Ann Thorac Surg 2002;74:939-940
© 2002 The Society of Thoracic Surgeons
How to do it
Coronary artery bypass via diaphragmatic approach with free graft
Norihiro Kondo, PhDa,
Kenji Takahashi, MD*a,
Masahito Minakawa, MDa,
Shigeru Oikawa, MDa,
Masaharu Hatakeyama, PhDa
a Department of Cardiovascular Surgery, Aomori Rousai Hospital, Hachinohe, Japan
Accepted for publication February 18, 2002.
* Address reprint requests to Dr Takahashi, Department of Cardiovascular Surgery, Aomori Rousai Hospital, 1 Minamigaoka, Shirogane, Hachinohe, Aomori, 031-0822 Japan
e-mail: takaken{at}aomorih.rofuku.go.jp
 |
Abstract
|
|---|
To avoid injury to patent bypass grafts or myocardium during median sternotomy in coronary artery bypass graft reoperation, we performed modified minimally invasive direct coronary artery bypass to the right coronary artery via diaphragmatic approach using the right gastroepiproic artery. In cases in which the right gastroepiproic artery cannot be used, this technique is performed with a free graft from the gastroduodenal artery. This approach is very useful for reoperation in these circumstances.
|
Introduction
|
|---|
In coronary reoperations, patent bypass grafts are sometimes injured during median sternotomy. Therefore, for reoperative cases with a patent graft, we have developed a method of modified minimally invasive direct coronary artery bypass via diaphragmatic approach, involving free grafting from the gastroduodenal artery (GDA) to the right coronary artery (RCA).
|
Technique
|
|---|
The patient is placed in supine position, with the costal arch raised about 10 cm with a pillow. The GDA (inflow site) is exposed and taped. The exposed portion includes the bifurcation of the common hepatic artery into the proper hepatic artery and the GDA. An approximately 5-cm incision is made in the central tendon of the diaphragm, and the pericardium is cut open; segment 3 (seg 3) and the posterior descending artery (4PD) are exposed. Anastomosis of the coronary artery (seg 3) and free graft is performed with an interrupted suture using 7-0 polypropylene. The graft is drawn to a presumptive part of the GDA through the front of the liver (anterohepatic route). After the GDA is clamped, an anastomotic orifice is created, and end-to-side anastomosis of the graft and GDA is performed with an interrupted suture using 7-0 polypropylene. After anastomosis, hemostasis is checked and the incisions in the pericardium and diaphragm are sewn up. No drain is placed in the peritoneal space. Postoperative angiography revealed that the graft was patent, and the right coronary artery was visible through the graft. The following paragraphs describe 2 cases in which this procedure was performed.
Case 1 was a 66-year-old man who underwent coronary artery bypass grafting (CABG) of four branches in 1993: left internal thoracic artery (LITA)-circumflex (Cx), right internal thoracic artery (RITA)-left anterior descending (LAD), Aorta (Ao)-seg 3 and Ao-seg 8 with saphenous vein graft (SVG). In January 1999, because of chest pain, cardiac catheterization was performed. Although LITA-Cx and Ao-LAD were patent, RITA-seg 8 and Ao-seg 3 were occluded. The RCA showed collateral blood flow from the Cx.
Case 2 was a 73-year-old man who underwent distal gastrectomy for gastric cancer in 1976, CABG of two branches (LITA-LAD and Ao-Cx with SVG) in 1991, percutaneous transluminal coronary angioplasty (seg 13) in 1992, and pacemaker implantation for sick sinus syndrome in 1994. In 1998, because of chest pain, cardiac catheterization was performed. Although the graft was patent, it showed long stenosis (90%) from seg 1 to seg 2.
