Ann Thorac Surg 1996;62:293-295
© 1996 The Society of Thoracic Surgeons
How to Do It
Coronary Ostial Reconstruction
Paul D. Ridley, MD,
James D. Wisheart, MCh
Department of Cardiothoracic Surgery, Bristol Royal Infirmary, Bristol, England
Accepted for publication March 4, 1996.
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Abstract
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We describe a technique for surgical coronary ostioplasty in which the coronary ostia are opened at their obtuse, rather than acute, angle of insertion into the aortic wall.
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Introduction
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See also page 295.
We have successfully employed the technique of surgical coronary ostioplasty in 6 patients (5 left coronary, 1 right coronary). Adjunctive procedures were performed in 4 patients (2 aortic valve replacement, 2 coronary artery bypass grafting). The indication for surgical ostioplasty was atherosclerotic coronary artery disease in 2 patients and nonatherosclerotic disease in 4 (2 ankylosing spondylitis, 1 congenital associated with supraaortic stenosis, 1 coronary artery spasm).
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Technique
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Left Coronary Ostioplasty
A median sternotomy is employed to open the chest, and cardiopulmonary bypass is established using an ascending aortic cannula and two caval cannulas. The patient is cooled and, if the aortic valve is competent, cardioplegia is administered into the aortic root. In the presence of aortic regurgitation, cardioplegia is given directly into the coronary arteries using small cannulas. The aorta is opened with a transverse incision on the front of the ascending aorta and, instead of being carried into the noncoronary sinus as it would be for aortic valve replacement, it is extended posteriorly around the right side of the aorta and leftward across the posterior wall into the left coronary sinus. Left coronary ostial stenosis is confirmed by direct vision, and the aortotomy incision is extended into the left main coronary artery (Fig 1
). Insertion of a narrow probe into the left main coronary artery facilitates this step. When the ostium is opened the origin of the left anterior descending and circumflex coronary arteries can be seen and their patency confirmed. The incision in the left main coronary artery is extended to a point just proximal to this bifurcation. A vein patch is inserted with a running Prolene (Ethicon, Somerville, NJ) suture from the point just proximal to the bifurcation of the left main coronary artery across the ostium and for a distance of 2 cm across the posterior part of the aorta, where it is sutured into the aortotomy (Fig 2A). The rest of the aortotomy is then closed with Prolene (Fig 2B).
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Fig 1. . An anterior aortotomy is extended posteriorly to open the left main coronary artery at its obtuse insertion into the aorta.
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Fig 2. . (A) A patch of saphenous vein is used to enlarge the left coronary ostium. (B) The aorta is closed, incorporating the vein patch to enlarge the coronary ostium. This view is drawn as if seen from behind the aorta. The other figures are drawn as seen by the surgeon.
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Right Coronary Ostioplasty
A transverse aortotomy is employed to open the aorta. The coronary ostia are inspected and the presence of right ostial stenosis is confirmed. A fine probe is inserted into the right coronary artery. A "sloped T" incision is then made from the aortotomy inferiorly toward and extending across the ostium of the right coronary artery and for 1 cm along its first part, cutting down onto the probe positioned within the artery (Fig 3). A patch of saphenous vein is then sutured across the proximal right coronary artery and its ostium and brought up to the wall of the aortic root until the original transverse incision is reached (Fig 4A). The transverse aortotomy is then closed with Prolene (Fig 4B).
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Fig 3. . A transverse aortotomy is employed to open the aorta and a T-shaped extension is then made to open the right coronary artery at its obtuse insertion into the aorta.
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Fig 4. . (A) A patch of vein is used to enlarge the right coronary ostium. (B) The aorta is closed, incorporating the vein patch to enlarge the right coronary ostium.
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Comment
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Coronary ostial stenosis may be localized or part of a more widespread coronary atherosclerotic disease. Localized coronary ostial stenosis is usually associated with aortic wall disease and has been described as a feature of syphilis, Takayasu's aortitis, and as a congenital lesion. Localized ostial stenosis may also arise secondary to radiotherapy and after a cardiac operation with direct perfusion of cardioplegia into the coronary ostia. As shown in this report, surgical ostioplasty also can be used to manage localized ostial lesions associated with ankylosing spondylitis.
Angioplasty for the treatment of proximal coronary artery disease is not new. Historically, it was associated with a high mortality [1], but in the modern era its efficacy has been demonstrated [2, 3]. However, it remains a rare operation and its future role is unknown. Our present position is that surgical coronary ostioplasty should not be used for atherosclerotic coronary artery disease, which is effectively treated by coronary artery bypass grafting, but should be considered for use in those patients who have localized ostial stenosis from other causes. Thus it is used for the treatment of aortic wall rather than coronary artery disease.
A posterior approach is used for the left coronary ostium as, with an anterior approach, awkward access via the transverse sinus is necessary. Excessive traction on the pulmonary artery may result [4] or it may prove necessary to transect the main pulmonary artery [5]. We find the coronary ostia are best opened from their obtuse insertion into the aorta.
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Footnotes
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Address reprint requests to Mr Ridley, 56 Alfred Hill, Kingsdown, Bristol, England BS2 8HN.
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References
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- Favaloro RG, Effler DB, Groves LK, Sheldon WC, Shirey EK, Sones FM. Severe segmental obstruction of the left main coronary artery and its divisions: surgical treatment by the saphenous vein graft technique. J Thorac Cardiovasc Surg 1970;60:469–82.[Medline]
- Hitchcock JF, deMedina R, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease. J Thorac Cardiovasc Surg 1983;85:880–4.[Abstract]
- Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg 1990;99:241–50.[Abstract]
- Ghosh PK. Coronary ostial reconstruction: technical issues. Ann Thorac Surg 1991;51:673–5.[Abstract/Free Full Text]
- Gaudiani VA, Siegel SB, McIntosh-Yellin NL. Left main coronary artery reconstruction after radiation therapy. Ann Thorac Surg 1994;58:567–9.[Abstract/Free Full Text]
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Abstract
Introduction
