Ann Thorac Surg 2001;72:915-916
© 2001 The Society of Thoracic Surgeons
Case report
Thoracodorsal artery as a free arterial graft for myocardial revascularization
Gen-ya Yaginuma, MD, PhDa,
Masahiro Sakurai, MDa,
Taiichiro Meguro, MDa,
Katsuya Ota, MDb
a Department of Cardiovascular Surgery, Division of Heart Institute, Sendai Kosei Hospital, Sendai, Japan
b Department of Plastic Surgery, Yamagata Prefectural Central Hospital, Yamagara, Japan
Accepted for publication August 23, 2000.
Address reprint requests to Dr Yaginuma, Department of Cardiovascular Surgery, Division of Heart Institute, Sendai Kosei Hospital, 4-15, Hirose-machi, Aoba-ku, Sendai 980-0873, Japan
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Abstract
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When complete arterial revascularization of coronary circulation cannot be accomplished using the internal thoracic artery and other conventionally used arterial conduits, the thoracodorsal artery may be an excellent alternative. We report the use of the thoracodorsal artery as a free arterial graft in 3 patients, describe the harvesting technique, and review the anatomy.
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Introduction
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The internal thoracic artery (ITA) has proved to be the conduit of choice for coronary arterial revascularization, largely because of the superior short- and long-term patency rates when compared to other conduits [1]. After being abandoned earlier as a satisfactory conduit, the radial artery (RA) has recently been used extensively in several centers [2]. The right gastroepiploic artery (GEA) [3] and the inferior epigastric artery (IEA) [4] have also been used for this purpose.
When complete revascularization cannot be obtained using these grafts, the thoracodorsal artery (TDA) may be a reasonable alternative, particularly in redo cases [5]. Musculocutaneous flaps employing the latissimus dorsi muscle depend on the TDA for arterial blood supply [6]. We have used the TDA as a free arterial graft for direct myocardial revascularization in 3 patients.
The inferior scapular artery (subscapular artery) arises from the axillary artery deep to the lateral border of the pectoralis minor and superficial to the medial border of the subscapularis muscle. It soon divides into two branches, a descending branch (TDA) and a posterior branch (circumflex scapular artery). The TDA averages 2.5 mm in diameter and is about 12 cm in length, including the portion proximal to the origin of the circumflex scapular. Distally, the TDA passes along the surface of the latissimus dorsi, eventually dividing into two branches, one to the latissimus dorsi and one to the serratus anterior. The TDA terminates by piercing the latissimus dorsi and joining the intercostal and lumbar network supplying soft tissue and skin.
The patient is positioned supine with the arms abducted about 90 degrees at the shoulders (Fig 1A). A vertical skin incision, about 10 cm in length is made along the lateral thoracic wall in the midaxillary line. The connective tissue between the latissimus dorsi and the serratus anterior is carefully dissected, and the TDA exposed by posterior traction on the latissimus dorsi. Harvest of the TDA is begun from its proximal portion using mostly sharp dissection with scissors, and applying metallic clips to the larger branches. The electrocautery is used on smaller branches and only at a safe distance from the main trunk of the TDA, similar to harvesting an ITA. The TDA is about 3.0 mm in diameter in its proximal portion and 2.0 mm distally. The average length is 12.0 cm. The left TDA can be harvested simultaneously with the left ITA and the right or left RA (Fig 1B).
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Fig 1. (A) The patient is positioned supine with the arms abducted about 90 degrees at the shoulders. (B) The left thoracodorsal artery (TDA) can be harvested simultaneously with the left internal thoracic artery (ITA).
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Case reports
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We do not routinely use bilateral ITAs in our practice, because of the risk of mediastinitis, particularly in patients with diabetes mellitus. Additionally, because of the risk of gastric cancer or ulcer in our patient population, we rarely use the GEA as a bypass conduit. We have used the TDA as a free graft in 3 patients.
Case 1
A 49-year-old diabetic male presented with unstable angina, and was found to have triple vessel coronary disease: 75% left main trunk (LMT), 75% obtuse marginal (OM), and 90% right coronary (RCA). The left RA had a localized stenosis. Coronary artery bypass grafting (CABG) x 3 was done using the left ITA to the left anterior descending (LAD) artery, the right RA to the RCA and the right TDA to the OM.
Case 2
A 51-year-old diabetic male with nondialysis-dependent renal failure presented with unstable angina, and was found to have severe coronary occlusive disease: 75% LM, 90% LAD, 90% left circumflex (LCX), 75% RCA, and 90% right postero-descending (RPD). Because of the projected need for hemodialysis in the future, the left RA was not available for use as a bypass conduit. CABG x 4 was done using the left ITA to the LAD and a composite right RA–left TDA graft sequentially to the LCX, the postero-lateral branch of the RCA (RPL) and the RPD.
Case 3
A 70-year-old male presented with complications following catheter intervention for an acute myocardial infarction. He had total occlusion of the LAD and its first diagonal branch (D1), a 90% stenosis of a large OM, and a patent stent on the RCA. Neither RA could be used because of severe atherosclerotic disease. CABG x 3 was done using the left ITA to the LAD and a left TDA as a Y-graft to the OM and D1 (Fig 2).
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Fig 2. The angiography after the operation showed that the thoracodorsal artery (TDA) graft (Y-graft) from the ascending aorta to the obtuse marginal (OM) and first diagonal branch (D1) was patent.
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Comment
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The TDA is the major arterial supply for musculocutaneous flaps that use the latissimus dorsi and the overlying soft tissues and skin. Its size and configuration make it suitable for use as a conduit for CABG when complete arterial revascularization cannot be accomplished with the more commonly used arterial conduits. The TDA can be quickly and easily harvested simultaneously with the ITA and RA, when appropriate.
Mathes and Nahai [6] have classified the arterial circulation of muscle into five patterns: Type I, a single vascular pedicle; Type II, a dominant pedicle and a minor pedicle; Type III, two dominant pedicles and a minor pedicle; Type IV, a segmental vascular pedicle, and Type V, one dominant pedicle and secondary segmental pedicles. The circulation of the latissimus dorsi is Type V; that is, the muscle, soft tissue and overlying skin are supplied by the TDA as a pedicle, but the rich anastamotic network with intercostal and lumbar arteries prevents necrosis of these tissues following removal of the TDA. However, one should not do extensive soft tissue dissection when harvesting the TDA to preserve these collateral vessels.
In our experience, the length of the TDA was 10 to 14 cm, adequate for use as a CABG conduit, either as a free graft or a Y-graft. Additionally, the skin incision used for harvesting the TDA, in the low axilla, is cosmetically quite acceptable. We have been pleased with our experience in using the TDA and feel that it is acceptable as a CABG conduit when the more commonly used arterial conduits are unavailable.
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Acknowledgments
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Dr William Gay edited this manuscript for English syntax and grammar. We thank him for his helpful suggestions.
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References
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Mathes S.J., Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 1981;67:177-187.[Medline]
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Abstract
Introduction
