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Ann Thorac Surg 1997;63:1776-1777
© 1997 The Society of Thoracic Surgeons

Case Report

Minimally Invasive Axillary-Coronary Artery Bypass

Wade L. Knight, MD, Clinton E. Baisden, MD, Charles G. Reiter, MD

Division of Cardiothoracic Surgery, Scott and White Clinic, Texas A&M University College of Medicine, Temple, Texas

Accepted for publication January 22, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 References
 
Axillary artery-to-coronary artery bypass using reversed saphenous vein provides a simple method of applying the minimally invasive coronary bypass grafting procedure when the internal thoracic artery is not an adequate conduit. Although this may allow extended use of the minimally invasive coronary bypass procedure, the long-term patency of this technique is unknown.


   Introduction
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 Footnotes
 Abstract
 Introduction
References
 
The minimally invasive direct coronary artery bypass grafting procedure most commonly involves anastomosis of the left internal thoracic artery (LITA) to the left anterior descending artery [1–4]. Previously, encountering an inadequate LITA conduit has meant abandoning the minimally invasive technique and resorting to median sternotomy for reversed saphenous vein aortocoronary bypass grafting. Extraanatomic bypass with reversed saphenous vein originating from the left axillary artery has allowed us to accomplish minimally invasive coronary bypass grafting without resorting to sternotomy despite an inadequate LITA. The procedure initially is performed as previously described [1, 3]. A short transverse incision over the left fourth costal cartilage allows removal of the cartilage and exposure of both the LITA and the left anterior descending artery, or even some diagonal branches. If the LITA is of adequate size, length, and flow, then the minimally invasive direct coronary artery bypass grafting procedure can be accomplished without concern. We prefer to use the LITA, presuming the long-term patency to be preferable to that of saphenous vein with minimally invasive direct coronary artery bypass grafting as for conventional coronary artery bypass grafting. However, if the LITA flow is inadequate, the caliber is too small, or the length of the LITA is too short, then the LITA is abandoned. The same incision and exposure is used to suture an adequately sized segment of reversed saphenous vein to the target coronary artery, most commonly the left anterior descending artery. A second short transverse incision is made belowthe clavicle to expose the left axillary artery (Fig 1AGo). The fibers of the left pectoralis major muscle are separated between the clavicular and sternal heads of the pectoralis major. The pectoralis minor is retracted laterally to allow exposure of the left axillary artery medial to the pectoralis minor muscle (Fig 1BGo). The axillary vein is usually superficial to the axillary artery and is retracted without injury. Care must be taken to avoid injury to the brachial plexus and its local branches. With the reversed saphenous vein-coronary anastomosis already completed, a tunnel is created from the site of the resected left fourth costal cartilage, behind the pectoralis major, superficial to the ribs, and medial to the pectoralis minor. This allows the reversed saphenous vein to be anastomosed proximally to the left axillary artery (Fig 1CGo). Placing the graft medial to the pectoralis minor obviates any possibility of pressure on the vein graft from the pectoralis minor muscle. Patency of the axillary-coronary graft is easily verifiable postoperatively by using a simple hand-held pencil Doppler probe.



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  		Fig 1. . Exposure of the left axillary artery for axillary-coronary bypass. (A) A transverse incision just below the clavicle is only 6 or 7 cm in length. (B) Pectoralis major muscle is divided in the direction of its fibers and the pectoralis minor muscle is retracted laterally, exposing the axillary vessels. (C) The reversed saphenous vein coronary graft is tunneled behind the pectoralis major medial to the pectoralis minor and anastomosed to the left axillary artery.

 
Of course, the long-term patency of this axillary-coronary bypass graft is unknown. We know from peripheral vascular surgery experience that longer axillary-femoral grafts done with prosthetic graft material have much poorer long-term patency than aortofemoral bypass grafting. Whether a shorter extraanatomic graft using autogenous saphenous vein from the left axillary artery to the coronary artery will have long-term patency comparable to that of an aortocoronary graft of similar length remains to be seen. We have only had occasion to use this technique in 1 patient. It was particularly beneficial in an elderly patient having a third-time redo procedure, avoiding the tedious dissection and risk of conventional coronary artery bypass grafting. Axillary-coronary bypass grafting may allow grafting of additional vessels using a minimally invasive approach, potentially extending the conduits available for other coronary arteries. This approach could be applied to the right coronary artery using the right axillary artery proximally. A large series with sufficient follow-up and late angiography is necessary to assess the long-term patency and effectiveness of axillary-coronary bypass. With long-term patency of the axillary-coronary grafting technique being unknown, some judgment must accompany the use of this method of revascularization.


   Footnotes
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 Footnotes
Abstract
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 References
 
Address reprint requests to Dr Knight, Division of Cardiothoracic Surgery, Scott and White Clinic, 2401 S 31st St, Temple, TX 76508.


   References
Top
 Footnotes
 Abstract
 Introduction
 References
 

  1. Robinson MC, Gross DR, Zeman W, Stedje-Larsen E. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Card Surg 1995;10:529–36.[Medline]
  2. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135–7.[Abstract/Free Full Text]
  3. Cooley DA. Limited access myocardial revascularization. A preliminary report. Tex Heart Inst J 1996;23:81–4.[Medline]
  4. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]



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This Article
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Clinton E. Baisden
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Right arrow Articles by Knight, W. L.
Right arrow Articles by Reiter, C. G.

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