In case 1, after upper median laparotomy, the right gastroepiproic artery (RGEA) was examined and judged not suitable for grafting; in case 2, the RGEA had previously been excised.
|
Comment
|
|---|
To avoid injury to patent bypass grafts or myocardium during median sternotomy in CABG reoperation, methods for reaching coronary arteries requiring bypass surgery have been devised [1–3]. The diaphragmatic approach [1] is very useful in cases requiring CABG to the RCA. Advantages of this approach include reduced bleeding, shortened operation time, and stabilization of the anastomotic site by adhesion of the pericardium and heart. In cases where the RGEA cannot be used (eg, postgastrectomy or hypoplastic RGEA; approximately 5% of cases, in our experience), bypass via the diaphragmatic approach with a radial artery or a saphenous vein is performed (Fig 1),
using the GDA as inflow. With this method, it is important to obtain a good view; for this, we use various devices. The costal arch is raised about 10 cm with a pillow. Using a Kent retractor on either side of the costal arch, a space is made between the diaphragm and the left lobe of the liver, and the RCA can be observed through the diaphragm. After the diaphragm is cut open, the heart is raised by suture fixation of the pericardium and the diaphragm ventral incisional edge to the cranial abdominal wall. Suture fixation of the end of each drape to the dorsal incisional edge of the pericardium and diaphragm is performed. Another side of each drape is fixed to the caudal side of the abdominal wall. The drapes depress the left lobe of the liver and prevent the intestines from protruding.
View larger version (36K):
[in this window]
[in a new window]
|
Fig 1. Scheme of the operative procedure. Anastomosis to right coronary artery (A), and distal anastomosis to gastroduodenal artery (B). (CBD = common bile duct; CHA = common hepatic artery; 4PD = posterior descending artery; GDA = gastroduodenal artery; Seg. 3 = segment 3).
|
|
First, distal anastomosis is performed. The 4PD is generally the best part of the RCA for use in anastomosis. However, in cases in which anastomosis to 4PD would be difficult, anastomosis to seg 3 is performed. Test clamping of the coronary artery is performed before anastomosis, and the existence of ST segment change or generation of arrhythmia is checked at this time. If ST segment change or a serious arrhythmia arises, an extracorporeal shunt from the femoral artery is inserted into the coronary arteries. When anastomosis to the atrioventricular node branch (4AV) is required, an incision line is extended 1 to 2 cm to the left so that 4AV can be exposed.
The part of the GDA used for anastomosis is the area where the proper hepatic artery and the GDA branch from the common hepatic artery. This part is not removed during lymph node dissection during gastrectomy [4]; there was no adhesion of it in case 2. Although the anterohepatic route has the advantage of allowing blood flow of a graft to be checked with a Doppler stethoscope, postoperative angiography showed that the graft might be bent by the edge of the left lobe of the liver (Fig 2).
Therefore, we cut the left hepatic triangle ligament and pass the graft through (posterohepatic route).
View larger version (166K):
[in this window]
[in a new window]
|
Fig 2. Postoperative angiography. Right coronary artery was visible through graft (1), and graft might be bent by edge of left lobe of liver (2). (CHA = common hepatic artery; GDA = gastroduodenal artery; PHA = proper hepatic artery; RA = radial artery; RCA = right coronary artery.)
|
|
Free grafting from the GDA to the RCA via the diaphragmatic approach is very useful for reoperation when the RGEA cannot be used.
|
References
|
|---|
- Minakawa M., Takahashi K., Kondo N., et al. Minimally invasive direct coronary artery bypass performed via diaphragmatic approach. Jpn J Thorac Surg 2000;54:288-292.
- Ricci M., Karamanoukian L.H., Jajkowski M.R., et al. The innominate artery as an inflow site in coronary reoperations without cardiopulmonary bypass. Ann Thorac Surg 2000;69:1606-1608.[Abstract/Free Full Text]
- Magovern J.A., Hunter T.J., Yoon P.D. Clinical results with left axillary to left anterior descending coronary artery bypass. Ann Thorac Surg 2000;71:561-564.[Abstract/Free Full Text]
- Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma, 13th ed. Tokyo: Kanehara and Co, Ltd, 1999:6-12.
This article has been cited by other articles:
|
|
|
|
 
K. Takahashi, K. Daitoku, M. Minakawa, N. Kondo, K. Naito, and S. Oikawa
Coronary artery bypass grafting using an abdominal artery as an inflow.
Ann. Thorac. Surg.,
July 1, 2006;
82(1):
69 - 73.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
