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Ann Thorac Surg 1998;65:625-627
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Value of Reversed Saphenous Vein in Minimally Invasive Direct Coronary Artery Bypass Graft Procedures

Department of Surgery, Shadyside Medical Center, Pittsburgh, Pennsylvania, USA

Accepted for publication August 22, 1997.

Dr Machiraju, Raj Cardiovascular Association, Shadyside Medical Center, 5200 Centre Ave, Pittsburgh, PA 15232.

	Abstract

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Background. Minimally invasive direct coronary artery bypass graft procedures are gaining acceptance for revision as well as primary coronary revascularization. When suitable, the left and right internal mammary arteries are preferred as bypass conduits; in other cases, the greater saphenous vein, used for standard coronary artery bypass graft procedures, may be useful to revascularize coronary artery branches during minimally invasive direct coronary artery bypass graft procedures.

Methods. We used the greater saphenous vein on three occasions during minimally invasive direct coronary artery bypass graft procedures (1) to revascularize the left anterior descending coronary artery by anastomosis to the left axillary artery in the infraclavicular region, (2) as an extension to the left internal mammary artery to reach the left anterior descending coronary artery, and (3) as a bridge from the splenic artery to bypass the distal right coronary artery.

Results. Postoperatively, all 3 patients had relief from symptoms of coronary artery insufficiency and none has been readmitted to the hospital with symptoms. Angiography or thallium studies were not performed to confirm graft patency because all patients were elderly and the risks of these procedures were considered to outweigh their potential benefit.

Conclusions. The greater saphenous vein is a potential bypass conduit for use in minimally invasive direct coronary artery bypass graft procedures as well as for coronary artery bypass graft procedures.

	Introduction

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Coronary artery bypass grafting (CABG) is the procedure of choice for most patients who have triple-vessel disease along with significant stenosis of the left anterior descending coronary artery (LAD). Percutaneous transluminal coronary angioplasty, although it is used aggressively in a select group of patients, is contraindicated because of the location of the stenosis, calcification of the arterial wall, or kinking or excessive tortuosity of the artery proximal to the area of stenosis or because of recurrent stenosis after percutaneous transluminal coronary angioplasty. In some of these patients, however, an open cardiac procedure is contraindicated because of advanced age, presence of severe chronic medical conditions, or a previous cardiac operation.

Minimally invasive direct coronary artery bypass grafting (MIDCABG), in which the left internal mammary artery (LIMA) is grafted to the LAD through a small left anterior thoracotomy, has been gaining popularity [1][2], and many patients with triple-vessel disease who are not candidates for percutaneous transluminal coronary angioplasty or for an open heart operation have been treated with a MIDCABG procedure combined with percutaneous transluminal coronary angioplasty to open other affected vessels [3]. However, what can be done for these patients when the arterial conduits are not available for direct grafting? We encountered this problem in 3 elderly patients, and we report here on their management using a free graft of reversed saphenous vein [4].

	Case Reports

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Patient 1
An 84-year-old man who had undergone coronary artery revascularization (grafting of the right internal mammary artery to the proximal LAD) 9 years previously was hospitalized several times in 12 months with symptoms of angina. Cardiac catheterization showed that the right internal mammary artery was patent but a stricture between it and the LAD had narrowed the vessel by more than 80%. Medical treatment was ineffective in relieving angina, so the stricture was dilated and a stent was placed, with immediate, although temporary, relief of symptoms.

The patient returned 1 month after stent placement with recurrence of angina, and a resting thallium study showed significant ischemia of the anterior wall of the left ventricle. The circumflex and right coronary arteries evidenced atherosclerotic changes, but the LAD was the only artery for which revascularization was indicated. Because of his advanced age, obesity, and history of a previous cardiac operation, we elected to perform a MIDCABG procedure. However, the LIMA had been injured during the initial CABG procedure and had been clipped approximately 5 cm distal to the point where it branched from the subclavian artery. We therefore elected to use a saphenous vein graft.

We performed a small left anterior thoracotomy in the fifth intercostal space and exposed the LAD between adhesions. We then made a separate incision in the left infraclavicular area to expose a portion of the left axillary artery, just posterior to the pectoralis minor muscle, that may be used for axillofemoral bypass or for cardiopulmonary bypass as described by Sabik and colleagues [5]. To place the graft without resecting any ribs, we tunneled subcutaneously in front of the pectoral muscle from the intercostal incision to the infraclavicular area. The graft of reversed saphenous vein was anastomosed at both locations using 7-0 Prolene (Ethicon, Somerville, NJ) (Fig 1Fig 2).

View larger version (154K): [in this window] [in a new window]   Reversed saphenous vein graft anastomosed to left anterior descending coronary artery.

View larger version (175K): [in this window] [in a new window]   Reversed saphenous vein graft anastomosed to left axillary artery.

