Ann Thorac Surg 1999;67:1817-1818
© 1999 The Society of Thoracic Surgeons
How to Do It
A new method of myocardial revascularization with the radial artery
Oscar R. Aguero, MDa,
José L. Navia, MDa,
José A. Navia, MDa,
Esteban Mirtzouian, MDa
a Department of Cardiovascular Surgery, San Camilo Clinic, Buenos Aires, Argentina
Accepted for publication January 4, 1999.
Address reprint requests to Dr Aguero, Department of Cardiovascular Surgery, San Camilo Clinic, Angel Gallardo 899, 1405 Buenos Aires, Argentina
e-mail: oaguero{at}intramed.net.ar
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Abstract
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We present a new method of myocardial revascularization. The radial artery is used in combination with the left internal mammary artery, thereby providing three distal end-to-side anastomoses to the left anterior descending coronary artery and other sites as determined by the coronary artery lesions. Arterial conduits form an anastomotic network between the left internal mammary artery and the radial artery in a horseshoe pattern. Three coronary arteries are revascularized by two arterial conduits in the left coronary system.
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Introduction
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The internal mammary artery (IMA) is the best graft for coronary revascularization because of long-term patency and freedom from recurrent angina and cardiac events [1]. Reports by Acar and associates [2] and Calafiore and co-workers [3] show excellent midterm (1–3 years) patency rates for the radial artery (RA) graft. These studies inspired us to use arterial conduits as bypass grafts for as many coronary arteries as possible. Here we describe the combined use of the left IMA (LIMA) and the RA so as to create an "anastomotic network" within the left coronary artery territory. In this procedure, developed by one of us (O.R.A.), the RA is used in such a way that a "horseshoe" pattern is made. The ends of the RA are anastomosed in an end-to-side fashion to a branch of the circumflex artery and a diagonal branch. Then the RA is attached to the LIMA in a side-to-side fashion, thus forming the anastomotic network.
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Technique
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The patient is prepared for coronary artery bypass grafting. The LIMA and RA are treated with papaverine hydrochloride, and the distal end of the RA is anastomosed to a branch of the circumflex artery, thus forming the distal branch of the "horseshoe." The anastomosis is achieved in a parallel end-to-side fashion with continuous 8-0 monofilament sutures. The RA pedicle is then attached to the epicardium with 6-0 silk sutures on both sides to avoid either twists or kinks. Then the other end of the RA is anastomosed to a diagonal branch using the same technique. As a result, both coronary arteries are linked by the RA in a horseshoe pattern (Fig 1). The LIMA is then sewn to the left anterior descending coronary artery in a similar fashion. The LIMA and the RA are carefully dissected from the surrounding veins, fascia, and adipose tissue. A longitudinal arteriotomy of 5 to 8 mm is performed on both arterial grafts, and they are attached by a parallel side-to-side anastomosis (Fig 2). Thus, three coronary arteries have been revascularized by means of two arterial conduits (Fig 3).
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Fig 3. Finished horseshoe-shaped "anastomotic network" of the radial artery and the left internal mammary artery.
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To date, we have used this technique in 30 patients. Sixty percent of them have undergone a postoperative angiographic study, and patency of each graft has been confirmed (Fig 4).
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Fig 4. Postoperative angiographic study: showing the anastomotic network. (DIAG = diagonal branch; LIMA = left internal mammary artery; LDA = left anterior descending coronary artery; OM-CX = obtuse marginal–circumflex coronary artery.)
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Comment
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On the basis of our early experience, we think our procedure can be used routinely. Compared with the sequential technique, it offers several advantages. We prefer the parallel side-to-side and end-to-side anastomoses because we believe they are hemodynamically more suitable and less likely to fail. Also, when thecondition of the patient so requires, the distal anastomosis technique allows the surgeon to perform more extended arteriotomies and open areas of atheromatous vessel, if needed. The time involved in performing distal anastomoses is reduced considerably. The horseshoe shape of the technique means that coronary arteries at different anatomic positions in the left ventricle, especially on the inferolateral wall, can be reached in contrast with the parallel pattern of the conventional sequential bypass technique. In addition, if one anastomosis becomes occluded, the other should stay open, because the blood flow is distributed independently; this is unlikely in sequential bypass grafts.
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Acknowledgments
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We are grateful to Bruce W. Lytle, MD, for his support and expert assistance in the preparation of this manuscript.
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References
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Loop F.D., Lytle B.W., Cosgrove D.M., et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
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Acar C., Jebara V.A., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660.[Abstract]
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Calafiore A.M., Di Giammarco G., Teodori G., et al. Radial artery and inferior epigastric artery in composite grafts: improved midterm angiographic results. Ann Thorac Surg 1995;60:517-524.[Abstract/Free Full Text]
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Abstract
Introduction
