Ann Thorac Surg 2000;69:641-642
© 2000 The Society of Thoracic Surgeons
How to Do It
Deep circumflex iliac artery as a free arterial graft for myocardial revascularization
Gen-ya Yaginuma, MDa,
Masahiro Sakurai, MDa,
Taiichiro Meguro, MDa,
Katsuya Ota, MDb,
Kazuo Abe, MDb
a Division of Heart Institute, Sendai Kosei Hospital, Sendai, Japan
b Yamagata Prefectural Central Hospital, Yamagata, Japan
Address reprint requests to Dr Yaginuma, Division of Heart Institute, Department of Cardiovascular Surgery, Sendai Kosei Hospital, 4-15, Hirose-machi, Aoba-ku, Sendai 980-0873, Japan
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Abstract
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When complete revascularization cannot be obtained with the internal thoracic artery and the other arterial grafts, the deep circumflex iliac artery (DCIA) may be an excellent alternative conduit. The deep circumflex iliac artery was used as a free graft for direct myocardial revascularization in 4 patients from January to July 1999. We describe our experience with this arterial conduit, review the anatomy of the artery, and present our harvesting technique.
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Introduction
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The use of internal thoracic artery (ITA) grafts has had a better patency rate than saphenous vein grafts [1]. Recently, other arteries have been used as grafts. As a revival, the radial artery [2] has been used in many cases. The use of the right gastroepiploic artery as a pedicle and similar use of the left gastroepiploic artery have been reported [3]. As another alternative conduit, use of the inferior epigastric artery as a free graft has been reported [4].
When complete revascularization cannot be obtained with these arterial grafts, the deep circumflex iliac artery (DCIA) may be an excellent alternative conduit. In plastic surgery, this vessel has been used as one of the most important donor vessels for the free transfer of groin flaps and living iliac bone [5]. The DCIA was used as a free arterial graft for direct myocardial revascularization in 4 patients from January to July 1999.
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Technique
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The deep circumflex iliac artery is a vessel (average diameter 2 mm, range 1.5 to 3 mm) arising from the lateral surface of the external iliac artery just above the inguinal ligament (Fig 1). It then passes obliquely upward and laterally in a straight line toward the anterior superior iliac spine, running along the posterior margin of the inguinal ligament in a fibrous tunnel formed by the line of attachment of the transversalis fascia and the iliacus fascia. As it approaches the anterior superior iliac spine, the artery gives rise to a number of branches. It pierces the transversalis fascia and makes a gentle curve as it passes backward along the anterior half of the inner lip of the iliac crest. It then pierces the transversus abdominis muscle to anastomose with the iliolumbar, superior gluteal, and intercostal arteries, and supplies vasculature to the overlying skin [6].
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Fig 1. The deep circumflex iliac artery (DCIA) is a vessel arising from the lateral surface of the external iliac artery (EIA) just above the inguinal ligament.
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A skin incision of approximately 8 cm in length was made in a lateral portion of the common femoral artery, 1 cm above and parallel to the inguinal ligament. After incision of the external fascia, the preperitoneal space was entered, but not the peritoneal cavity, and the transitional zone of the external iliac and common femoral arteries with the origin of the DCIA was adequately exposed. The dissection started from the origin of the DCIA on the external iliac artery. The pedicle was further separated from its surrounding loose connective tissue using sharp dissection with scissors and electrocautery as well as hemoclips for control of larger branches. The DCIA in a fibrous tunnel formed by the line of attachment of the transversalis fascia and iliacus fascia could be harvested easily in a short time (Fig 2). The length of the arterial graft varied from 8 to 10 cm. The proximal diameter varied from 2.0 to 3.0 mm and the distal diameter from 1.5 to 2.0 mm.
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Fig 2. The DCIA in a fibrous tunnel formed by the line of attachment of the transversalis fascia and iliacus fascia can be harvested easily in a short time.
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Extracorporeal circulation was performed with cannulation of the aorta and the right atrium with a two-staged single cannula through a median sternotomy. A membranous oxygenator was used, and perfusion was performed at a temperature of 36°C. Additional myocardial protection was achieved with cardioplegic solution (potassium chloride, Ringer’s acetate, and autogenous blood with a hematocrit value of 15% to 20%) at 36°C. The DCIA-coronary artery anastomosis was made with a 7-0 polypropylene running suture. The DCIA graft was anastomosed to the ITA, end-to-side, as the side arm of the composite graft.
The angiography at 1 month after the operation showed that the early patency rate of the DCIA graft was 100% (Fig 3).
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Fig 3. The angiography at 1 month after the operation showed that the DCIA graft was anastomosed to the ITA, end-to-side, as the side arm of the composite graft.
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Comment
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In plastic surgery, the DCIA has been used as one of the most important donor vessels for the free transfer of groin flaps. When complete revascularization cannot be obtained with the internal thoracic artery and the other arterial grafts, the DCIA may be an excellent alternative conduit. Harvesting the DCIA as described can be accomplished efficiently in a short time without entering the peritoneal cavity and with no special instrumentation. It can be harvested simultaneously with the internal thoracic artery and the radial artery. We have encountered no detrimental early or late sequelae of the abdominal component of the operation. This artery supplies the soft tissue and the bony wall of the iliac fossa, lower abdominal wall, and a disc of skin over the iliac crest. Although this artery was used as the free arterial graft, necrosis of these tissues was uncommon, because of its rich anastomosis anteriorly, laterally, and posteriorly, with the named arteries. The skin incision used for harvesting the DCIA ran along the inherent skin fold, so the incisional scar was minimal. Also, incisional hernia was not observed.
The length of the DCIA graft varied from 8 to 10 cm; therefore, we used the DCIA graft as the side arm of the composite graft. The anastomosis between the ITA and the DCIA was easy, because the diameter discrepancy was minimal. The DCIA may be a valuable branching graft of the composite graft when complete revascularization cannot be obtained with the conventional arterial grafts.
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References
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Puig L.B., Ciongoli W., Cividanes G.V.L., et al. Inferior epigastric artery as a free graft for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:251-255.[Abstract]
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Taylor G.I., Townsend P., Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps (clinical work). Plast Reconstr Surg 1979;65:745-759.
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Accepted for publication September 27, 1999.
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Abstract
Introduction
