Ann Thorac Surg 1996;62:1525-1526
© 1996 The Society of Thoracic Surgeons
Case Report
Use of a Free Radial Artery Graft for Correction of Bland-White-Garland Syndrome
Richard F. Brodman, MD,
Henry J. Issenberg, MD,
Julie S. Glickstein, MD,
Rosemary Frame, RN
Department of Cardiothoracic Surgery and Division of Pediatric Cardiology, Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
Accepted for publication June 5, 1996.
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Abstract
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A radial artery free graft was used to create a two-coronary artery system for a 15-month-old child with Bland-White-Garland syndrome. The anomalous left main coronary artery originated from the proximal right pulmonary artery.
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Introduction
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An early aggressive surgical approach in infants with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is warranted. With improvements in techniques of coronary reimplantation in infants gained from arterial switch procedures, direct reimplantation of the anomalous left coronary artery from the pulmonary artery to the aorta has been associated with excellent early results [1, 2]. However, other alternatives may have their place to achieve a two-coronary artery system. We report use of a free radial art ery graft to achieve a two-coronary artery system as the origin of the left main originated from the proximal right pulmonary artery.
A 15-month-old girl was first noted to have a heart murmur at 3 months of age. At 9 months of age, echocardiography showed a dilated left ventricle with decreased shortening fraction and moderate mitral insufficiency. A thallium study was interpreted as normal. The diagnosis was coronary atrioventricular fistula. Coil embolectomy was planned when she reached 10 kg, as she was essentially asymptomatic with normal growth and development. Cardiac catheterization, however, revealed ALCAPA with moderate mitral insufficiency, left ventricular ejection fraction of 0.68, and a ratio of pulmonary blood flow to systemic blood flow of 1.1.
Intraoperative photoelectric plethysmography (Ohmeda Inc, Louisville, CO) was performed to assess adequacy of ulnar collateral flow in the left forearm. The operative procedure was performed through a median sternotomy. After the heart was suspended in a pericardial cradle, the distance from the aorta to the left anterior descending artery was measured to be 6.5 cm in a gentle curve. We then elected to harvest 6.5 cm of the radial artery from the mid-left volar forearm, which measured 11 cm from the elbow crease to the wrist. A 6.5-cm skin incision was used, and the determined length of the radial artery was harvested using our previously described technique [3]. The child was placed on a standard intraoperative diltiazem (Marion Merrell Dow Inc, Kansas City, MO) administration protocol [3, 4].
The radial artery internal diameter measured 2 to 2.5 mm after harvesting. Using moderate hypothermia, antegrade blood cardioplegia was given with both pulmonary artery branches occluded. The main pulmonary artery was opened longitudinally, the orifice of the ALCAPA was identified in the proximal right pulmonary artery and was oversewn in two layers with 5-0 polypropylene, and the main pulmonary artery was closed. The radial artery was beveled and sutured to a 3-mm arteriotomy in the left anterior descending artery with 8-0 polypropylene, and with the ascending aorta partially clamped, the proximal anastomosis was performed to a 4-mm punched aortotomy using 8-0 polypropylene. The aortic cross-clamp time was 23 minutes, and the cardiopulmonary bypass time was 1 hour 7 minutes. The child's postoperative course was uncomplicated, and she has done well in follow-up. Repeat catheterization at 1-year follow-up shows normal left ventricular function, trace mitral insufficiency, and a widely patent radial artery graft (Fig 1
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Fig 1. . Digital aortogram showing radial artery free graft (thick arrow) from ascending aorta to the partially filled LAD (thin arrow).
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Comment
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The use of the radial artery free graft for surgical correction of ALCAPA in infants and children offers a surgical option that is safe and technically not demanding to surgeons who do not encounter ALCAPA frequently in their practices. Unlike the internal thoracic artery and saphenous vein in infants, the radial artery is adequate in size and length to use as a coronary artery bypass graft. The use of direct coronary reimplantation techniques achieves a normal or near-normal anatomic appearance of the left coronary system after ALCAPA repair in children. However, this procedure may be technically more demanding than the use of a radial artery free graft in circumstances where the anomalous left coronary artery comes off the nonfacing sinus of the main pulmonary artery or right pulmonary artery [5–8]. We used the approach described after reading of the technical difficulties encountered in a similar case with the left coronary origin from the right pulmonary artery reported earlier from a center with a large experience [1].
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Footnotes
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Address reprint requests to Dr Brodman, Department of Cardiothoracic Surgery, Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467.
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References
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- Vouhé PR, Baillot-Vernant F, Trinquet F, et al. Anomalous left coronary artery from the pulmonary artery in infants. J Thorac Cardiovasc Surg 1987;94;192–9.[Abstract]
- Vouhé PR, Tamisier D, Sidi D, et al. Anomalous left coronary artery from the pulmonary artery: results of isolated aortic reimplantation. Ann Thorac Surg 1992;54:621–7.[Abstract]
- Reyes AT, Frame R, Brodman RF. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118–26.[Abstract/Free Full Text]
- Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652–60.[Abstract]
- Doty DB, Chandramouli B, Schieken RE, Lauer RM, Ehrenhaft JL. Anomalous origin of the left coronary artery from the right pulmonary artery. J Thorac Cardiovasc Surg 1976;71:787–91.[Abstract]
- Alexi-Meskhishvili V. Anomalous left coronary artery surgery [Letter]. Ann Thorac Surg 1990;50:511.[Medline]
- Sese A, Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta. Ann Thorac Surg 1992;53:527–9.[Abstract]
- Tashiro T, Todo K, Haruta Y, Yasunaga H, Nagata M, Nakamura M. Anomalous origin of the left coronary artery from the pulmonary artery new operative technique. J Thorac Cardiovasc Surg 1993;106:718–22.[Abstract]
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Abstract
Introduction
