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Ann Thorac Surg 1996;61:771-772
© 1996 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Geisinger Medical Center, Danville, PA 17822-1343
To the Editor:
I read with great interest the article by Tixier and Acar [1], who reported using the radial artery graft as a coronary–coronary artery bypass graft for an obstructed right coronary artery, in a situation that is uncommon, because the radial artery is usually long enough to reach the posterior descending artery and the posterior ventricular branches, even when the anastomosis is performed in the distal portion of these vessels.
A similar technique has been described by Rowland and Grooters [2], using a vein graft from the proximal to the distal right coronary artery. Alternatively, an inferior epigastric artery may also be used as a coronary–coronary artery bypass graft. In 1991, my colleagues and I used an inferior epigastric artery as a coronary–coronary artery bypass graft, which was anastomosed proximally to the acute marginal artery, and distally to the posterior descending artery (Fig 1
). More recently, we used an inferior epigastric artery as a coronary–coronary artery bypass graft (from the acute marginal artery to a posterior left ventricular branch) in a 79-year-old patient with a heavily calcified ascending aorta, which precluded the safe application of a clamp in the aorta. The right gastroepiploic artery was used as an in-situ graft for the posterior descending artery, the left internal mammary artery for the anterior descending, and a radial artery graft was anastomosed proximally to the side of the left internal mammary artery, and distally to an obtuse marginal artery. The ``no-touch'' technique, with mild systemic hypothermia and intermittent fibrillatory arrest, was employed in our second patient [3]. Both patients have remained asymptomatic since the operation, and have not been restudied.
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Although we have used the radial artery graft very frequently during the past 3 years (205 patients between November 1992 and September 1995), and we believe that it is a very dependable conduit, especially in patients in whom the saphenous veins are inadequate or not available, we have been using it predominantly to bypass obstructive lesions in the circumflex artery and its branches [5]. In our experience, the length of the radial artery has not been a problem. Furthermore, the radial artery has a larger lumen and is easier to handle than the inferior epigastric artery, which we seldom use at present. Despite the improved patency rates observed in a recent series reported by Acar and associates [6], we consider the radial artery to be the third graft of choice because it is a free graft and may develop intimal hyperplasia, and because the long-term patency is yet unknown.
In summary, the technique described by Tixier and Acar is a reasonable option in patients with poor-quality or unavailable saphenous veins, if the ascending aorta is heavily calcified (to avoid aortic clamping) or if the radial artery graft was cut too short to reach from the aorta to the posterior descending artery. Different types of free arterial grafts, as well as vein grafts, may also be used as coronary–coronary artery bypass grafts as an alternative method of revascularization. However, they are only applicable to a small number of patients, because the coronary ostia are frequently diseased in patients with a heavily calcified ascending aorta. Under such circumstances, a pedicled right gastroepiploic artery graft is preferable to the right coronary artery or its branches. Even if the ascending aorta is free of disease, the in-situ right gastroepiploic artery is probably a better graft.
References
Department of Cardiovascular Surgery, Hopital Bichat, 46 Rue Henri-Huchard, 75018 Paris, France
To the Editor:
It is interesting to see that various types of conduits, and particularly arterial grafts, can be used successfully for coronary–coronary artery bypass. Just like Dietl, my colleagues and I believe that the pedicled internal mammary artery remains the graft of choice in coronary bypass grafting. The question raised is: which is the best arterial graft to complement the internal mammary artery? The gastroepiploic artery is a pedicled graft, which constitutes an obvious advantage over the radial artery. However, harvesting of the gastroepiploic artery requires a laparotomy, which necessarily implies a certain morbidity. In addition, its wall is thin and friable, making the anastomosis to a thick-walled right coronary artery more difficult. Furthermore, the diameter of the gastroepiploic artery is frequently smaller than that of the target coronary vessel, suggesting the possibility for segmental hypoperfusion. In our view, the sole disadvantage of the radial artery (ie, as a free graft) is widely overcome by the safety of its harvesting, the ease of the anastomosis thanks to its resistant vascular wall, and its good size match with the coronary vessels. At present, the radial artery has become our graft of choice for the right coronary system.
This article has been cited by other articles:
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  G. Ramasubrahmanyam, K. Venkata Ramana Raju, G. Nagasaina Rao, N. Varma N V, K. C. Venkateswara Rao, G. Usha Rani, and D. Prasada Rao Extrafascial Harvesting of Radial Artery for Coronary Artery Grafting Asian Cardiovasc Thorac Ann, September 1, 1999; 7(3): 252 - 253. [Abstract] [Full Text] [PDF]
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