Ann Thorac Surg 2000;69:1606-1608
© 2000 The Society of Thoracic Surgeons
How to do it
The innominate artery as an inflow site in coronary reoperations without cardiopulmonary bypass
Marco Ricci, MD, PhDa,
Hratch L. Karamanoukian, MDa,
Mark R. Jajkowski, MDa,
Giuseppe D’Ancona, MDa,
Jacob Bergsland, MDa,
Tomas A. Salerno, MDa
a Division of Cardiothoracic Surgery and Center for Minimally Invasive Cardiac Surgery, Kaleida Health System and State University of New York at Buffalo, Buffalo, New York, USA
Address reprint requests to Dr Karamanoukian, Division of Cardiothoracic Surgery, Buffalo General Hospital, 100 High St, Buffalo, NY 14203
e-mail: lisbon5{at}yahoo.com
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Abstract
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The innominate artery was used as an inflow site in 20 patients undergoing redo coronary operations without cardiopulmonary bypass. This technique was adopted when extensive adhesions and old patent grafts were present, to avoid dissection of the ascending aorta and eliminate the risk of graft injury or embolization. This strategy considerably facilitated construction of proximal anastomoses and was associated with favorable perioperative outcomes.
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Introduction
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Coronary artery bypass grafting without cardiopulmonary bypass is an important alternative to conventional myocardial revascularization [1]. One of the advantages of this technique is represented by, but is not limited to, avoidance of extracorporeal circulation, with its detrimental systemic effects [2]. Recent refinements of techniques of cardiac elevation and mechanical stabilization [3] have made primary and reoperative off-pump myocardial revascularization technically feasible, so that even lateral and inferior wall coronary arteries (ie, distal right coronary artery, posterior descending artery, marginal branches of the circumflex artery) can be grafted on the beating heart [4]. Although advances in techniques of mechanical stabilization and coronary exposure have considerably facilitated performance of distal anastomoses on the beating heart, construction of proximal anastomoses during primary or redo operations has remained essentially unchanged. In fact, except in those patients in whom coronary revascularization is accomplished by exclusively using pedicled arterial grafts (right or left mammary arteries, right gastroepiploic artery), the ascending aorta is commonly used as inflow conduit in the vast majority of patients. Manipulation of the ascending aorta during redo operations, however, may be technically difficult and can result in inadvertent graft injury or distal embolization when patent aortocoronary grafts are present [5].
On the basis of these considerations, the aim of the present article is to describe an alternative technique, which consists of using the innominate artery as an inflow site for coronary grafts in off-pump coronary reoperations.
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Technique
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The reason for using the innominate artery for construction of proximal anastomoses is to avoid dissection and manipulation of the ascending aorta in the presence of old patent grafts, and particularly tenacious adhesions related to previous operations. In this setting, injury to patent coronary grafts supplying graft-dependent areas of myocardium may be catastrophic, and placement of a lateral occlusion clamp on the ascending aorta is often problematic. In our patients this strategy was adopted when a preoperative carotid duplex did not reveal any significant carotid stenosis (50% or more) and intraoperative palpation of the innominate artery showed absence of calcifications or severe atherosclerotic disease. Proximal anastomoses on the innominate artery are constructed using a running 6-0 Prolene (Ethicon, Somerville, NJ) suture after partial occlusion clamping of the artery has been accomplished (Fig 1). In our experience, we have noted that a maximum of two proximal anastomoses can be performed on the innominate artery (Fig 2). Alternatively, patients requiring more than two coronary grafts, and in whom the left internal mammary artery has been previously used, can be managed by constructing the proximal anastomosis of the additional coronary graft on one of the grafts originating from the innominate, in a T or Y configuration (Fig 3).
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Fig 1. A partial occlusion clamp is placed on the innominate artery, and the proximal anastomosis of a vein graft is constructed using 6-0 Prolene in a running fashion.
