Ann Thorac Surg 1997;63:561-562
© 1997 The Society of Thoracic Surgeons
How To Do It
"LIMA Fissure" for a Tension-Free IMA Graft in Emphysema
Podila Sita Rama Rao, MCh,
Krishna M. Natarajan, FRCA,
Graham Morritt, FRCS
Departments of Cardiothoracic Surgery and Cardiothoracic Anaesthesia & Intensive Care, South Cleveland Hospital, Middlesbrough, United Kingdom
Accepted for publication August 15, 1996.
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Abstract
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Tension on the mammary artery pedicle is a major concern during coronary artery bypass in asthmatic patients with emphysematous lungs. We are sharing here a simple and effective solution to this problem.
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Introduction
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See also page 562.
Several techniques have been described to increase the length of the internal mammary artery (IMA) pedicle [1, 2]. These are used either singly or in combination to allow a tension-free distal left IMA–left anterior descending coronary artery anastomosis in asthmatic patients with grossly emphysematous lungs. The currently available techniques include skeletonization of the IMA [1–4]; division of the internal mammary vein and extending dissection to the mammary artery's origin from the subclavian artery, incising the pericardium in line with the pulmonary artery, and performing retrothymic tunneling of the mammary artery [3, 4]; and multiple incisions on the endothoracic fascia and the block of tissue around the IMA [2, 4]. Although some authors recommend taking down the mammary artery well beyond its bifurcation [3] to achieve additional length, it is desirable to anastomose the IMA just proximal to the bifurcation, where it has a maximum luminal diameter for anastomosis. The specific issue of overinflated lung was addressed earlier by suturing a pericardial flap to the chest wall [5]. There is some concern about this technique regarding reoperations and the possibility of pericardial flap tearing and compressing the mammary artery at a future date [4]. The present technique does not have these problems, whereas it further optimizes the length of mammary artery. It gives the shortest straight route to the left anterior descending artery across the apical segment of the upper lobe in emphysematous lung and also avoids stretching of the IMA by the overinflated lung during any future episodes of bronchospasm.
We have employed this technique, with gratifying results, during redo coronary bypass grafting in an asthmatic patient with grossly emphysematous lung. This patient had a previous saphenous venous graft on the mid-left anterior descending artery, and the current anastomosis was possible only on the distal left anterior descending artery. When ventilation resumed at the end of bypass, it was obvious that the skeletonized full-length mammary artery was under tension because of the emphysematous lungs, and this was further aggravated by an episode of bronchospasm. The apical segment of the left upper lobe was then split with bovine pericardium-buttressed staples (Peri-Strips; Bio-Vascular, Inc, St. Paul, MN) such that the left IMA ran comfortably through the resulting fissure (Fig 1
) and was brought into the surgical field through an incision in the pericardium. The fissure was created to align with the path of the IMA. It was deep enough not to cause any stretch on the IMA even when the lung was fully inflated. Similar application of this technique on the right side may be useful when indicated.
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Fig 1. . (1) Apical segment of left upper lobe split with bovine pericardium-buttressed staples. This "LIMA fissure" allows the shortest, straight, tension-free route for the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). (2) Distended and emphysematous lung.
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We believe this method is an effective addition to the cardiac surgeon's armamentarium. It provides a simple solution to the long-standing dilemma in using IMA in asthmatic and emphysematous patients.
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Footnotes
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Address reprint requests to Mr Morritt, Division of Cardiothoracic Surgery, South Cleveland Hospital, Marton Rd, Middlesbrough, United Kingdom TS4 3BW.
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References
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- Nasef SAM, Angelini GD. Preparation of the internal mammary artery. Br J Hosp Med 1990;45:339–42.
- Cosgrove DM, Loop F. Techniques to maximize mammary artery length. Ann Thorac Surg 1985;40:78–9.[Abstract/Free Full Text]
- Brown AH, Dougenis D. Dissection of the two internal mammary arteries with maximal exposure and minimal adverse sequel by means of an inexpensive, simple, atraumatic retractor. J Thorac Cardiovasc Surg 1991;102:753–6.
- Martinez MJ, Garcia-Rinaldi R, Traad EA. Minimizing internal mammary artery anastomotic tension [Letter]. Ann Thorac Surg 1988;46:712.
- Todd EP, Earle GF, Jaggers R, Sekela M. Pericardial flap to minimize internal mammary artery anastomotic tension. Ann Thorac Surg 1987;44:665–6.[Abstract/Free Full Text]
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Abstract
Introduction
