phenol) means, partial ligation
of the coronary sinus, the use of asbestos or
tale poudrage, and mediastinopexy. In a
series of 347 patients in which this type of
procedure was employed during a period of
approximately 4 years, Beck?® reported an
operative mortality of 6 per cent and a total
mortality after discharge from the hospital
of 9.2 per cent. Of the 295 patients who
were still living at the end of this period,
32 per cent were classified as having an
excellent result and 62 per cent a good result.
Using a somewhat similar procedure on 57
patients, Thompson and Plachta?" reported
an operative mortality of 12 per cent with
results classified as 90 per cent improved
in 50 per cent of the cases and 75 per cent
improved in 40 per cent of the cases. Advo-
cates of this procedure have been able to
demonstrate that it provides an increase in
the survival rate of dogs following ligation
of the anterior descending coronary artery
and have contended that this is due to in-
crease in intercoronary anastomoses. On the
other hand Gage and his associates,?* using
an experimental procedure that produced
gradual occlusion of the circumflex and ante-
rior descending branches of the left coronary
artery, were unable to demonstrate any bene-
ficial effects of poudrage in terms of a de-

Circulation, Volume XXIII, January 1961

crease or delay in mortality or a reduction
in incidence of gross infarction.

Particularly important in this connection
and in the critical evaluation of these indirect
revascularization procedures as emphasized
by these authors as well as by Gregg and
Sabiston”® is the concept of whether or not
they can produce an increase in collateral
circulation above that produced by the dis-
ease itself.

Second to the Beck I operation in clinical
popularity has been the bilateral ligation of
the internal mammary arteries, frequently
combined with’ poudrage or — retrosternal
neurolysis. This procedure was first suggested
by Fieschi in Italy in 193915 and employed
in a number of patients with coronary insuffi-
ciency by De Marchi, Battezzati, and Tag-
liaferro.16 The pericardiophrenic arteries
arising from the internal mammary arteries
supply a significant quantity of blood to
the pericardium and give origin to small
vessels to the posterior wall of the left
atrium. In necropsy preparations vascular
communications are demonstrable between
the internal mammary artery and the coro-
nary circulation. In this country Glover and
his associates!” 9° employed this technic in
the treatment of coronary arterial disease,
reporting relief of angina in 68 per cent of
patients with an operative mortality of 7
per cent. The simplicity of the procedure,
the variable course of the disease, and the
relatively low associated operative mortality
undoubtedly account for the widespread
acceptance of this procedure prior to ade-
quate clinical or experimental evidence that
this operation significantly altered myocardial
blood flow. Sabiston and Blalock®! and nu-
merous other investigators in experimental
studies have demonstrated no evidence of value
in internal mammary ligation. Even under
special laboratory conditions permitting an
inerease in flow in the ligated mammary arte-
ries, no significant increase in retrograde
coronary flow nor protection of the heart
against coronary arterial occlusion could be
demonstrated. The clinical results following |
sham operations, i.e., transection of the
114

sternum without mammary ligation, are as
good as those receiving the ligation.®”

In 1946 Vineberg®? first proposed, and later
he and other investigators demonstrated, that
if a systemic artery such as the carotid, sub-
clavian, or internal mammary artery were
implanted in a myocardial tunnel, the artery
would eventually form anastomoses with the
terminal branches of the coronary arteries.
These arteriolar communications tend to
occlude by intimal and medial thickening in
the normal heart; these obliterative changes,
however, do not take place in an ischemic
ventricle. Although these vascular channels
remain patent and undoubtedly conduct some
blood, flow studies have shown this magnitude
of flow to be disappointingly small.** *°
Vineberg®® in 1958 reported the results of
this procedure in 59 patients. In 17 patients
with angina pectoris at rest the operative
mortality was 59 per cent. In 40 patients
with less severe symptoms the operative mor-
tality was 5 per cent, with 78 per cent
markedly improved after surgery. The un-
predictable augmentation of myocardial blood
flow combined with the technical problems
associated with a suecessful operation has
prevented wide acceptance of this procedure
for the present.

