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Ann Thorac Surg 2004;78:313-314
© 2004 The Society of Thoracic Surgeons

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Case report

Aortovenous bypass graft to the posterior left ventricle in absence of an identifiable coronary artery

^a Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada

Accepted for publication November 25, 2002.

^* Address reprint requests to Dr Scully, Division of Cardiovascular Surgery, Toronto General Hospital, Eaton Bldg N-14-224, 200 Elizabeth St, Toronto, Ontario, Canada, M5G 2C4, USA
e-mail: hugh.scully{at}uhn.on.ca

	Abstract

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We report the case of a 70-year-old woman with significant intermediate coronary artery stenosis who underwent a series of stent procedures, ultimately leading to compromise of the origin of the circumflex artery. Intraoperatively, identification of an obtuse marginal coronary artery was impossible due to a thick layer of epicardial fat, calcification of the posterior atrioventricular groove, and an adherent, thickened pericardium. Therefore, a saphenous vein graft to the posterior vein of the left ventricle was constructed with ligation of the vein cephalad. This uncommon approach to surgical revascularization effectively relieved the patient's angina and may be of use in other difficult cases.

	Introduction

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The concept of arterializing coronary veins to revascularize ischemic myocardium is not new. Extensive animal investigation in the 1970s demonstrated that selective arterialization of a coronary vein can be successful in perfusing a region of myocardium. However, few human case reports exist, and with the absence clinical trials and long-term outcome data, the use of venous arterialization has been advocated in desperate situations only. We report the use of a saphenous vein graft from the aorta to the posterior vein of the left ventricle (LV) in a patient with unstable angina, in whom the stenosed obtuse marginal artery could not be identified.

A 70-year-old obese female patient presented with unstable angina pectoris (UAP) in July 2001. Cardiac history revealed several previous admissions for UAP. Her cardiac risk factors included hypertension, hypercholesterolemia, and a family history of ischemic heart disease. During an admission in February 2001, the patient underwent coronary angiography that demonstrated a left-dominant circulation and a severe isolated stenosis of the intermediate branch of the left coronary artery. The patient underwent percutaneous transluminal coronary angioplasty (PTCA) and stenting of the proximal intermediate artery, and she was symptom-free for 7 weeks. Her chest pain recurred in April 2001, and a repeat coronary angiogram revealed an in-stent stenosis of the intermediate artery as well as a new stenosis of the circumflex coronary artery. Percutaneous transluminal coronary angioplasty of the stent was performed and another stent was inserted in the proximal intermediate artery. The patient's chest pain recurred again several weeks thereafter. A repeat coronary angiogram in June 2001 revealed an 80% ostial stenosis of both the intermediate and circumflex arteries. Percutaneous transluminal coronary angioplasty was again performed, but was unsuccessful. Echocardiography at the time of the most recent admission revealed normal LV systolic function. A persantine myocardial perfusion stress test with sestamibi demonstrated completely reversible defects in the posterolateral wall with minor extension into the anterolateral basilar wall.

The patient was taken to the operating room on an urgent basis with a view to surgical revascularization. Angiography had demonstrated no apparent compromise of the left main and left anterior descending (LAD) coronary arteries, but the intermediate coronary artery was deemed too small for bypass. Therefore, we planned for a single saphenous vein bypass graft to the circumflex artery territory. Intraoperatively, a number of difficulties were encountered. The patient's tissues were quite friable and she had evidence of recent pericarditis. The heart itself was hypertrophied and encased in a 1- to 2-cm layer of epicardial fat, which made definition of the coronary vessels extremely challenging. Additionally, there was significant calcification posteriorly along the atrioventricular groove. The heart was dissected and mobilized with great care to avoid ventricular disruption.

The patient was placed on cardiopulmonary bypass (CPB) and the heart was arrested with antegrade cold blood cardioplegia. There was very poor cooling of the anterior, anterolateral, apical, and posterior LV walls, leading to speculation that there was compromise of the left main coronary artery. Despite being embedded deeply in fat, the LAD was identified and bypassed with a saphenous vein graft (the left internal thoracic artery was not harvested because an LAD graft had not been anticipated). Cold cardioplegia was again introduced into the aortic root, resulting in much better cooling of the anterior, anterolateral, and apical walls.

We then attempted to identify the obtuse marginal branch of the circumflex artery. However, after 1 hour of difficult dissection, the only vessel that could be identified was a posterior vein of the LV. The decision was therefore made to construct a saphenous vein graft from the aorta to the posterior LV vein. The vein was then ligated cephalad to create retrograde arterial flow into the venous circulation.

A terminal shot of warm cardioplegia was administered and the cross-clamp was removed. Spontaneous sinus rhythm occurred shortly thereafter, and the patient was easily weaned off CPB. Neither intropes nor an intraaortic balloon pump was required. The total cross-clamp time was 100 minutes and the CPB time was 135 minutes. The patient remained hemodynamically stable upon her return to the intensive care unit.