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Fig 3. In patients necessitating more than two coronary grafts, and in whom the left internal mammary artery has been previously used, two vein grafts can be based on the innominate artery, and a third coronary graft can be connected to one of the other two, in a T or Y configuration.
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Pitfalls and technical details of coronary revascularization on the beating heart have all been previously described in the literature [1, 6, 7]. Adequate exposure and mechanical stabilization of all target vessels allow grafting of all coronary arteries without cardiopulmonary bypass, including those located on the lateral and inferior wall of the heart (distal right coronary artery, posterior descending artery, and marginal branches of the circumflex artery). In the setting of reoperations, however, extensive dissection of the epicardium from adhesions is often avoided, and limited to areas of myocardium where target coronary arteries are located. Not only does this strategy reduce the risk of injuring old patent grafts, but it also contributes significantly in improving stability and target immobilization. Ischemic preconditioning by occluding the target coronary artery for 3 to 5 minutes is routinely performed. During construction of distal anastomoses, preservation of distal flow within the target coronary artery is usually accomplished by using an intracoronary shunt-occluder. Importantly, a bloodless field is maintained using a CO2 blower/saline aerosolizer [8]. On completion of distal and proximal anastomoses, graft patency is routinely assessed using the Doppler-based technique transit time flow measurement, as previously described [9].
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Comment
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Reoperative coronary revascularization without cardiopulmonary bypass has been recently introduced as an alternative to conventional myocardial revascularization in an attempt at reducing morbidity and mortality [7, 10]. Although a less invasive surgical approach may not protect from the dangers of sternal reentry, avoidance of cardiopulmonary bypass in the setting of coronary reoperations obviates instrumentation of the ascending aorta for cannulation and cross-clamping. In these patients, manipulation of the ascending aorta and old coronary grafts can be totally eliminated by using saphenous vein grafts whose proximal anastomoses are constructed on the innominate artery, alone or in combination with pedicled arterial conduits (ie, left internal mammary artery to left anterior descending coronary artery). In our experience, such a strategy was used in less than 7% of all coronary reoperations performed without cardiopulmonary bypass (20 of 290 patients). In fact, it was used in those patients presenting with patent coronary grafts in combination with extensive adhesions involving the ascending aorta, when it was believed that dissecting the aorta would have considerably increased the risk of graft injury, or placement of the lateral occlusion clamp on the aorta would have been technically cumbersome.
Although the use of the innominate artery as an alternative inflow conduit for coronary grafts has been previously described in the management of patients with calcified ascending aorta [11], an argument could be made as to whether the use of the innominate artery in this setting would prevent cerebral embolization [12]. In fact, there has been evidence to suggest that the likelihood of this vessel being involved by atherosclerotic disease in the presence of aortic disease is considerable, and it may be as high as 30% [13]. As a result, manipulation of the innominate artery in the presence of severe aortic disease should be discouraged, as it may potentially result in cerebral embolization and adverse neurologic outcome. Similarly, the use of the innominate artery for construction of proximal anastomoses was avoided in patients in whom a preoperative Duplex scanning revealed evidence of significant carotid stenosis, especially on the left side. Unlike the ascending aorta, in fact, lateral occlusion clamping of the innominate artery often results in near-total or total occlusion of the lumen of the artery, as a consequence of the smaller size of the vessel. This may lead to suboptimal cerebral perfusion in those patients affected with severe occlusive disease of the carotid arteries, especially on the left side. Based on these considerations, we routinely perform Duplex of the carotid arteries preoperatively, and we avoid manipulation of the innominate artery in those patients with significant cerebrovascular disease.
In conclusion, the innominate artery was used successfully as inflow site of coronary grafts in a limited number of patients. Although data regarding long-term outcomes are currently lacking, this strategy considerably facilitated potentially cumbersome reoperations, and was associated with favorable perioperative outcomes.
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References
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Accepted for publication December 22, 1999.
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Abstract
Introduction