It should be noted that, experimentally,
arterialization of the coronary sinus (the Beck
II operation) affords the most effective pro-
tection against ventricular fibrillation follow-
ing acute coronary occlusion.*° The anasto-
mosis of a systemic artery to the coronary
sinus is, however, fraught with many tech-
nical difficulties, requires a second procedure
to ligate the coronary sinus partially, and
clinically has had an operative mortality of
15 to 20 per cent. The resulting beneficial
hemodynamic changes are usually lost within
6 months after operation.

Numerous investigators have attempted to
graft richly vascularized tissues upon the
surface of the heart. At present it has been
difficult to demonstrate conclusively a signifi-
cant flow of b'ood from the graft to the heart
wall. Each worker has stressed the importance
of the epicardial barrier to these revasculari-

DeBAKEY, HENLY

zation procedures. Removal of the epicardium
by mechanical or chemical means allows for
better surface revascularization.?’ There is
no strong evidence that any of these vascular
pedicles significantly improves the myocardial
circulation. Attempts to. revascularize the
myocardium from within the ventricular
chamber by means of small plastic T tubes
imp'anted within the wall of the ventricle
have not justified clinical application.*®® °°

More recently, still another procedure has
been introduced by Day and hillehei,*® con-
sisting in the creation of a right-to-left shunt
by anastomosis between the pulmonary artery
and left atrium to lower arterial oxygen sat-
uration and thus utilize the stimulation of
hypoxia in the development of interecoronary
anastomosis. Experimentally they were able
to demonstrate a significant increase in inter-
coronary anastomosis within 1 month after
operation and reported dramatic improvement
in one patient in which this procedure was
used.

The direct surgical approach is aimed at
increasing arterial inflow through the coro-
nary arteries by removal of the occlusive le-
sion or by anastomosis of a systemic artery
to the coronary arteries distal to the occlu-
sion. This approach is based upon the dem-
onstration that patients with angina pectoris
not infrequently have partial or complete
occlusion of a major coronary artery in the
proximal portions of the vessel, which is seg-
mental in character with a relatively normal
distal arterial bed.'* In light of this evidence
and the fact that effective methods have been
developed for the treatment of similar seg-
mental occlusive lesions in peripheral vascu-
lar disease, it was only natural to consider
application of these procedures, such as re-
section and graft replacement, endarterec-
tomy, the bypass graft, and the patch graft
to segmental coronary occlusive disease. The
feasibility of utilizing these procedures has
been well demonstrated by an _ increasing
number of investigators in clinical studies as
well as in experimental animals.4!-*? In the
clinical application of these procedures par-
ticu'ar interest has been devoted to endarter-

Circulation, Volume XXIII, January 1961
SYMPOSIUM ON CORONARY HEART DISEASE 115

 

Figure 1
Photograph showing bypass Dacron graft between
aorta and left circumflex coronary artery in dog
that maintained coronary flow satisfactorily fol-
lowing ligation of left main coronary artery.

ectomy following the original report of Bailey
and associates** on its successful employment
in 2 patients. More recently Kattus and his
associates °° 56 have reported their observa-
tions on a series of 11 patients suffering from
incapacitating angina pectoris in which coro-
nary endarterectomy was performed. Among
the 5 patients surviving operation, results
were considered excellent in 2, good in 1, and
fait in 2.

Efforts to utilize the bypass graft principle
by some form of systemic-to-coronary artery
anastomosis have been predominantly, if not
completely, experimental in nature. Some of
the earliest attempts of this kind were re-
ported by Murray and his associates,®° who
utilized the carotid artery as a free o-aft
from the aorta to the left anterior descending
coronary artery. Among 17 dogs in which this
procedure was performed, 5 survived 21%
hours to 8 days without infarction. A higher
rate of successful resu'ts was more recently
reported by Thal and associates,®? who anas-
tomosed the left internal mammary artery to
the left circumflex coronary artery over a
glass cannula to permit blood flow during the
anastomosis. Fifty per cent of the animals

Circulation, Volume XXIII, January 1961

 

 

Figure 2

Coronary arteriogram made 24 hours after instal-
lation of bypass graft between aorta and left
circumflex coronary artery demonstrating patency
of anastomosis and filling of distal branches of
crcumflex artery.

survived the operation and the anastomoses
were found to be patent 2 to 6 months later
in 41 per cent. Somewhat similar results have
been obtained in our laboratory with use of
a knitted Dacron graft 3 to 5 mm. in diameter
attached proximally by end-to-side anastomo-
sis to the ascending aorta and distally by a
similar anastomosis to the left circumflex
coronary artery or the left anterior descend-
ing coronary artery with the use of a tem-
porary internal shunt (figs. 1-3). Following
completion of the anastomoses, the left main
coronary artery is ligated, leaving the left
ventricle dependent on the graft for its blood
supply. These grafts have functioned in about
oO per cent of the cases.