The patient recovered well with no postoperative complications, and was discharged home on postoperative day 9. The patient is currently angina-free 16 months postoperatively and has no restrictions on her level of activity.

	Comment

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The feasibility of perfusing myocardium through coronary veins was first suggested by Pratt in 1898 [1]. The concept was particularly appealing given that the coronary venous system does not develop severe arteriosclerosis. Beck and colleagues proposed a global attempt at retrograde coronary venous perfusion in 1948, well before the advent of coronary artery bypass grafting (CABG). The Beck II procedure consisted of a free vein graft from the aorta to the coronary sinus, with a second operation 2 to 3 weeks later to ligate the coronary sinus [2]. Initially, arterial blood perfusing the coronary sinus was shown to be reaching the capillary bed. However, with a high mortality rate (approximately 30%) and evidence of early graft thrombosis [3], clinical acceptance did not follow.

With the advent of CABG in the late 1960s, interest in venous retroperfusion quickly receeded. However, CABG was soon discovered to have its own limitations, particularly in patients with diffuse atherosclerotic disease and small coronary arteries. Arterialization of coronary veins therefore regained its appeal. Several investigators in the 1970s examined the technique of selective arterialization of the coronary venous system to reverse venous flow in precise areas of ischemia. Such procedures entailed the construction of a coronary venous bypass graft (CVBG) with ligation of the vein cephalad to the anastomosis, thus avoiding an arterio-venous fistula through the coronary sinus. Results from animal studies were contradictory [4]. Some researchers reported reversal of ischemia, improved myocardial perfusion, and improved LV contraction post-CVBG. Hochberg, one of the major contributors to the field, demonstrated that CVBG to an acutely ischemic LV could improve blood flow by almost three times, with all layers of myocardium receiving increased blood flow [5]. In addition, long-term studies in dogs revealed patency of 10 of 14 grafts 5 months postoperatively. Other investigators, however, reported that CVBG caused striking myocardial hemorrhage and congestion, and resulted in distal vein fibrosis and luminal stenosis within a few weeks.

The efficacy of selective coronary vein arterialization has yet to be adequately studied in humans. The few case series that exist in the literature consist of small groups of patients who had selective venous bypass operations in conjunction with CABG. The effectiveness of the technique is therefore difficult to interpret. A 1986 survey of American cardiac surgeons reported 41 cases of CVBG being performed because conventional CABG was thought to be unsuitable [6]. Eighty-eight percent of patients improved symptomatically, 92% survived long-term, and 12 of 13 grafts studied by postoperative coronary angiography were found to be patent.

Clearly, the number of CVBGs performed in humans is too small to draw meaningful conclusions regarding the utility of this procedure. We are encouraged however, by this patient's postoperative outcome, although interpretation is complicated by the addition of an LAD graft. Unfortunately, no postoperative image studies were obtained to document improved myocardial perfusion. Other revascularization techniques such as trans-myocardial revascularization (TMR) may also have been effective, but are not available at our hospital. Nevertheless, we believe the technique of CVBG may be an innovative and effective approach in difficult cases of surgical revascularization and deserves further exploration.

	References

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1. Pratt F.H. The nutrition of the heart through the vessels of Thebesius and the coronary veins. Am J Physiol 1898;1:86-103.[Free Full Text]
2. Beck C.S., Leighninger D.S. Operations for coronary artery disease. JAMA 1954;156:1226-1233.[Abstract/Free Full Text]
3. Eckstein R.W., Leighninger D.S. Chronic effects of aorta-coronary sinus anastomosis of Beck in dogs. Circ Res 1954;2:60-72.[Abstract/Free Full Text]
4. Hochberg M.S., Austen W.G. Selective retrograde coronary venous perfusion: a collective review. Ann Thorac Surg 1980;29:578-588.[Abstract/Free Full Text]
5. Hochberg M.S., Roberts W.C., Morrow A.G., Austen W.G. Selective arterialization of the coronary venous system: encouraging long-term flow evaluation utilizing radioactive microspheres. J Thor Cardiovasc Surg 1979;77:1-12.[Abstract]
6. Hochberg M.S., Roberts A.J., Parsonnet V., Fisch D. Selective arterialization of coronary veins: clinical experience of 55 American heart surgeons. In: Mohl W., Faxon D.P., Wolner E., eds. Clinics of CSI. New York: Springer-Verlag, 1986:195-201.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alexander Kulik Michael A. Borger Hugh E. Scully Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kulik, A. Articles by Scully, H. E. Search for Related Content PubMed PubMed Citation Articles by Kulik, A. Articles by Scully, H. E. Related Collections Coronary disease