Ann Thorac Surg 1996;61:1848-1849
© 1996 The Society of Thoracic Surgeons
How To Do It
Maximal Utilization of the Left Internal Mammary Artery for Coronary Bypass Grafting
Lawrence I. Bonchek, MD,
Mark W. Burlingame, MD,
Brad E. Vazales, MD,
Edward F. Lundy, MD, PhD
Mid-Atlantic Heart Institute at Lancaster General Hospital, Lancaster, Pennsylvania
Accepted for publication January 8, 1996.
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Abstract
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A technique is described for using the internal mammary artery to bypass the left anterior descending coronary artery and another adjacent coronary artery even when the alignment of the two vessels is not favorable for a conventional sequential graft. The distal end of the mammary artery is amputated and used to construct a Y graft to the anterior descending artery and to the secondary target vessel.
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Introduction
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The internal mammary artery (IMA) is universally accepted as the conduit of choice for coronary bypass grafting. Although the left IMA (LIMA) is most often used as a single bypass graft to a branch of the left coronary system, it may also be used as a sequential graft to two arteries, usually to the left anterior descending coronary artery (LAD) and to one of its diagonal branches. The preferred technique for the side-to-side anastomosis of a sequential graft is to align the LIMA parallel with the upper coronary artery so that the longitudinal incision in the side of the LIMA is parallel to the longitudinal incision in the coronary artery (Fig 1
). In some patients, however, the diagonal coronary artery arises from the LAD so far proximally, or diverges from it at such an obtuse angle, that the LIMA cannot reach both vessels sequentially even if the LIMA is routed posterior to the phrenic nerve or is used as a free graft. In other patients, there may be sufficient length for a sequential graft, but only with the LIMA perpendicular to the diagonal coronary artery, which mandates a ``diamond'' anastomosis. Although a perpendicular diamond anastomosis is easily done with a saphenous vein, it is much less desirable with an IMA because of the danger of distorting and narrowing the smaller IMA at the side-to-side anastomosis. To circumvent this problem and to allow use of the LIMA for more than one graft to the left coronary artery system when a conventional sequential graft is not feasible, we have used excess length from the terminal portion of the LIMA to construct a Y anastomosis to other branches of the left coronary artery system.
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Fig 1. . The preferred technique for a sequential left internal mammary artery graft side-to-side to a diagonal coronary artery and end-to-side to the left anterior descending coronary artery. The side-to-side anastomosis is done with the anastomosed segment of the left internal mammary artery parallel to the diagonal coronary artery.
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Technique
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If one wishes to use an arterial conduit to graft the LAD and an adjacent vessel, but a sequential LIMA graft is not feasible, the length of the LIMA needed for a pedicled graft to the LAD alone is ascertained. Excess length is usually obtainable by a combination of complete dissection of the LIMA pedicle proximally including division of the IMA vein if necessary, multiple fasciotomies of the LIMA pedicle, and proper positioning of the LIMA in a deep pericardial slit so the LIMA lies medial to the left upper lobe rather than anterior to it. In many cases, the Y-graft technique also allows the LAD to be grafted more proximally than would be possible with a sequential graft, thus further increasing the available excess length of the LIMA. The LIMA is dilated with intraluminal papaverine, and the excess terminal portion of the LIMA, which is often at least 3 cm in length, is resected. This segment is anastomosed end-to-side to the diagonal branch of the LAD, and the terminal end of the LIMA is then anastomosed end-to-side to the LAD. The proximal end of the short free segment of IMA is anastomosed to the side of the LIMA (Fig 2). The sequence of the distal anastomoses may be reversed for convenience and exposure, but the IMA-to-IMA anastomosis is done last, without aortic clamping, while the patient is being rewarmed. Occasionally, the resected distal segment of the LIMA is long enough to be used for a Y graft to a ramus intermedius branch (Fig 3).
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Fig 2. . The Y anastomosis is depicted. The excess terminal portion of the internal mammary artery is resected, and it is used to bypass a widely diverging diagonal branch of the left anterior descending coronary artery. Both distal anastomoses are longitudinal. See text for further details.
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Fig 3. . A Y graft in which the excess terminal segment of the left internal mammary artery is sufficient to reach a ramus intermedius coronary artery.
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Comment
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We have used this technique more than a dozen times over several years and have had no occasion to restudy a patient with this type of graft. Because these grafts are placed to the most essential coronary arteries, it seems reasonable to assume that occlusion of these grafts would have been clinically apparent.
Our approach is based on established principles that have been reported by others for somewhat different techniques, such as anastomosing the proximal end of saphenous veins [1] or the right IMA [2] to the side of the LIMA. Thus, the technical principles we describe have been proved to be sound, and are not unique. Indeed, we and others have also used the gastroepiploic artery, the inferior epigastric artery, or segments of the radial artery from the side of the IMA to branches of the left coronary system. The thrust of this report, however, is to point out that the LIMA pedicle alone should always be viewed as having the potential for more than one bypass, and surplus length should not be amputated unless it has no use.
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Footnotes
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Address reprint requests to Dr Bonchek, 555 N Duke St, PO Box 3555, Lancaster, PA 17604-3555.
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References
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- Mills NL. Physiologic and technical aspects of internal mammary artery coronary artery bypass grafts. In: Cohn LH, ed. Modern techniques in surgery. Cardiothoracic surgery. Mt. Kisco, NY: Futura, 1982;48:1–19.
- Tector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. Total revascularization with T grafts. Ann Thorac Surg 1994;57:33–9.[Abstract/Free Full Text]
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Abstract
Introduction