Another procedure that has been studied
experimentally in our laboratory is concerned
116

DEBAKEY, HENLY

 

Figure 3

Diagrams depicting (a) aorta-to-coronary artery bypass graft showing relationship
to heart and aorta; (b-d) technic of insertion of internal polyethylene shunt and tts
withdrawal upon completion of anastomosis and (e) maintenance of entire coronary
circulation by means of a trifurcated bypass graft.

with the use of the patch graft.°’ We have
used this procedure extensively in the sur-
gical treatment of other forms of well-local-
ized atherosclerotic occlusive disease with or
without endarterectomy, and it has been
found particularly valuable in lesions involv-
ing smaller arteries such as the internal
carotid, vertebral, and popliteal arteries.
These small patches of autogenous or syn-
thetic graft material provide replacement of
a sufficient part of the circumference of the
artery to permit restoration of a normal lu-
men following arteriotomy. Successful appli-
eation of this procedure to the coronary
artery of dogs has been demonstrated in our
laboratory (figs. 4-6). On this basis and from
our clinical experience with its use in other
small arteries, the patch graft would seem to
have some advantages in the treatment of cer-
tain forms of well-localized coronary artery
occlusive lesions.

It is thus apparent that a wide variety of
surgical procedures has been devised and
advocated for the purpose of improving myo-
cardial circulation. Extensive investigations
have also been done to evaluate the results
of these procedures. In general the experi-
mental design of most of these studies has
employed one or more of the following cri-
teria of benefit: (1) reduction in the amount
of myocardial damage or in mortality rate in
the group of animals having the experimental
‘‘protective’’ operation as compared with the
controls following occlusion of a test artery,
such as ligation of the left anterior descend-
ing coronary artery; (2) increase in retro-
grade coronary backflow in the experimen-
tally treated animals as compared with the
controls; and (3) morphologic evidence of
new vessel formation following the experi-
mental procedure. Evaluation of results of
clinical application of these various proce-

Circulation, Volume XXIII, January 1961
SYMPOSIUM ON CORONARY HEART DISEASE 117

 

Figure 4
Photographs illustrating (a) arteriotomy of left
circumflex coronary artery with internal polyethyl-
ene shunt in place.

dures has been based largely upon such eri-
teria as survival rate, symptomatic improve-
ment, and increased work or exercise capacity,
with the patient serving as his own control. A
wide range of operative mortality has been
reported for these various surgical approaches
from less than 5 per cent for the simpler pro-
eedures to over 50 per cent for the more
extensive operations.

Efforts to assess the relative value of these
various methods of surgical treatment of
coronary insufficiency are fraught with many
difficulties. As indicated previously, these are
due in large measure to the highly variable
course of the disease and to lack of precise
and accurate criteria of benefit. Particularly
striking is the remarkable similarity in the
clinical results following these widely varying
methods as reported by their respective ad-
vocates. This would suggest that they all
possess some common factor or mechanism
other than improvement in coronary circula-
tion. This is well exemplified by the subse-
quent demonstration in well-controlled stud-
ies that certain procedures, such as ligation
of the internal mammary artery, do not in-

Circulation, Volume XXIII, January 1961

 

Figure 5
Appearance of vessel (fig. 4) after closure of ar-
tery with use of Dacron patch graft to avoid
constriction of lumen.

