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Ann Thorac Surg 1998;66:1867
© 1998 The Society of Thoracic Surgeons

Correspondence

Innovative uses of saphenous vein grafts in minimally invasive coronary surgery

Eduardo A. Tovar, MDa

a Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, and University of California, Irvine Medical Center, Orange, CA, USA

To the Editor

I read with great interest the article by Machiraju and colleagues [1] in which they describe three case reports where arterial conduits were unavailable for grafting via minimally invasive direct coronary artery bypass (MIDCAB) and they had to resort to saphenous vein grafts (SVG). In their first case they performed an axillo-SVG to left anterior descending coronary artery bypass similar to the one reported by Knight and associates in The Annals in June 1997 [2] with the exception that they used a subcutaneous instead of a subfascial tunnel. In a letter to the editor commenting on Knight and associates’ work, Coulson and Bakhshay [3] reported a group of patients in whom they had performed this operation. They, however, tunneled the SVG through the bed of the resected anterior portion of the second rib, which, according to Knight [4], provides a more protected course for the SVG. I would agree that an intrathoracic tunnel is preferable [5]. However, removal of the anterior portion of the first rib rather than the second may provide certain advantages: It allows easier exposure of the axillary artery, the SVG does not have to go over the first rib as it enters the pleural cavity, and the chest wall does not lose as much stability when lower costal cartilages are resected to expose the left anterior descending coronary artery.

In the context of the present letter, I would like to report a case of an 85-year-old female who had formerly undergone a double-vessel coronary bypass grafting. The patient presented with recurrent angina 6 years after her initial operation. A coronary angiogram depicted a new lesion distal to the left internal mammary artery-left anterior descending coronary artery anastomosis (Fig 1). A short SVG was used to bypass the left internal mammary artery to the left anterior descending coronary artery just distal to the stenotic area using an anterior thoracotomy (Fig 2). This allowed the patient an early discharge 2 days after surgery. The patient remains angina-free at 8 months of follow-up.



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  		Fig 1. Angiogram depicts post left internal mammary artery to left anterior descending coronary artery anastomotic stenosis. Left internal mammary artery-left anterior descending coronary artery anastomotic site (white arrow). Saphenous vein graft bypass (not shown) performed from left internal mammary artery (upper arrow) to distal left anterior descending coronary artery (lower arrow).

 


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  		Fig 2. Mediastinotomy incision 7 days after surgery.

 
I congratulate Machiraju and colleagues as well as the rest of the above-mentioned authors for their provocative work and agree that these operations should be reserved for a select group of patients.

References

  1. Machiraju V.R., Culig M.H., Heppner R.L., Minella R.A., O’Toole J.D. Value of reversed saphenous vein minimally invasive direct coronary artery bypass graft procedures. Ann Thorac Surg 1998;65:625-627.[Abstract/Free Full Text]
  2. Knight W.L., Baisden C.E., Reiter C.G. Minimally invasive axillary-coronary artery bypass. Ann Thorac Surg 1997;63:1776-1777.[Abstract/Free Full Text]
  3. Coulson A.S., Bakhshay S. Axillary-coronary bypass. Ann Thorac Surg 1998;65:304.[Medline]
  4. Knight W.L. Axillary-coronary bypass. Ann Thorac Surg 1998;65:304-305.
  5. Tovar E.A., Blau N., Borsari A. Axillary artery-coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:242-243.[Free Full Text]



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Ann. Thorac. Surg., May 1, 1999; 67(5): 1485 - 1487.
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