Ann Thorac Surg 1996;62:901-902
© 1996 The Society of Thoracic Surgeons
Case Report
Radial Artery From Left Subclavian Artery in Redo Coronary Artery Bypass Grafting
Antonio M. Calafiore, MD,
Hisayoshi Suma, MD
Department of Cardiac Surgery, University "G. D'Annunzio," Chieti, Italy
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Abstract
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In redo coronary artery bypass grafting a left anterior thoracotomy can be used, if necessary, to avoid a dangerous repeat median sternotomy. In 2 patients with a well-functioning left internal mammary artery graft to a left anterior descending artery attached to the sternum, a radial artery was used with the left subclavian artery as the blood source. This technique can be used successfully in selected cases when a left thoracotomy is advisable and an arterial graft is preferred to a saphenous vein.
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Introduction
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In redo coronary artery bypass grafting (CABG), one or more arterial conduits can be used in the great majority of the patients [1]. When a previously implanted left internal mammary artery (LIMA) is patent and adherent to the sternum with a LIMA-dependent left anterior descending artery, a repeat sternotomy becomes dangerous, as any injury to the graft can cause the patient's death. A left anterolateral thoracotomy is then advisable [2]. However, the possibility of using an in situ graft is limited with this approach.
We herein report 2 patients, operated on at the Division of Cardiac Surgery of the University of Chieti, who underwent repeat CABG via a left thoracotomy in which a left radial artery, proximally anastomosed to a left subclavian artery, was used.
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Case Reports
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Patient 1
A 53-year-old man had a previous CABG in 1988 for effort angina after an inferior myocardial infarct. For return of angina, he underwent a repeat angiography, which showed a patent LIMA on a LIMA-dependent left anterior descending artery and the occlusion of the two venous grafts on an important obtuse marginal branch (OM) and on a small and diseased posterior descending artery. A diagonal branch also had a severe stenosis at the origin. The left ventricular function deteriorated, as the ejection fraction decreased from 0.51 to 0.35.
As the angiography showed that the LIMA was attached to the sternum, the patient was reoperated on via a left anterolateral thoracotomy. The femoral vessels were exposed and the left radial artery was harvested as previously described [3]. The chest was opened and the pericardial adhesions were dissected. The OM and diagonal branches were found, whereas the posterior descending artery was not scheduled for a new graft. A segment of saphenous vein was harvested and the femoral vessels were cannulated after systemic heparinization. The body temperature was lowered to 25°C; during this time, the left subclavian artery was isolated and clamped by means of a side clamp, and the proximal anastomosis of the radial artery was performed using a 6/0 Prolene (Ethicon, Somerville, NJ) suture. As the anastomotic site was located before the LIMA origin, the occlusion of the subclavian artery, even if partial, could reduce critically the flow in the LIMA and then in the left anterior descending artery. For this reason the construction of the proximal anastomosis during the cooling time was mandatory. When the scheduled temperature was reached, cardiopulmonary bypass was temporarily discontinued, the OM branch incised, and the distal anastomosis performed using an 8/0 Prolene suture. Cardiopulmonary bypass was reestablished, and the proximal anastomosis of the saphenous vein was performed on the descending thoracic aorta with the aid of a side clamp. Cardiopulmonary bypass was then again arrested, and the distal anastomosis on the diagonal branch was performed. The patient was then rewarmed, the heart defibrillated, and the operation concluded as usual. The two periods of circulatory arrest lasted 8 minutes 30 seconds and 9 minutes 30 seconds, respectively, separated by a reperfusion time of 6 minutes 30 seconds; the cardiopulmonary bypass time was 125 minutes.
The postoperative course was uneventful. Early postoperative angiography showed well patent grafts. Twelve months later the patient was asymptomatic, angiography showed patent grafts (Fig 1
), and the ejection fraction increased to 0.45.
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Fig 1.. The radial artery (RA) arises from the left subclavian artery before the origin of the left internal mammary artery (LIMA) (A) and goes to the obtuse marginal (OM) branch of the circumflex artery (B).
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Patient 2
A 53-year-old patient had a previous CABG in 1992 for effort angina after an inferior myocardial infarct. For return of angina after minimal effort he underwent angiography, which showed a patent LIMA to a LIMA-dependent left anterior descending artery and the proximal occlusion of a segment of saphenous vein grafted, sequentially, to a small first OM branch, to an important second OM branch, and to a small and diseased posterior descending artery. As the LIMA was clearly attached to the sternum, the same operation as in the previous patient was scheduled. A single graft was used, a left radial artery from the left subclavian artery to the second OM branch. The period of circulatory arrest lasted 17 minutes, and the cardiopulmonary bypass time lasted 81 minutes.
The postoperative course was uneventful. Early postoperative angiography showed a well patent radial artery on the OM. Ten months later the patient was asymptomatic, and angiography showed a widely patent radial artery.
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Comment
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Use of the radial artery, which can only be used as a free arterial graft, has recently been revived [4]. We suggested avoidance of the use of the proximal anastomosis on the ascending aorta as the wall stress at the aortic level is higher of that in the native position of the artery [5]. Moreover, there is a mismatch between aortic and radial walls, and the ascending aorta is often diseased [6, 7]. The technique described by us [6, 7] uses an internal mammary artery as the blood source; this is not possible in redo CABG via a left thoracotomy if the LIMA was used previously. The choice of the left subclavian artery as the proximal anastomotic site offers many advantages: this artery is less diseased than the descending thoracic aorta, it is easy to reach, and its wall stress is similar to that of the LIMA. Circulatory arrest, as proposed by Suma and associates [2], makes the distal anastomosis easy.
The technique described by us can be used every time a left thoracotomy is a reasonable option for repeat CABG and the use of an arterial graft is advisable. Moreover, the radial artery can become a new blood source for other arterial free grafts, like the inferior epigastric artery or a free right gastroepiploic artery, if a more complex arterial revascularization is required.
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References
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- Galbut DL, Traad EA, Dorman MJ, et al. Bilateral internal mammary artery grafts in reoperative and primary coronary bypass surgery. Ann Thorac Surg1991;52:20–8.[Abstract]
- Suma H, Kigawa I, Horii T, Tanaka J, Fukuda S, Wanibuchi Y. Coronary artery reoperation through the left thoracotomy with hypothermic circulatory arrest. Ann Thorac Surg1995;60:1063–6.[Abstract/Free Full Text]
- Calafiore AM, Teodori G, Di Giammarco G, et al. Coronary revascularization with the radial artery: new interest for an old conduit. J Cardiac Surg1995;10:140–6.[Medline]
- Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg1992;54:652–60.[Abstract]
- Thubrikar MJ, Robicsek F. Pressure-induced arterial wall stress and atherosclerosis. Ann Thorac Surg1995;59:1594–603.[Abstract/Free Full Text]
- Calafiore AM, Di Giammarco G, Luciani N, et al. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg1994;58:185–90.[Abstract]
- Calafiore AM, Di Giammarco G, Teodori G, et al. Radial artery and inferior epigastric artery in composite grafts: improved midterm angiographic results. Ann Thorac Surg1995;60:517–24.[Abstract/Free Full Text]
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Abstract
Introduction
