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Ann Thorac Surg 1998;66:2096-2098
© 1998 The Society of Thoracic Surgeons

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Case Reports

Off-pump coronary bypass using interposed radial artery graft

^a First Department of Surgery, Osaka University Medical School, Osaka, Japan

Accepted for publication May 22, 1998.

Address reprint requests to Dr Matsuda, First Department of Surgery, Osaka University Medical School, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
e-mail: (matsuda{at}surg1.med.osaka.-u.ac.jp)

	Abstract

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We describe a patient with severely diseased ascending aorta and small internal mammary arteries, who underwent off-pump coronary artery bypass to the left anterior descending coronary artery and right coronary artery using composite arterial grafts consisting of the pedicled proximal internal mammary artery and interposed radial artery graft. The interposed radial artery graft provides advantages, such as making coronary anastomosis on the beating heart easier and to increasing the flow potentiality of the internal mammary artery.

	Introduction

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Despite improvements in surgical technique and myocardial preservation, severely atherosclerotic ascending aorta is still one of the serious risk factors in coronary artery bypass operations [1]. The aortic no-touch technique using in situ arterial grafts has been advocated to avoid unfavorable complications such as cerebral embolism and aortic dissection [2]. We encountered a patient who had not only calcified ascending aorta but also internal mammary arteries (IMAs) with calibers too small to be directly anastomosed to the left anterior descending coronary artery and right coronary artery (RCA). Here we describe an off-pump coronary bypass using composite arterial grafts with interposition of a half radial artery (RA) graft between each IMA and coronary artery.

A 68-year-old woman known to have heterozygous familial hypercholesterolemia and a serum total cholesterol level reaching 518 mg/dL experienced chest pain on exertion 6 years previously. She successfully underwent percutaneous balloon angioplasty to the stenotic lesion of the circumflex coronary artery at that time. Recently, she began to have chest oppression on moderate exertion. Physical examination showed both RAs to be slightly sclerotic with good pulsation, and results of Allen’s test were negative in both sides. Exercise-stress Thallium²⁰¹ myocardial scintigraphy demonstrated myocardial ischemia in the anterior and inferior lesions. Coronary angiography showed 75% stenosis of the ostial lesion of the RCA, 50% stenosis of the left main trunk, and 75% stenosis of the lesion just proximal to the left anterior descending artery. Left ventriculography showed nearly normal wall motion with an ejection fraction of 0.75. Aortography and computed tomography showed that the ascending aorta had circular calcification with mild stenosis in its proximal portion, and moderate dilatation in its mid and distal portions. Angiographic studies showed that the bilateral IMAs had a small caliber in their mid and distal portions without any sclerotic findings and that the right gastroepiploic artery was hypoplastic.

Because of the severely diseased ascending aorta, coronary revascularization with aortic no-touch technique was indicated. After the median sternotomy, bilateral IMAs were mobilized with semiskeletonization from the origin to the bifurcation. They had small calibers at their mid and distal portions as preoperative angiography had shown. However, their proximal portions were relatively acceptable in size. The free flow rate of each IMA graft was less than 30 mL/min at the distal portion, even after the intraluminal injection of papaverine, but increased to 90 mL/min at the proximal portion. Furthermore, both anastomotic sites of the left anterior descending artery and RCA were found to be thick walled. Therefore, a left RA was harvested for interposed arterial graft between each IMA and coronary artery. With the continuous administration of diltiazem and esmolol and the use of a coronary artery stabilizer, the distal side of the distal half RA graft was anastomosed to the left anterior descending artery using a continuous 7-0 polypropylene suture without cardiopulmonary bypass after the occlusion of the proximal and distal left anterior descending artery by snaring. Then, its proximal side was anastomosed end-to-side to the proximal portion of the left IMA using a continuous 8-0 polypropylene suture. The proximal half RA graft was anastomosed first to the distal RCA and second to the proximal portion of the right IMA in a similar fashion. The arteriotomy of the RCA was done with a 2.5-mm punch because of its thick wall. The postoperative course was uneventful. Exercise-stress Thallium²⁰¹ myocardial scintigraphy showed no ischemia, and postoperative angiography obtained on day 21 revealed both grafts well patent (Fig 1). Little arteriosclerotic change was seen at histologic examination of each graft stump harvested at the operation.

View larger version (151K): [in this window] [in a new window]   Fig 1. Angiography 21 days postoperatively revealed both grafts and anastomoses (arrowheads) well patent. (A) Frontal view of the right internal mammary arterial graft (RIMA) with an interposition of radial artery graft (RA) to the right coronary artery (RCA). (B) Left anterior oblique view of the left internal mammary artery (LIMA) with an interposition of radial artery (RA) graft to the left anterior descending coronary artery (LAD).

	Comment

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A proximal end-to-side anastomosis of the free arterial graft to the pedicled IMA has been advocated, with excellent early results [6]. The long-term patency of an in situ IMA graft was proved in patients with familial hypercholesterolemia [7]. Recently, midterm results of the RA graft were reported to be excellent, with a patency rate of 84.2% after 5 years [5]. Even though the present report is limited to a case and follow-up, this technique is expected to provide acceptable long-term results similar to those of in situ arterial grafts.

	References

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1. Roach G.W., Kanchuger M., Mangano C.M., et al. Adverse cerebral outcomes after coronary bypass surgery. New Engl J Med 1996;335:1857-1863.[Abstract/Free Full Text]
2. Hisayoshi S. Coronary artery bypass grafting in patients with calcified ascending aorta: aortic no-touch technique. Ann Thorac Surg 1989;48:728-730.[Abstract]
3. Buffolo E., Andrade J.C.S., Branco J.N.R., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
4. Sweeny M.S., Frazier O.H. Device-supported myocardial revascularization: safe help for sick hearts. Ann Thorac Surg 1992;54:1065-1070.[Abstract]
5. Acar C, Ramshey A, Pagny JY, et al. Five-year results of coronary bypass grafting using the radial artery. Proceedings of the 77th Annual Meeting of American Thoracic Surgery; Washington, DC, May 6, 1997:100–1.
6. Buche M., Schroeder E., Devaux P., Louagie Y.A.G., Schoevaerdts J.C. Right internal mammary artery extended with an inferior epigastric artery for circumflex and right coronary bypass. Ann Thorac Surg 1992;53:381-383.[Abstract]
7. Takahashi T., Nakano S., Shimazaki S., et al. Long-term appraisal of coronary bypass operations in familial hypercholesterolemia. Ann Thorac Surg 1993;56:499-505.[Abstract]

This article has been cited by other articles:

				R. G. Fuster, J. Estornell, O. Gil, and J. A. Montero Arterial graft extension with radial artery: a method of total arterial revascularization Eur. J. Cardiothorac. Surg., October 1, 2004; 26(4): 839 - 841. [Abstract] [Full Text] [PDF]

				T.-P. Tsai Using saphenous vein segments to extend internal mammary conduits during MIDCAB when arterial interposition grafts are contraindicated: intermediate term results Ann. Thorac. Surg., October 1, 2000; 70(4): 1446 - 1446. [Full Text] [PDF]

				T. Takahashi, S. Ohtake, Y. Sawa, G. Matsumiya, and H. Matsuda Reply Ann. Thorac. Surg., October 1, 2000; 70(4): 1446 - 1447. [Full Text] [PDF]

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): Shigeaki Ohtake Hikaru Matsuda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takahashi, T. Articles by Matsuda, H. Search for Related Content PubMed PubMed Citation Articles by Takahashi, T. Articles by Matsuda, H.