 

Figure 6
Diagrams (a-d) depicting technical aspects of
arterial repair of circumflex coronary artery with
aid of internal shunt and small Dacron patch graft.

crease circulation.®°® Obviously the major
difficulty in the critical evaluation of these
methods of surgical treatment clinically lies
in the lack of precise and accurate methods of
demonstrating increased myocardial flow.®® ®

Despite these considerations there are rea-
sons to believe that the surgical approach to
this problem offers some promise.*! Certainly
for the relief of intractable pain uncontrolled
by medical means, surgical methods by one
of the simpler procedures, such as neurectomy
118

or chemical or mechanical de-epicardializa-
tion, may be employed with a low operative
risk and high incidence of relief of pain. The
most meaningful surgical approach to this
problem, however, would seem to lie in those
procedures designed to restore normal blood
flow in the obstructed segment of the coro-
nary arterial tree by methods, such as endar-
terectomy, bypass graft, or patch graft, that
have proved so effective elsewhere. Better
general acceptance and more widespread clin-
ical application of these methods, however,
await further developments along certain
lines including particularly proper selection
of patients for this purpose, diminution in
the risk of operation, and good evidence of
long-term maintenance of restored circula-
tion. Precise and accurate localization of the
lesion is probably the most important factor
in proper selection of patients for operation.
While certain tests may be of indicative value
in this regard, in the final analysis angiog-
raphy is absolutely essential for this pur-
pose.®*-®! For this reason recent developments
providing safer and improved methods of
coronary arteriography are most encourag-
ing. "1 Ready application of coronary arte-
riography will not only be of great value in
the preoperative selection of patients for
operation but will also provide more precise
and accurate evaluation of the operative pro-
cedure by subsequent visualization of the
coronary arterial tree. Progressive develop-
ments along these lines and increasing experi-
ence gained with application of these surgical
procedures in segmental occlusive lesions in
other small arteries should permit further
refinements in technic and improvements in
surgical management which would lower the
operative risk to acceptable levels. There are
sufficiently encouraging reasons to_ believe,
therefore, that more intensive investigations
of this approach toward relief of coronary
occlusive disease are fully justified.

References
1. HEBERDEN, W.: Some account of a disorder of the
breast. M. Tr. College Physicians 2: 59, 1768.
2. OSLER, W.: The Lumleian lectures on angina
pectoris. Lancet p. 839, 1910.

10.

ii;

12.

13.

14,

15.

DEBAKEY, HENLY |

Cootry, D. A., Henty, W. S., Amap, K. H., anp
CHAPMAN, D. W.: Ventricular aneurysm fol-
lowing myocardial infarction: Results of sur-
gical treatment. Ann. Surg. 150: 595, 1959.

FRANGOIS-FRANK, ©. E.: Signification physio-
logique de la resection du Sympathique dans
la maladie de Basedow, 1’epilepsie, 1’idiotie
et le glaucome. Bull. Acad. de méd., Paris, 3
Serie, 41: 565, 1899.

JONNESCO, T.: Traitement chirurgical de l’angine
de poitrine par la resection du sympathique
cervico-thoracic. Bull. Acad. de méd. 84: 93,
1920.

OCHSNER, A., AND DEBAKEY, M. E.: The surgical
treatment of coronary disease. Surgery 2: 478,
1937.

BiuMeaArt, H. L., Levine, 8S. A., AND BERLIN,
D. D.: Congestive heart failure and angina
pectoris. The therapeutic effect of thyroidec-
tomy on patients without clinical or pathologie
evidence of thyroid activity. Arch. Int. Med.
51: 866, 1933.

PARSONS, W., AND PurKs, W. K.: Total thy-
roidectomy for heart disease. Ann. Surg. 105:
722, 1937.

Buum@ArT, H. L., FREEpDBERG, A. S., AND BuxKa,
R. B.: Treatment of euthyroid cardiac patients
by producing myxedema with radioactive
iodine. Proc. Soe. Exper. Biol. & Med. 67:
190, 1948.

BuLuMGART, H. L., FREEDBERG, A. S., AND KuR-
LAND, G. S.: Hypothyroidism produced by
radioactive iodine (I) in the treatment of
euthyroid patients with angina pectoris and
congestive heart failure. Circulation 1: 1105,
1950.

BLuMGART, H. L., FREEDBERG, A. S., AND KuR-
LAND, G. 8.: Treatment of incapacitated euthy-
roid eardiae patients with radioactive iodine.
J.A.M.A. 157; 3; 1955.

