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Ann Thorac Surg 1996;62:1865-1866
© 1996 The Society of Thoracic Surgeons

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How To Do It

Innominate and Subclavian Arteries as an Inflow of Free Arterial Graft

Department of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan, and Cattedra di Cardiochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy

Accepted for publication July 17, 1996.

	Abstract

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To find a suitable inflow site for free arterial grafts in myocardial revascularization, I used the innominate artery for the radial artery graft in 4 patients and the left subclavian artery for three radial grafts and one free gastroepiploic artery graft. All 8 patients were alive, and all five restudied grafts were all patent. The innominate and subclavian arteries are suitable in terms of better wall matching and avoidable aortic clamping in cases of atherosclerotic ascending aorta.

	Introduction

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Current enthusiasm for extensive use of arterial conduits in coronary artery bypass grafting (CABG) brought us increased opportunity to use free arterial grafts such as radial and inferior epigastric artery in addition to the in situ internal thoracic and gastroepiploic artery grafts [1].

One of the major concerns with the free arterial graft is its proximal anastomosis. When the thin-walled and small-caliber arterial graft is anastomosed to the thick-walled aorta, early graft closure is more likely. Also, the proximal anastomosis becomes more difficult and aortic clamping is dangerous if the ascending aorta is severely atherosclerotic. To solve those problems, I used the innominate artery and the left subclavian artery as inflow sites of the free arterial graft in CABG.

	Technique

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From 1993 to 1996, CABG using free arterial grafts, of which the proximal anastomosis was made to the innominate or left subclavian artery, was performed in 8 patients.

The innominate artery was chosen as an inflow site of the radial artery graft in 4 patients at primary CABG. All those patients had atherosclerotic ascending aorta. The left subclavian artery was used for the radial artery graft in 3 patients and for the free gastroepiploic artery graft in 1 patient at redo CABG with the left thoracotomy approach. Patent old graft to the anterior heart or suspected severe retrosternal adhesion are the indications for the left thoracotomy approach.

All patients were male with a mean age of 65 years (range, 39 to 73 years). The sites of distal anastomosis of the graft were one anterior descending, one diagonal, and six circumflex arteries.

At operation, the proximal anastomosis between the graft and the innominate or subclavian artery was made first before institution of cardiopulmonary bypass. Then the graft could be handled just as the in situ graft (Fig 1). With use of a fine, small side-bite clamp, cerebral blood flow was maintained during the graft–innominate artery anastomosis. Before clamping of the innominate artery, careful evaluation of the artery by palpation was necessary to avoid stroke. A longitudinal (8 to 10 mm) narrow triangular opening was made by sharp knife to the host artery, and the proximal end of the graft was cut back relatively longer (about twice as long as its diameter) to avoid perpendicular take off. Then the graft to the host artery anastomosis was made by continuous suture with single 7-0 polypropylene.

View larger version (83K): [in this window] [in a new window]   Fig 1. . Radial artery graft anastomosed to the innominate artery at its proximal site.

	Results

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All 8 patients were alive and well. There was no perioperative infarction or stroke.

Postoperative angiography was performed in 5 patients: of the innominate–radial artery in 2 patients, the subclavian–radial artery in 2 patients, and the subclavian–gastroepiploic artery in 1 patient. All five grafts were patent at postoperative restudy at 1 week, 2 weeks, 1 year (2 patients), and 2 years. In the remaining 3 patients with no postoperative angiography, exercise test was negative (Fig 2).

View larger version (133K): [in this window] [in a new window]   Fig 2. . Free gastroepiploic artery graft anastomosed to the left subclavian artery proximally and to the anterior descending artery distally at the second reoperation through a left thoracotomy. This angiogram was taken 2 years postoperatively.

	Comment

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	Footnotes

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Address reprint requests to Dr Suma, Department of Cardiovascular Surgery, Mitsui Memorial Hospital, 1, Kanda Izumicho, Chiyodaku, Tokyo 101, Japan.

	References

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1. Calafiore AM, Di Giammarco G. Complete revascularization with three or more arterial conduits. Semin Thorac Cardiovasc Surg 1996;8:15–23.[Medline]
2. 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 Surg 1995;60:1063–6.[Abstract/Free Full Text]
3. Loop FD, Lytle BW, Cosgrove DM, Golding LA, Taylor PC, Stewart RW. Free (aorto-coronary) internal mammary artery graft. J Thorac Cardiovasc Surg 1986;92:827–31.[Abstract]
4. Puig LB, Ciongolli W, Cividanes GVL, et al. Inferior epigastric artery as a free graft for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:251–5.[Abstract]
5. Nishida H, Soltanzadeh H, Grooters R, Thieman KC. Coronary–coronary bypass with internal mammary artery. Ann Thorac Surg 1988;46:577–8.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hisayoshi Suma Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Suma, H. Search for Related Content PubMed PubMed Citation Articles by Suma, H.