Patient 2
An 82-year-old woman who had undergone CABG with cardiopulmonary bypass several years previously had development of unstable angina. All of the vein grafts placed during the previous operation were occluded, except for a saphenous vein graft to the right coronary artery, which was moderately diseased, and stenosis of the left main trunk was severe. Percutaneous transluminal coronary angioplasty was contraindicated by the condition of the coronary vessels, and we believed that the patient’s general condition precluded an open heart procedure. We therefore planned to graft the LIMA to the LAD in a MIDCABG procedure.

The MIDCABG procedure went as planned until dissection of the LIMA, which appeared fragile and developed an intramural hematoma. We transected the artery repeatedly more proximally until the vessel walls and lumen appeared normal, but at this point the LIMA was too short to reach the LAD. We therefore used a small segment of reversed saphenous vein as a bridge between the LIMA and the LAD. Blood flow in the LIMA was excellent and the patient made an unremarkable recovery.

Patient 3
An 80-year-old woman who had undergone open heart CABG previously presented with unstable angina as a result of stenosis of the right coronary artery. The caliber of the right coronary artery distal to the stenosis seemed excellent and the LIMA graft to the LAD and vein graft to the marginal branch of the circumflex placed at her previous operation were patent.

We planned to bypass the distal right coronary artery with a graft of gastroepiploic artery, placed through a small subxiphoid incision as demonstrated by Fonger and reported by Westaby and Benetti [6]. However, we found the gastroepiploic artery to be too small for use as a coronary arterial conduit. We did find a fairly large splenic artery, and we used a reversed segment of saphenous vein as a bridge from the splenic artery to the right coronary artery. The patient’s recovery from the operation was uneventful.

	Comment

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From the early years of coronary artery surgery, cardiothoracic surgeons have performed CABG operations on beating hearts and used the LIMA [7] and saphenous vein grafts to revascularize coronary arteries. The development of techniques for myocardial protection led to cardiopulmonary bypass becoming standard for these procedures, especially in the United States. However, a recent report [8] of the success of more than 700 double- and triple-graft coronary artery bypass procedures performed on beating hearts led surgeons to explore new ways of performing a number of procedures without stopping the heart [9].

With the advent of new instruments and minimally invasive [10] approaches using video-assisted or Port-Access (Heartport Inc, Redwood City, CA) [11] cardiopulmonary bypass procedures, surgeons are attempting not only LIMA to LAD grafts but Y graft techniques that place burdens on the LIMA-to-LAD grafts, for example anastomosing the radial artery and right internal mammary artery to other branches such as the diagonal and first marginal branch. We believe that the LIMA should be attached exclusively to the LAD and that alternate sources of inflow and bypass conduits should be evaluated, such as the saphenous vein techniques used in the cases we report.

The success of our technique is demonstrated by the fact that all 3 patients in this report had immediate relief of angina postoperatively and have not had recurrence of symptoms. We did not perform angiography or thallium studies to confirm patency of the grafts because vessels that were used for bypass were all fairly large in diameter, those that were used would have caused anginal symptoms if flow had been insufficient, and the patients were all at greater risk of complications of angiography or thallium studies because of their ages and previous cardiac histories.

Major arterial structures outside the chest that may be used as a conduit include the axillary artery. Arteries that have been used in the past for proximal anastomosis of a vein graft include the innominate arteries, subclavian arteries [12], and descending thoracic aorta [13].

Repeat CABG without cardiopulmonary bypass was performed by Fanning and associates [14], and use of a MIDCABG procedure in 6 patients who had previously undergone CABG was reported by Boonstra and associates [15].

Now that MIDCABG procedures are gaining wider acceptance, as is use of the Port-Access system, surgeons may begin to perform bypass grafts to other vessels such as the diagonal and first marginal branch. A segment of the radial artery, right internal mammary artery, or saphenous vein may be used as a free graft and tunneled up into the infraclavicular area for proximal anastomosis to the left or right axillary artery. The axillary artery can be exposed fairly safely in the infraclavicular area, especially by surgeons who are familiar with using the axillary artery for axillofemoral bypass. In fact, recently Sabik and associates [5] used the axillary artery itself for cardiopulmonary bypass in a patient with a calcified ascending aorta, and we have used the axillary artery in 1 patient for bypass during repair of a ruptured aortic arch aneurysm and abdominal aortic aneurysm with thrombus.

We found the axillary artery to be easily accessible and, because the subclavian artery has already proved to be useful in supplying the internal mammary artery, adding a vein graft to reach the axillary artery appears to make sense as a means to increase inflow to the coronary arteries.

	References

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This Article Abstract Full Text (PDF) 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): Michael H. Culig Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Machiraju, V. R. Articles by O'Toole, J. D. Search for Related Content PubMed PubMed Citation Articles by Machiraju, V. R. Articles by O'Toole, J. D.