Ann Thorac Surg 2003;76:954-955
© 2003 The Society of Thoracic Surgeons
How to do it
The "
-Anastomosis": a new revascularization technique for coronary bifurcations
Massimo Bonacchi, MDa*,
Edvin Prifti, MD, PhDa,
Gabriele Giunti, MDa
a Department of Cardiac Surgery, Careggi Hospital, University of Florence, Florence, Italy
Accepted for publication December 5, 2002.
* Address reprint requests to Dr Bonacchi, Department of Cardiac Surgery, University Hospital of Florence, Policlinico Careggi, Viale Morgagni, 85, 50134 Firenze, Italy
e-mail: mbonacchi{at}hotmail.com
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Abstract
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We report the "
-anastomosis," a new technique permitting the revascularization of both coronary branches beyond a bifurcation by using a single arterial graft. This technique consists of a longitudinal incision in the main coronary artery, which extends to both coronary branches beyond the bifurcation. The arterial conduit’s distal extremity is cut vertically and tailored to produce a "bipetal" shape, which is used to enlarge and create an acceptable roof for both coronary branches beyond the bifurcation.
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Introduction
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Improved survival and reduced cardiac events have been documented in patients receiving the left (LIMA) and right internal mammary artery (RIMA) [1] to achieve total arterial myocardial revascularization (TAMR) [2, 3]. In selected patients the atherosclerotic lesion may be localized to one of the coronary bifurcations: sometimes both, the main coronary vessel and its branches beyond the bifurcation are severely stenotic or occluded. Herein we are reporting the "-anastomosis," a new technique permitting the revascularization of both coronary branches beyond the bifurcation by using a single arterial graft.
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Technique
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After a median longitudinal sternotomy, the LIMA and/or RIMA are harvested in a skeletonized fashion and the radial artery (RA) is harvested according to the "pedicled technique" [2].
"-Anastomosis" construction
The coronary bifurcation presenting a critical stenosis is identified. The main coronary artery involved is gently incised proximally to the bifurcation employing a scalpel and then extended by Potts scissors, further to the main coronary branch beyond the bifurcation. After identifying the second coronary vessel, another arteriotomy is performed, initiating from its origin and extended beyond the stenotic lesion (Fig 1A).
If the coronary vessel, before bifurcation, or its branches is occluded, the coronary endoartherectomy is performed to rebuild the intraluminal space. The distal extremity of the arterial conduit (caliber > 3 mm) is cut vertically and opened, enough to have a comparable size to the length of the major coronary arteriotomy extension, thus creating an anterior distal flap of the arterial conduit. Then the graft’s distal extremity is incised approximately in the midline, depending on the direction and caliber of the secondary coronary branch, and more or less deeply according to the length of major postbifurcation coronary vessel’s atherotomy (Fig 1B). The arterial graft is effectively tailored to obtain a "bipetal" shape and the arterial petals are trimmed. These "petals" are used to enlarge and create an acceptable roof for both coronary branches beyond the bifurcation. The anastomosis is performed using a continuous 8-0 polypropylene suture, initiating from the main coronary artery (Fig 1C). After completing the anastomosis, the residual adventitial tissue around the anastomosis area is removed to avoid the early or later graft stenosis.
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Fig 1. The schematic presentation of the "-anastomosis" construction. (A) The longitudinal incision of the main coronary vessel extended to both coronary branches beyond the bifurcation. (B) The distal extremity of the arterial graft is effectively tailored to obtain a bipetalous shape. (C) Anastomosis completion. (X = length of the vertical arterial graft incision; Y = length of one of the constructed arterial graft’s petalus; Z = wideness of one of the graft’s petalus.)
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Twelve "-anastomoses" were constructed; in 7 patients with the RA (6 at the right coronary artery crux, and 1 at the circumflex bifurcation) and in 5 other patients with LIMA (3 at the bifurcation between the left anterior descending artery [LAD] and the diagonal branch, and 2 at the bifurcation between the LAD and the first septal branch). The postoperative coronary angiography in 6 patients revealed a good patency of the "-anastomosis" with excellent run-off in both their distal branches (Figs 2A, 2B).
At follow-up the treadmill stress test was negative in all cases.
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Comment
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The use of the internal mammary arteries (IMAs) have developed in an incremental manner from anastomosing the in situ LIMA to LAD, to the use of bilateral IMAs and preconstructed grafts [2, 3] due to its excellent long-term outcome [1, 4]. Length limitation is the main disadvantage of the arterial grafts. It is difficult to achieve TAMR when secondary but relevant branches, such as the diagonal artery, are involved because of atherosclerotic disease at the bifurcation sites, or for any reason one of the IMAs or RA do not have an acceptable caliber or flow, or have been damaged during the harvesting procedure.
When the disease involves any coronary tree’s bifurcation, an alternative might be to graft both vessels distal to the bifurcation, using a single arterial graft for each branch, or by constructing a composite graft. This alternative necessitates the construction of two distal anastomoses and the respective proximal anastomosis. Another option is to revascularize the most important branch beyond the bifurcation, although residual ischemia might be feasible. Another strategy is to use a single arterial graft anastomosed end-to-side to the most important branch and side-to-side to the other coronary branch.
The described "-anastomosis" might be an alternative to such revascularization strategies. The "-anastomosis" offers a series of advantages: smaller length of the used arterial grafts compared with composite grafts or single grafts, TAMR in multicoronary diseased patients and, with increasing experience, shorter cross-clamping time is possible despite the complexity of distal anastomosis construction. The main disadvantage of the "-anastomosis" is that its construction involves the pathologic coronary walls. This may lead to technical difficulties particularly in the presence of thick calcifications or coronary occlusion. Nevertheless, even in these cases, we performed the endoartherectomy and later the "-anastomosis" construction. Another limitation of this technique is the arterial conduit diameter, which should be 
3 mm. According to our experience, when the diameter less than 3 mm, it is very difficult to create two arterial petals of an acceptable size, enough to satisfy the enlargement of the native coronary vessel’s diameter. We believe that the "-anastomosis" is a possible surgical alternative to achieve TAMR and should be part of the surgical armamentarium.
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References
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- Lytle B.W., Blackstone E.H., Loop F.D., et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
- Prifti E., Bonacchi M., Frati G., Proietti P., Giunti G., Leacche M. Lambda graft with the radial artery or free left internal mammary artery anastomosed to the right internal mammary artery: flow dynamics. Ann Thorac Surg 2001;72:1275-1281.[Abstract/Free Full Text]
- Tector A.J., Amundsen S., Schmahl T.M., Kress D.C., Peter M. Total revascularization with T grafts. Ann Thorac Surg 1994;57:33-39.[Abstract]
- Calafiore A.M., Contini M., Vitolla G., et al. Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts. J Thorac Cardiovasc Surg 2000;120:990-996.[Abstract/Free Full Text]
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Abstract
Introduction