BLUMGART, H. L., SCHLESINGER, M. J., AND
Davis, D.: Studies on relation of clinical mani-
festations of angina pectoris, coronary throm-
bosis, and myocardial infaretion to pathologic
findings, with particular reference to signifi-
eance of collateral circulation. Am. Heart J.
19: 1, 3940,

SzILAGYI, D. E., McDoNnaLp, R. T., AND FRANCE,
L. C.: The applicability of angioplastie pro--
cedures in coronary atherosclerosis: An esti-
mate through postmortem injection studies.
Ann. Surg. 148: 447, 1958.

THOMPSON, 8S. A.: Development of cardio-peri-
cardial adhesions following the use of tale.
Proc. Soc. Exper. Biol. & Med. 40: 260, 1939.

BATTEZZATI, M., TAGLIAFERRO, A., AND DE MARCHI,
G.: The ligature of the two internal mammary

Circulation, Volume XXIII, January 1961
SYMPOSIUM ON CORONARY HEART DISEASE

16.

rg

18.

19;

20.

21.

22.

23.

24.

25.

26.

28.

29.

arteries in disorders of vascularization of the
myocardium. Minerva med. 46: 1173, 1955.

DE Marcui, G., BaTTezzatt, M., AND TAGLIAFERRO,
A.: Influenze della legature delle arterie mam-
marie interne sulla insufficienza miocardia.
Minerva med. 47: 1184, 1956.

Ghoves,- ho P., “Davina, Je C° Kyias“®. #.,
BearD, J. C., Trout, R. A., ann KivcHett,
J. R.: Ligation of the internal mammary
arteries as a means of increasing blood supply
to the myocardium. J. Thoracic Surg. 34:
661, 1957.

THomMpsoN, S. A., AND Raispeck, M. J.: Cardio-
pericardiopexy; the surgical treatment of
coronary arterial disease by the establishment
of adhesive pericarditis. Ann. Int. Med. 16:
495, 1942. :

O’SHAUGHNESSY, L., Stomge, D., AND WATSON,
F.: Surgical revascularization of the heart;
experimental basis. Lancet 1: 617, 1939.

Baxst, A. A., Boury, S. J., Morsz, W., AND
LoEwrE, L.: Experimental surgical treatment
of pedicled pectoral muscle grafts. Angiology
8: 308, 1957.

Kung, J. L., Stern, H., Bloomer, W. E., AND
Lizespow, A. A.: The application of an induced
bronchial collateral cireulation to the coronary
arteries by cardiopneumopexy. I. Anatomical
observations. Am. J. Path. 32: 663, 1956.

GARAMELLA, J. J., GrorGE, V. P., ANDERSEN,
J. G., Dirmanson, M. L., anp Hay, L. J.:
Modified cardiopneumopexy employing pul-
monary segmental resection: A  wmortality-
infaret study. Ann. Surg. 146: 864, 1957.

Key, J. A., Kerein, F. G., Martineau, Y., AND
LECKEY, R. G.: A method of supplementing
the coronary circulation by a jejunal pedicle
graft. J. Thoracic Surg. 28: 320, 1954.

VINEBERG, A., AND WALKER, J.: Six months’ to
six years’ experience with coronary artery
insufficiency treated by internal mammary
implantation. Am. Heart J. 54: 851, 1957.

Beck, C. S., aND LEIGHNINGER, D. S.: Operations
for coronary artery disease. J.A.M.A. 156:
1226, 1954.

—: Coronary heart disease after twenty-five
years. J. Thoracic Surg. 36: 329, 1958.

THOMPSON, 8S. A., AND Puacnta, H.: Fourteen
years’ experience with eardiopexy in the treat-
ment of coronary artery disease. J. Thoracic
Surg. 27: 64, 1951.

Gack, A. A., Ouson, K. C., AND CHARDACK,
W. M.: Cardiopericardiopexy. An experimental
evaluation. Ann. Surg. 147: 289, 1958.

Greece, D. E., AND SaBIsTON, D. C., Jr.: Current
research and problems of the coronary cireu-
lation. Circulation 13: 916, 1956.

Circulation, Volume XXIII, January 1961

30.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

119

KITCHELL, J. R., GLOVER, R. P., anD Kyte, R. H.:
Bilateral internal mammary artery ligation for
angina pectoris. Am. J. Cardiol. 1: 46, 1958.

SABISTON, D. C., JR., AND BLALocK, A.: Experi-
mental ligation of the internal mammary artery

and its effect on coronary occlusion. Surgery
43: 9, 1958.

