Ann Thorac Surg 2001;72:636-637
© 2001 The Society of Thoracic Surgeons
How to do it
Extended use of radial artery with Y-graft technique for complete arterial revascularization
Ahmet Turan Yilmaz, MDa,
Ertugrul Özal, MDa,
Celalettin Günay, MDa,
Mehmet Arslan, MDa,
Harun Tatar, MDa
a Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Ankara, Turkey
Accepted for publication April 5, 2001.
Address reprint requests to Dr Yilmaz, Department of Cardiovascular Surgery, Gülhane Military Medical Academy, 06018 Etlik, Ankara, Turkey
e-mail: ozals{at}tr.net
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Abstract
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One of the biggest problems encountered during complete arterial revascularization is difficulty obtaining sufficient graft length to perform multiple distal anastomoses. We describe a technique of dividing the radial artery during harvest and forming one or more composite Y-grafts to allow end-to-side rather than sequential anastomoses without substantially decreasing usable conduit length. This approach has merit and may be helpful in some patients who require complex arterial grafting.
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Introduction
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The goal of coronary artery bypass operations is complete revascularization, and there is increasing interest in total arterial revascularization to achieve this goal because of the relatively high late failure rate of saphenous vein grafts [1]. The availability of arterial conduit long enough to perform complete arterial revascularization is a limitation of the procedure, and it is mandatory to adjust the length of the available graft to serve the need. To overcome this problem, sequential or composite grafting techniques or a combination of these has been developed, and one conduit is used for more than one distal anastomosis [2]. However, sequential grafting with arterial grafts may not be convenient in every situation, and surgical technique can be challenging. Also, the classic radial artery (RA) Y-graft technique has the disadvantage of shortening the graft length. We describe a modification of the RA Y-graft technique in which each segment is based on the previous segment for more than one end-to-side distal anastomosis without substantially shortening graft length before the patient is placed on cardiopulmonary bypass.
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Technique
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During left internal mammary artery (LIMA) harvesting, the RA is dissected. Its distal end is cut, and the proximal end is left in situ. The pericardium is opened. In patients in whom the proximal end of the RA Y-graft is anastomosed to the ascending aorta, the distance between the aorta and the first distal anastomosis is measured with a silk suture or with the surgeon’s left index finger while the heart is full and beating. When the RA Y-graft is constructed as a composite graft with the LIMA, the distance between the left border of the main pulmonary artery and the first distal anastomosis is measured in the same way. With preservation of the measured length from its origin at the brachial artery, the RA is divided, and the distal segment is anastomosed side-to-end 1 to 1.5 cm proximal to the in situ trunk (Fig 1).
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Fig 1. Construction of radial artery Y-graft in forearm. Radial artery Y-graft with three limbs is prepared. Blood flow in each limb is controlled by pulsatile flow from the brachial artery. The taper property of the radial artery from the proximal end to the distal end is emphasized.
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If more than two distal anastomoses are planned, the distances between the other limbs of the RA Y-graft are calculated both by cineangiographic views and by direct measurement on the beating heart. An additional 1 to 2 cm per measured length is included. The RA is divided, and the distal portion is anastomosed side-to-end to the preceding proximal portion (see Fig 1). The proximal anastomosis of each limb on the previous limb is performed as a Y anastomosis using running 7-0 polypropylene.
All limbs of the Y graft are assessed for adequate flow with pulsed blood from the brachial artery. Papaverine hydrochloride, 2 mg/mL, diluted with blood is injected through the distal end of the graft. The skin incision in the forearm is closed and the brachial end of the graft is left attached until cross-clamp application or construction of a LIMA–RA composite graft. In all our patients, the LIMA was anastomosed to the left anterior descending coronary artery. Other occluded coronary arteries were bypassed in an end-to-side fashion using an RA Y-graft.
We have used this technique in 17 patients, and grafting strategy was successful in all but 2 of them. In these 2 patients, the distal limb did not reach the target vessel, and local endarterectomy was required. Three patients have undergone postoperative angiographic study, and patency of each graft segment was confirmed. All patients remain free from angina, and results of thallium stress tests during follow-up (range, 2 to 18 months) have been negative.
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Comment
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When a sequential anastomosis with an arterial graft is performed, a longitudinal anastomosis technique is preferable to a diamond-shaped technique because it provides a wider ostium, causes less turbulant flow, prevents anastomotic stricture, avoids distortion of the coronary artery or graft, and is easier to do [3–5]. However, the most important problem encountered during complete arterial revascularization using a sequential anastomosis technique is insufficient graft length for the configuration of the graft, especially when more than two anastomoses are performed. To solve the problem of graft length insufficiency, a LIMA–RA composite graft can be constructed, but this may not be possible in every case (eg, poor quality of LIMA or two adjacent coronary artery branches).
In the classic Y-graft technique, the graft is usually not long enough for more than two anastomoses. Compared with that technique, our method shortens the graft length much less. Construction of the classic Y-graft requires prolonged times of cardiac arrest and cardiopulmonary bypass [2]. In addition, making a Y-graft in the pericardium is technically more difficult than doing one in the forearm. An RA Y-graft built using one technique preserves its taper property, and this provides more physiologic flow hemodynamics. Besides this, there are at least four advantages to constructing an RA Y-graft before it is severed from the brachial artery. Patency of the anastomoses can be tested using pulsatile blood. A minimal period of ischemia and maximal dilatation of the prepared graft are achieved by leaving it attached to the brachial artery until cross-clamp application or anastomosis to the LIMA. Any bleeding from an anastomosis or a little branch can be visualized and controlled easily. All proximal anastomoses of the Y-graft segments are performed during preparation of the IMA, thus decreasing the time of operation.
The major difficulty of our technique is measuring correctly. The distances between the limbs of the RA Y-graft must be calculated properly because the graft is constructed before the distal anastomoses are performed. The most important step is to correctly gauge the distance between the proximal anastomosis of the RA Y-graft and the first distal anastomosis and the distance between the proximal anastomosis and the last distal anastomosis (the length of the Y graft). We have encountered no problems related to measurement and lengths of the segments. Because we add 1 to 2 cm to the measured distances, the construction of intermediate limbs has not been a problem.
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References
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Sundt T.M., III, Barner H.B., Camillo C.J., Gay W.A., Jr Total arterial revascularization with an internal thoracic artery and radial artery T graft. Ann Thorac Surg 1999;68:399-405.[Abstract/Free Full Text]
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Barner H.B. Techniques of myocardial revascularization. In: Edmunds L.H., ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:481-534.
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Barner H.B. The continuing evolution of arterial conduits. Ann Thorac Surg 1999;68:S1-S8.
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Aguero O.R., Navia J.L., Navia J.A., Mirtzouian E. A new method of myocardial revascularization with the radial artery. Ann Thorac Surg 1999;67:1817-1818.[Abstract/Free Full Text]
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Slater A.D., Gott J.P., Gray L.A., Jr Extended use of bilateral internal mammary arteries for coronary artery disease. Ann Thorac Surg 1990;49:1014-1015.[Abstract/Free Full Text]
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