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Ann Thorac Surg 2001;71:2086-2087
© 2001 The Society of Thoracic Surgeons
a Division of Cardiovascular Surgery, The Toronto Hospital, Department of Surgery, University of Toronto, Toronto, Ontario M5G 2C4, Canada
e-mail: robert.cusimano{at}uhn.on.ca
To the Editor
We read with great interest the article written by Ricci and associates [1] regarding prevention of graft kinking in redo "off-pump" circumflex revascularization through left thoracotomy.
We have performed five reoperative posterior revascularization procedures using "off-pump" techniques through left thoracotomy. Initially, our approach paralleled the initial approach of Ricci and colleagues [1]. Our first 2 patients involved passing saphenous vein grafts from the circumflex system to the descending thoracic aorta inferior to the inferior pulmonary ligament. Subsequently, we altered our technique based on two reasons. First, due to the general increasing incidence of atherosclerosis as one proceeds along the aorta toward the diaphragm, there is potential difficulty in placing the partial occluding clamp safely, especially with complex atheromatous disease. Thickening of the aorta due to atheroma may also lead to difficulties in performing adequate anastomoses using a partial occluding clamp in patients with a heavy atherosclerotic burden. Second, due to factors described by Pagni and associates [2] regarding increasing phase delay of graft flow with increasing distance from the aortic valve compared to coronary blood flow, we believe it would be safer and better to place the aortic anastomoses as proximal as possible to allow adequate graft flow and to diminish systolic flow reversal within the grafts.
Our subsequent 3 patients involved 1 patient in whom a single coronary artery bypass graft with a saphenous vein was constructed from an obtuse marginal branch of the circumflex artery to the distal aortic arch, with the vein brought superior to the hilum. Two other patients received double coronary artery bypasses. One patient received a radial artery from the ramus intermedius and a saphenous vein graft from an obtuse marginal branch and the second patient had a sequential graft from two obtuse marginal vessels. Both patients had their bypasses carried superior to the hilum and both had proximal anastomoses constructed to the proximal descending thoracic aorta. Thus, in each of these latter 3 patients we passed the vessels superior to the hilum and anastomosed them to the distal arch/proximal descending aorta. In this manner we avoid the intrahilar dissection of Ricci and colleagues. Graft turgor and pulmonary stenting against the mediastinum prevent kinks and as long as ample room superior to the hilum is maintained, excessive draping around the hilum is prevented. Graft patency and excellent diastolic flow are confirmed using Doppler flow measurements.
The method of Ricci and associates addresses some of our earlier concerns, but we believe avoidance of the hilum and intrahilar structures, as well as a more proximal aortic anastomosis, may offer the patient a safer operation with theoretically better graft flow characteristics.
References
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