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Ann Thorac Surg 1999;68:2190
© 1999 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Cliniques Universitaires Saint-Luc Ave Hippocrate 10, B-1200 Bruxelles, Belgium
Invited commentary
The authors report their experience with arterial patch angioplasty for reconstruction of proximal coronary artery stenosis. Their technique is neatly illustrated and the authors should be commended for their excellent results.
We too have used the technique in a few patients also requiring conventional bypass surgery; the rationale is to maintain the patency of the left main stem, particularly in younger patients. Old age is not an absolute contraindication, but, with increasing experience, it appears that the left main stem is more frequently grossly calcified in patients more than seventy years of age, and it is not always possible to place the sutures "securely in the adventitial tissue." Why then undertake a more risky procedure in patients not likely to survive for the very long term?
Interestingly, three patients presented with concomitant left main and proximal right coronary artery stenoses: none of them were young females with fibromuscular stenoses as we have suspected in our experience.
With regard to the technical approach, I still do not believe that it is advantageous in all cases to transect the ascending aorta. Using the anterior approach, it is always possible to use an oblique incision in order to lessen the angle of the patch at the ostial junction. Yet, as a surgeon, I would prefer to have an acute angle at the junction than to incise through a calcified segment of the left main coronary artery. We more and more favor the anterior approach over the posterior one because it enables the surgeon to carry the incision into either the roof, or the posterior wall or the anterior wall of the left main according to the intraoperative findings. In the authors experience, the calcifications of the left main are more often localized on the posterior wall, probably because the anterior wall is protected from the head of pressure by the acute angle. The authors have been seduced by the quality of the exposure in their last six patients. I believe that, in most of the cases, they would enjoy a comparable quality of exposure without transecting completely the ascending aorta, even if this artifice allows them to mobilize the aortic root in an anterior direction.
The authors have chosen to administer warfarin for two months postoperatively. This is an additional burden for the patient and is it really mandatory in all cases? The internal thoracic artery is undoubtedly the ideal onlay patch. However, they then lose the advantage of a complete preservation of the arterial graft material. The idea of using a segment of saphenous graft rests on the finding that the proximal segments of the occluded saphenous grafts at reoperation nearly always are free of arteriosclerosis; one explanation might be a protection of the venous endothelium by the prostacyclin secreted by the endothelium of the adjacent aorta.
I have enjoyed reading and discussing this interesting work. This technique is obviously still appealing to innovative and skillful surgical teams.
Related Article
Ann. Thorac. Surg. 1999 68: 2185-2189.
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