Ann Thorac Surg 1998;66:1431-1432
© 1998 The Society of Thoracic Surgeons
How to Do It
Intraoperative "direct" LIMA angiography for beating heart operations
Mohammad Bashar Izzat, FRCS(CTh)a,
M. Hazem El-Zufari, MDa,
Anthony P.C. Yim, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
Accepted for publication May 29, 1998.
Address reprint requests to Prof Izzat, Section of Cardiac Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, NT, Hong Kong
e-mail: (izzat{at}cuhk.edu.hk)
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Abstract
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The importance of the angiographic assessment of coronary bypass grafts performed on the beating heart has been recognized. We describe a simple technique for intraoperative angiography of left internal mammary artery to left anterior descending coronary artery grafts that does not require selective left internal mammary artery catheterization. This method allows immediate appraisal of the graft, hence enabling the surgeon to revise any graft or anastomosis abnormality immediately and to verify optimal results of beating heart operations.
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Introduction
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Multiple coronary artery revascularization through a median sternotomy without cardiopulmonary bypass is becoming a permanent part of the cardiac surgeon’s armamentarium. Nevertheless, there are still concerns surrounding the accuracy of graft-to-coronary artery anastomoses performed on the beating heart, particularly that of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD). Indeed, routine intraoperative angiographic assessment of LIMA-to-LAD grafts performed without cardiopulmonary bypass has been shown to detect unexpected abnormalities, allow immediate revision of the graft, and improve the results of coronary operations on the beating heart [1–5].
We describe here a technique for intraoperative LIMA angiography during composite arterial grafting procedures. This technique is simple and expeditious, and it does not require selective LIMA catheterization.
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Technique
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Standard median sternotomy and complete LIMA mobilization are performed while the assistant harvests the left radial artery. The proximal end of the radial artery is anastomosed to the posterior aspect of the proximal LIMA in an inverted Y fashion with 7-0 Prolene sutures (Ethicon, Scotland), as described previously [6]. Hemostatic clips are applied to the distal ends of both grafts, which are allowed to distend with the arterial blood pressure (Fig 1). The pericardium is then opened, and a site for the anastomosis to the LAD is selected. The LAD is snared on either side by two silicone vascular loops (Quest Medical, Inc, Allen, TX), and the LIMA-to-LAD anastomosis is performed with a continuous 7-0 Prolene suture.
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Fig 1. Intraoperative view of the composite radial artery-left internal mammary artery grafts. (Arrows = radial artery.)
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Angiographic assessment of the LIMA graft is performed with a standard C-arm fluoroscopy device (BV300; Philips, Shelton, CT). Iopamidol contrast medium (Iopamiro; Bracco, Milan, Italy) is injected by hand into the free distal end of the radial artery through a 20F Teflon catheter (Angiocath; Becton Dickinson Vascular Access, Sandy, UT). Straight anterior and lateral views define clearly the patency of both the radial artery and the LIMA, the anastomoses, and the distal and proximal runoff into the LAD (Fig 2). The radial artery is then used to revascularize the lateral or inferior walls of the left ventricle.
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Fig 2. Intraoperative direct angiography in the same patient shows a good result. (Long arrows = radial artery; white arrows = left anterior descending artery; wide arrows = left internal mammary artery.)
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Comment
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Evaluating coronary artery bypass grafts angiographically is essential for the critical appraisal of operations performed on the beating heart because poor coronary grafting may not manifest immediately with clinical signs of ischemia [5, 7]. When angiography is performed intraoperatively, graft patency is confirmed instantly, and if an abnormality is detected, the graft can be revised immediately so that no patient leaves the operating room with an inadequate revascularization [4, 5].
Intraoperative angiography has been performed through selective catheterization of the LIMA via femoral or radial artery cannulations [4, 5]. Even though these techniques are relatively straightforward and easy to learn, they are more commonly performed by cardiologists than by cardiac surgeons [3]. The technique described here, however, does not require selective catheterization of the LIMA; hence, it is more expeditious, does not require the availability of a cardiologist in the operating room, and avoids the potential risk of dissection of the LIMA during its selective catheterization. Another notable advantage of this method is that only a small volume of contrast medium (usually 3 to 5 mL) is required, whereas a much bigger volume is ordinarily used while locating the LIMA take-off from the left subclavian artery. This is clinically relevant in the presence of renal failure, a category of patients who are not routinely considered for operations without cardiopulmonary bypass by many surgeons.
Evidently, the applicability of this technique is limited to composite arterial grafting procedures, and the radial artery-to-coronary artery anastomoses cannot be assessed. The potential for radial artery spasm, which may follow its dissection and manipulation, did not appear to be of concern in our experience. Indeed, the ability to evaluate the radial artery conduit is an added feature of this method.
In summary, we have described here a technique for intraoperative LIMA angiography during composite arterial grafting procedures. This technique can be easily performed by the surgeon and allows immediate appraisal of coronary bypass grafts. Because the surgeon is able to revise any graft abnormality immediately, an optimal outcome from operation on the beating heart is achieved.
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References
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- Izzat M.B., Yim A.P.C. MIDCABG: lessons learned from routine "on-table" angiography. Ann Thorac Surg 1997;64:1872-1874.[Free Full Text]
- Izzat M.B., Yim A.P.C. Trouble shooting in minimally invasive direct coronary artery bypass. Lancet 1997;350:665-666.[Medline]
- Lazzara R.R., McLellan B.A., Kidwel F.E., Combs D.T., Hanlon J.T., Young E.K. Intraoperative angiography during minimally invasive direct coronary artery bypass operations. Ann Thorac Surg 1997;64:1725-1727.[Abstract/Free Full Text]
- Elbeery J.R., Chitwood W.R. Intraoperative catheterization of the left internal mammary artery via the left radial artery. Ann Thorac Surg 1997;64:1840-1842.[Abstract/Free Full Text]
- Izzat MB, Yim APC, El-Zufari MH. Routine intraoperative angiography improves the results of off-pump coronary artery grafting. Chest (in press).
- Calafiore A.M., Di Giammarco G., Luciani N., Maddestra N., Di Nardo E., Angelini R. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg 1994;58:185-190.[Abstract]
- Izzat M.B., Yim A.P.C. Didn’t they do well? [Editorial]. Ann Thorac Surg 1997;64:1-2.[Free Full Text]
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Abstract
Introduction
