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Ann Thorac Surg 2001;71:2087-2088
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, The University of Miami, and The Jackson Memorial Hospital, Miami, FL 33136, USA
e-mail: tsalerno{at}med.miami.edu
To the Editor
We appreciate the interest of Privitera and associates for our article regarding a technique that we use to prevent graft kinking during coronary revascularization of the circumflex territory through the left thoracotomy approach [1]. Their letter, as well as many other articles that have recently appeared in the literature, confirms that new and innovative modalities of coronary revascularization are being used with increasing frequency, and that avoidance of cardiopulmonary bypass in coronary artery bypass grafting is gaining popularity.
The use of left thoracotomy approach in coronary artery reoperations is appealing in certain situations, as it avoids the hazards of sternal reentry, complications associated with extensive dissection of the heart from adhesions, and the use of cardiopulmonary bypass [2]. This is of particular value in patients who present for coronary artery reoperation and who have patent internal mammary arteries previously used for grafting. Privitera and coworkers are to be commended for using the left thoracotomy approach in these situations. In fact, despite its attractiveness, this procedure presents some aspects that may be particularly challenging. For instance, identifying coronary targets on the lateral wall of the heart may occasionally be difficult and time-consuming. The possibility of kinking the conduit interposed between the circumflex system and the distal descending thoracic aorta is real. This has prompted us to explore alternative techniques to avoid this complication, which was described in our article [1].
We agree with Privitera and associates that interposing the conduit from the circumflex system to the distal aortic arch or to the proximal descending thoracic aorta, using the "suprahilar" route, may be a valid alternative in some situations, particularly in the presence of severe atherosclerotic changes in the distal descending thoracic aorta. In our experience, consisting of more than 150 patients performed using this approach [2], when the distal descending thoracic aorta was severely involved by atherosclerosis, the distal arch and proximal descending aorta were also involved to some extent as well. For this reason, in these situations we have occasionally used other sources of inflow to the coronary grafts, such as the left subclavian artery [3]. In our experience, this vessel has been often found to be spared of atherosclerosis.
In contrast to what Privitera and associates hypothesized, there is no convincing evidence in the literature suggesting that constructing proximal anastomoses more proximally on the aorta results in improved graft flow dynamics, as these are predominantly influenced by the diastolic pressure in the descending thoracic aorta [4, 5]. In this regard, we routinely assess coronary graft flow dynamics in all patients undergoing coronary revascularization using the transit time flow measurement technique [4]. High diastolic flow values, in combination with low pulsatility index [4], are commonly observed in patients whose coronary grafts are connected to the distal descending thoracic aorta.
Furthermore, dissection of the distal aortic arch or proximal descending thoracic aorta can be associated with injury of surrounding structures, such as the recurrent laryngeal nerve. In addition, exposure of the circumflex system when performing the operation through a posterolateral thoracotomy on the fifth intercostal space is superior to that obtained when the proximal descending thoracic aorta is used and the incision is made on the third or fourth intercostal space. Despite these limitations, this technique described by Privitera and associates provides an alternative modality for revascularization through the left thoracotomy approach.
References
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