Dimonp, E. G., Kirriz, C. F., Crockert, J. E.,
AND Ropriaurez, L. M.: A elinical study of
internal mammary ligation for angina pectoris
with sham operations. Presented at Seventh
Annual Meeting, American College of Cardi-
ology, St. Louis, Missouri, May 22, 1958.

VINEBERG, A. M.: Development of anastomosis
between coronary vessels and _ transplanted
internal mammary artery. Canad. M.A.J. 55:
117, 1946.

Baxkst, A. A., MAniauia, R., ADAM, A., AND
BaILeEy, C. P.: The physiologic and pathologie
evaluation of the implantation of the internal
mammary artery into the left ventricular myo-
eardium for the treatment of coronary artery
disease. Surgery 38: 349, 1955.

SABISTON, .D.: C., -JR.,° Fautevx, J. \P..° ann
BuaLock, A.: An experimental study of the
fate of arterial implants in the left ventricular
myocardium. Ann. Surg. 145: 927, 1957.

VINEBERG, A. M.: Coronary vascular anastomosis
by internal mammary artery implantation.
Canad. M.A.J. 78: 871, 1958.

HARKEN, D. E., Buack, H., Dickson, J. F., III,
AND WILSON, H. E., III: De-epicardialization:
Simple, effective surgical treatment for angina
pectoris. Circulation 12: 955, 1955.

GOLDMAN, A., GREENSTONE, S .M., Preuss, F. S.,
Strauss. 8. H., anp Coane, EN-SHuU: Experi-
mental methods for producing a_ collateral
circulation to the left heart directly from the
left ventricle. J. Thoracic Surg. 31: 364, 1956.

Massimo, C., AND Borri, L.: Myocardial revas-
cularization by a new method of carrying blood
directly from the left ventricular cavity into
the coronary circulation. J. Thoracic Surg.
34: 257, 1957.

Day, S. B., AND LILLEHEI, C. W.: Experimental
basis for a new operation for coronary artery
disease; a left atrial-pulmonary artery shunt
to encourage the development of interarterial
intercoronary anastomoses. Surgery 45: 487,
1959.

ABSOLON, K. B., Aust, J. B., Varco, R. L., AND
LILLEHEI, C. W.: Surgical treatment of oeclu-
Sive coronary artery disease by endarterectomy
or anastomotic replacement. Surg., Gynec. &
Obst. 103: 180, 1956.

BAKER, N. H., AND GRINDLAY, J. H.: Technic of
experimental systemic-to-coronary-artery anas-
120

43.

44,

45.

46.

47.

48.

49.

50.

ol.

52.

53.

54,

55.

56.

57.

tomosis. Proce. Staff Meet., Mayo Clin. 34:
497, 1959.

CANNON, J. A., LONGMIRE, W. P.; AND KATTUS,
A. A.: Considerations of the rationale and

technique of coronary endarterectomy for
angina pectoris. Surgery 46: 197, 1959.

CARTER, E. L., AND Rotu, E. J.: Direct non-suture
coronary artery anastomosis in the dog. Ann.
Surg. 148: 212, 1958.

GOTTESMAN, L.: Direct surgical relief of coronary
artery occlusion. Am. J. Cardiol. 2: 315, 1958.

HAEGER, K.: Collateral coronary circulation
produced by plastic prosthesis. An experimental
study. Acta chir. scandinav. 16: 196, 1959.

LONGMIRE, W. P., JR., CANNON, J. A., AND
Kartus, A. A.: The surgical treatment of
angina pectoris. Arch. Int. Med. 104: 886,
1959.

May, A. M., AND BAILEY, CO. P:: Coronary en-
darterectomy. J. Internat. Coll. Surg. 29: 160,
1958.

Moorgt, T. C., AND RIBERI, A.: Maintenance of
coronary circulation during systemic-to-coronary
artery anastomosis. Surgery 43: 245, 1958. —

MurRAY, G.: Resection of atheromatous segments
of coronary arteries and graft replacement.
Read before Congress of International College
of Angiology, Lisbon, Portugal, September
1953.

MurRRAY, G., PORCHERON, R., MHILARIO, J.,
AND ROSCHLAU, W.: Anastomosis of a systemic
artery to the coronary. Canad. M.A.J. 71: 594,
1954.

