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Ann Thorac Surg 2001;71:1401-1402
© 2001 The Society of Thoracic Surgeons

Correspondence

Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery: Reply

Marco Ricci, MDa, Hratch L. Karamanoukian, MDa, Giuseppe D’Ancona, MDa, Jacob Bergsland, MDa, Tomas A. Salerno, MDb

a Division of Cardiothoracic Surgery, State University of New York at Buffalo, Buffalo General Hospital, 100 High St, Buffalo, NY 14203, USA
b Division of Cardiothoracic Surgery, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA

e-mail: lisbon5{at}yahoo.com

To the Editor

We read with interest the letter by Radermecker and colleagues [1] in which the authors described a case of avulsion of the left internal mammary artery (LIMA) from the left anterior descending (LAD) coronary artery after minimally invasive direct coronary artery bypass (MIDCAB). As in the case previously described by our group [2], their report demonstrates that while innovative approaches to coronary artery surgery are under experimentation, new complications are reported.

We agree with the authors [1] that although the exact mechanism of avulsion remains unclear, the insufficient dissection of the LIMA from the chest wall probably plays an important role in the pathogenesis of this complication. In fact, even though the LIMA-to-LAD graft may not appear to be under tension immediately after completion of the distal anastomosis, stretching of the graft may develop postoperatively as a result of strenuous exercise [1, 2]. In this setting, it is plausible that vigorous physical activity may result in abrupt respiratory excursions and movement of intrathoracic organs that, in turn, may cause tension on the LIMA with the risk of disruption of the anastomosis to the LAD.



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  		Fig 1. Possible mechanism of avulsion of an H-graft during cardiopulmonary resuscitation (CPR). The displacement of the sternum during chest compression (A) and release (B) may result in stretching of the H-graft with potential disruption of the proximal or distal anastomosis.

 
Of note, we have recently reported a case of avulsion of a saphenous vein graft from the LAD in a patient who underwent MIDCAB using the H-graft procedure [3]. This technique, as described by Cohn and associates [4], entails the interposition of a segment of saphenous vein or arterial conduit between the LIMA and the LAD, thereby limiting dissection of the LAD from the chest wall, which can be quite tedious and time consuming when performed through a small anterior thoracotomy. In our patient, this complication occurred during the early postoperative period, as a result of closed chest cardiopulmonary resuscitation performed for unexpected cardiac arrest. As there has been evidence to suggest that closed chest cardiac massage routinely causes 1 to 2 inch displacement of the sternum [3], we hypothesized that separation of the H-graft from the LIMA could have resulted from vigorous chest compressions [3] (Fig 1).

In light of these consideration, in accordance with Radermecker and colleagues [1], we believe that thorough dissection and mobilization of the LIMA from the chest wall during MIDCAB almost certainly represents the most effective method of preventing this rare but potentially lethal complication. Similarly, great care should be taken in ensuring extra length of the conduit interposed between the LIMA and the LAD during the H-graft procedure. It may also be advisable to secure the LIMA to both the epicardium and pericardial edges with tacking sutures, as this may effectively prevent anastomotic disruption in the face of increased tension on the LIMA graft. These technical details may be especially important in patients with severe chronic obstructive pulmonary disease, as lung hyperinflation may further aggravate stretching of the coronary graft. Furthermore, although early postoperative mobilization is undoubtedly beneficial, strenuous physical activities and heavy exercising should probably be discouraged for several weeks after surgery.

References

  1. Radermecker M.A., Grenade T., Desiron Q., Limet R. Avulsion of the left internal mammary artery after minimally invasive coronary bypass. Ann Thorac Surg 2001;71:1401.[Free Full Text]
  2. McMahon J., Bergsland J., Arani D.T., Salerno T.A. Avulsion of the left internal mammary artery after minimally invasive coronary bypass. Ann Thorac Surg 1997;63:843-845.[Abstract/Free Full Text]
  3. Ricci M., Karamanoukian H.L., D’Ancona G., Jajkowski M.R., Bergsland J., Salerno T.A. Avulsion of H graft during closed-chest cardiopulmonary resuscitation after minimally invasive coronary bypass grafting. J Cardiothorac Vasc Anesth 2000;14:586-587.[Medline]
  4. Cohn W.E., Suen H.C., Weintraub R.M., et al. The H graft: An alternative approach for performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 1998;115:148-151.[Abstract/Free Full Text]

Related Article

Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery
Marc A. Radermecker, Thierry Grenade, Quentin Desiron, and Raymond Limet
Ann. Thorac. Surg. 2001 71: 1401. [Extract] [Full Text] [PDF]




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