Discussion
Intramyocardial course of a coronary artery is an inborn anomaly and
defined as the intramural location of the artery through the myocardium.
[8,9] According to pathological serious the prevalence of
intramyocardial course ranges from 5% to 86% [10,11] and from
0.5% to 33% in angiographic series [13-14]. E A Vanker et al,
observed IMLAD in 293 patients undergoing CABG out of 1349 and reported
the prevalence of IMLAD as 21.7%. [1] In our study, the prevalence
of the IMLAD in patients undergoing CABG was 13%.
Thanks to the advantages of revealing the properties of coronary artery
obstructive lesions, conventional CAG remains the gold standard imaging
procedure for the diagnoses of coronary artery diseases.[15,16] In
some of the CAG procedures, LAD is seen diving into the myocardium at an
acute angle and coming back to the epicardial layer following a variable
length of course composing a “wide-U” imaging(Cicekcioglu sign), which
is seen more clearly on the right anterior oblique position. This LAD
depression sign was observed to have a correlation with the
intraoperative detection of IMLAD.
In case of an IMLAD as a target artery to be bypassed, there may be
compelling situations for the surgeon in terms of distal anastomosing
process. There are several options for locating IMLAD during surgery.
One is “Blind dissection” which is applied by dissecting myocardium in
the epicardial region of the anterior interventricular groove. This
technique may cause a severe damage to the subepicardial myocardium
resulting with the perforation of the ventricles. [17-19] Another
solution is using the great cardiac vein, which usually has a course in
the epicardial fat and stays more superficially than the artery, as a
leading point. Using a coronary probe, which is inserted to the artery
from the distal visible part, is another technique. However, the risk of
perforating the coronary artery may cause serious intraoperative
morbidities. [20] Performing doppler ultrasound with a color doppler
microprobe, intraoperative fluorescence angiography and cineangiography
are other less invasive but respectively more expensive techniques for
locating IMLAD. [21-24]