SABISTON, D. C., JR.: Coronary endarterectomy.
Am. Surg. 26: 219, 1960.

THAL, A. Pi. Perry, J. F., Jk. Minute, fF. A,
AND WANGENSTEEN, O. H.: Direct suture
anastomosis of the coronary arteries in the
dog. Surgery 40: 1023, 1956.

BAILEY, C. P., May, A., AND LEMMON, W. M.:
Survival after coronary endarterectomy in man.
J.A.M.A. 164: 641, 1957.

Kattus, A. A., LONGMIRE, W. P., JR., CANNON,
J. A., WINFIELD, M. E., anp Davis, J. H.:
Diagnostic and functional evaluation of candi-
dates for coronary endarterectomy. Arch. Int.
Med. 104: 870, 1959.

LONGMIRE, W. P., JR., CANNON, J. A., AND
Kattus, A. A.: Direct-vision coronary endar-
terectomy for angina pectoris. New England
J. Med. 259: 993, 1958.

CRAWFORD, E. S., BEALL, A. C., JR., ELLIS, P. R.,
JR., AND DEBAKEY, M. E.: A technic per-
mitting operation upon small arteries. Surg.
Forum, Am. Coll. Surg. 10: 671, 1960.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

vi.

DrBAKEY, HENLY

ADAMS, R.: Internal mammary artery ligation
for coronary insufficiency. New England J.
Med. 258: 1138, 1958.

ECKENHOFF, J. E., HAFKENSCHIEL, J. H., Har-
MEL, M. H., GOODALE, W. T., LUBIN, M., BING,
R. J., AND Kety, S. S.: Measurement of coro-
nary blood flow by the nitrous oxide method.
Am. J. Physiol. 152: 356, 1948.

SEVELIUS, G., AND JOHNSON, P. C.: Myocardial
blood flow determined by surface counting and
ratio formula. J. Lab. & Clin. Med. 54: 669,
1959.

BLALOocK, A., AND SABISTON, D. C., JR.: The
coronary artery disease problem. Western J.
Surg., Obst. & Gynec. 67: 18, 1959.

Hoyos, J. M., anp Det Campo, C. G.: Angiog-
raphy of the thoracic aorta and coronary
vessels, with direct injection of an opaque
solution into the aorta. Radiology 50: 211,
1948.

JONSSON, G.: Visualization of the coronary
arteries. Acta radiol. 29: 536, 1948.

RADNER, S.: An attempt at the roentgenologic
visualization of the coronary blood vessels in
man. Acta radiol. 26: 497, 1945.

Di GUGLIELMO, L., AND GurTTapAuRO, M.: A
roentgenologiec study of the coronary arteries
in the living. Acta radiol., Suppl., 97: 1, 1952.

HELMSwWoRTH, J. A., McGuire, J., AND FELSON,
B.: Arteriography of the aorta and its branches
by means of the polyethylene catheter. Am.
J. Roentgenol. 64: 196, 1950.

MiIuuER, E. W., Kourr, W. J., AND HUGHES, C. R.:
Angiography of the coronary arteries in dogs.
ITI. During perfusion with a heart-lung ma-
chine in combination with cardiac arrest in
coronary artery surgery. Cleveland Clin. Quart.
24: 1238, 1957.

Sones: F. M., Jk, Suirny, EB. K.,° Provuprit,
W. L., AND Westcott, R. N.: Cine-coronary
arteriography. Proceedings of the 32nd Scien-
tific Sessions, American Heart Association.
Philadelphia, 1959, p. 773.

THaL, A. P., LESTER, R., RicHarps, L. 8., AND
Murray, J.: Coronary arteriography in arterio-
sclerotic disease of the heart. Surg., Gynec.
& Obst. 105: 457, 1957.

THaL, A. P., RicHarpDs, L. S., GREENSPAN, R.,
AND Murray, M. J.: Arteriographic studies of
the coronary arteries in ischemic heart disease.
J.A.M.A. 168: 2104, 1958.

WEstT, J. W., AND GuzMAN, S. V.: Coronary
dilatation and constriction visualized by selee-
tive arteriography. Circulation Research 7:
527, 1959.

Circulation, Volume XXIII, January 1961