Ann Thorac Surg 1999;67:1485-1487
© 1999 The Society of Thoracic Surgeons
Case Reports
Extrathoracic subclavian internal thoracic artery bypass grafting
Eduardo A. Tovar, MDa,b
a Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA
b University of California, Irvine Medical Center, Orange, California, USA
Accepted for publication October 27, 1998.
Address reprint requests to Dr Tovar, 100 E. Valencia Mesa Dr, Suite 301, Fullerton, CA 92835
e-mail: ETovarMD{at}aol.com
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Abstract
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Interval development of a significant stenosis at the origin of the left internal thoracic artery (LITA) after this vessel has been used to revascularize the anterior descending coronary artery may be an indication for reoperation. We present an extrathoracic approach to bypass the proximal segment of the LITA that allows patients with this lesion a quick recovery, short hospital stay, and early resumption of normal activity.
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Introduction
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The subclavian artery becomes the axillary artery immediately after it crosses the first rib as it emerges from the thoracic cavity. Both of these arteries have been used in the past as inflow sites to revascularize the coronary arteries [1–3]. Even though the subclavian artery is normally accessed via thoracotomy, its terminal portion can be approached through a supraclavicular extrathoracic access. Recently, we encountered a case in which the axillary artery could not be used as a source of inflow. As a result, we decided to employ the subclavian artery using an extrathoracic approach.
A 76-year-old man with a known history of coronary artery disease, a previous nephrectomy, and moderate renal failure was seen in consultation. In 1979, the patient underwent a double coronary artery bypass grafting. In 1994, the patient developed recurrent symptoms, at which time we performed a four-vessel coronary artery bypass grafting using the left internal thoracic artery (LITA) to the left anterior descending, and three saphenous vein grafts (SVG). Recently, the patient developed severe recurrent anginal symptoms. A coronary angiogram showed occlusion of both native coronary ostia. All grafts were patent, however, a subtotal lesion was found at the origin of the LITA. In addition, the patient had a 95% right internal carotid artery stenosis and a 75% left axillary artery stenosis, both asymptomatic. Different options were discussed with the patient, who decided to proceed with surgery. We staged the operations and initially performed a right carotid endarterectomy with a patch angioplasty. The following day we performed an extrathoracic subclavian LITA bypass with an SVG, and the patient was discharged from the hospital 1 day later. A subsequent Doppler study showed normal graft function, and the patient remains symptom-free at 3 months follow-up.
A 5-cm transverse incision is performed 2 cm below and parallel to the clavicle just lateral to the sternochondral junction (Fig 1). The pectoralis major muscle is split in an avascular plane between its clavicular and sternal heads. The first rib is identified, and the intercostal muscles inserted in its inferior aspect are divided. A periosteal elevator is used to free the underside of the rib from the pleura. The subclavius and anterior scalene muscles are carefully divided on top of the rib, gently retracting the axillary vessels. The rib is divided with a rongeur at the costochondral junction. The rest of the costal cartilage is carefully removed until the LITA is exposed. The rib is transected posteriorly with rib shears. A second 4-cm skin incision, 2 cm above and parallel to the clavicle, is made (Fig 1). The omohyoid muscle is divided. The phrenic nerve is identified and protected. The subclavian artery is circumferentially dissected and encircled with a vessiloop. Heparin is given (80 U/kg of body weight), and two stay sutures are passed through the lateral portion of the fascia that surrounds the LITA and retracted laterally to allow better visualization. The LITA is snared proximally and distally, and an arteriotomy is followed by the insertion of an intravascular shunt (Research Medical Inc, Midvale, UT). Both ends of the shunt protrude through the snares, which remain distal to the stenosis. The anastomosis is completed with 7-0 polypropylene suture using either a free arterial or venous graft. The flow is restored through the LITA and the graft is passed below the clavicle and anterior to the intact pleura. The subclavian artery is isolated with a small curved vascular clamp, and the anastomosis is completed with the same suture material (Fig 2).
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Fig 1. Seventy-six year-old patient 1 week after an extrathoracic subclavian LITA bypass grafting. Notice the left supra and infraclavicular incisions and two previous midsternotomy scars. A right carotid endarterectomy incision is also present.
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Fig 2. Schematic representation of an extrathoracic subclavian LITA bypass grafting. The costal cartilage and the anterior portion of the first rib have been removed.
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Comment
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Minimally invasive procedures are constantly being sought out in order to solve complex clinical situations [4, 5]. This is particularly the case in high-risk patients in whom just to place them on cardiopulmonary bypass represents a challenging task. The case presented in this report was considered for a catheter procedure. However, because of its complexity and high risk, an operative approach was selected. Direct access of the portion to the subclavian artery at the origin of the LITA to reimplant this vessel would have required a trap-door incision. Instead, the patient underwent an extrathoracic operation that produced minimal discomfort and a short hospital stay, allowing him to resume a normal lifestyle only days after surgery. Either an arterial conduit (such as the radial artery) or a reversed saphenous vein graft can be used in this procedure. Finally, subclavian sticks are contraindicated in this group of patients.
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Addendum
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At 1 year in follow-up the patient remains asymptomatic. During an angiogram to evaluate the left carotid artery, an injection of the left subclavian artery shows a patent graft (Fig 3).
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Fig 3. One-year follow-up left subclavian angiogram shows a widely patent subclavian-internal thoracic artery bypass graft (between white arrows). The ostial stenosis of the LITA is not visible in this projection.
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References
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Fanning W.J., Kakos G.S., Williams T.E., Jr Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486-489.[Abstract]
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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]
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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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Machiraju V.R., Culig M.H., Heppner R.L., Minella R.A., O’Toole J.D. Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures. Ann Thorac Surg 1998;65:625-627.[Abstract/Free Full Text]
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Tovar E.A. Innovative uses of saphenous vein grafts in minimally invasive coronary surgery. Ann Thorac Surg 1998;66:1867-1868.[Free Full Text]
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Abstract
Introduction
