Ann Thorac Surg 2004;78:1078-1080
© 2004 The Society of Thoracic Surgeons
Case report
Coronary-coronary radial artery graft for single, distal LAD lesion
Du
ko G. Ne
i
, MD, PhD*,a,
Milan V. 
irkovi, MDa,
Aleksandar M. Kneevi, MD, BCha,
Ljup
o A. Mangovski, MD, BCha
a Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia and Monte Negro, Yugoslavia
Accepted for publication June 23, 2003.
* Address reprint requests to Dr Nei, Department of Cardiac Surgery, Dedinje Cardiovascular Institute, M. Tepiæa 1, Belgrade, Serbia and Monte Negro 11040, Yugoslavia
nezic{at}eunet.yu
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Abstract
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Radial artery segment has been used as a coronary-coronary graft for single, distal lesion of the large left anterior descending coronary artery running well over the cardiac apex. In our opinion this technique may occasionally be an attractive approach for bypassing very distal lesions of large coronary arteries combined with regular arterial or venous grafting of the target artery if proximal stenosis is also present. The remnant of the radial artery can be used for grafting of another diseased artery (eg, the large first marginal branch of the circumflex artery in our case report).
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Introduction
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In the early days of coronary surgery, resection of coronary segments and termino-terminal interposition of saphenous vein (VSM) grafts were reported [1]. Nowadays coronary-coronary bypass grafting (CCBG) has been performed [2] in patients with such specific characteristics such as porcelain aorta or heavily calcified ascending aorta, arch and supra-aortic branches, or when we are faced with inadequate length of available graft material. Although the internal mammary artery (IMA) is unquestionably the best coronary graft, it is sometimes (used as an in situ graft) too short for grafting of distal lesions. Alternatively, a short segment of IMA, radial artery, or VSM may be used for distal CCBG. The proximal remnant of both IMAs can easily be used as an in situ or free graft as well as a radial artery remnant.
A 47-year-old man was admitted with progressive angina (New York Heart Association functional class III on admission) not relieved by optimal medical therapy. A previous stress test was strongly positive. Hypertension was the only risk factor for coronary artery disease. Cardiac catheterization and angiocardiography revealed good left ventricular function (ejection fraction, 0.55) with severe double-vessel disease. There were two consecutive stenoses of 80% on the circumflex artery and first marginal branch (inconvenient for percutaneous transluminal coronary angioplasty) and long (4 cm in length) up to 80% stenosis for the distal third of the large left anterior descending coronary artery (LAD) running well over the cardiac apex (Figs 1, 2).
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Fig 1. Preoperative angiogram (posteroanterior caudal view) shows severe stenosis on the distal third of the large left anterior descending coronary artery running well over the cardiac apex (arrows).
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Due to progressive angina, bypass surgery was planned and accomplished. We harvested the radial artery from the nondominant arm, leaving both IMAs for eventual redo surgery. As there was no proximal stenosis on the LAD, we decided to use only a short segment (5.5 cm in length) of the radial artery to perform a coronary-coronary bypass (proximal and distal connections were done as termino-lateral anastomosis) over the single, distal stenosis. We also grafted a large first marginal branch of the circumflex artery with the remnant of radial artery. The proximal radial artery graft anastomosis to the aorta was done using a single-clamp technique, which was easier to pick up the good part of the aortic wall for the proximal anastomotic site. The aortic cross-clamp time was 52 minutes. The heart returned spontaneously to sinus rhythm, and the patient was easily weaned from cardiopulmonary bypass. The patient's postoperative course and convalescence progressed without any difficulty, and he was discharged with no angina. A pre-discharge check angiogram was performed on postoperative day 11 that showed a patent coronary-coronary, radial artery graft (Figs 3, 4). The patient has been on regular follow-up for 3 months, and he is presently in the New York Heart Association functional class I with a normal stress test.
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Fig 3. Postoperative angiogram in the same patient, showing patent coronary-coronary, radial artery graft (double arrow) for distal left anterior descending coronary artery (right anterior oblique view).
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Fig 4. Postoperative angiogram (left anterior oblique view), showing severe stenosis on the left anterior descending artery (white arrows) and patent coronary-coronary, radial artery graft (black arrows).
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Comment
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Primarily used in the beginning of aorto-coronary bypass surgery (termino-terminal interposition of VSM between two parts of resected coronary artery) [1], CCBG was revised by Biglioli and colleagues [3], and from a hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed. Furthermore, progression of coronary disease at the site of proximal anastomosis (the most critical point of this technique) has never been observed in a large series of CCBG (as in Nottin and colleagues [4] series of 143 patients with a total of 148 coronary-coronary bypass grafts, with a maximum follow-up of 7 years). Coronary-coronary bypass grafts were performed on the right coronary artery in 134 patients (90.5%), and saphenous vein grafts were used in 35 of these patients (26.1%, most in their early experience). There was an interesting point by Mills in the Discussion of Nottin and colleagues' [4] article that patients with follow-ups after 10 years were found to have right coronary artery disease that had progressed to the ostia in nearly half of the CCBG controls (15 patients). Considering that arteriosclerosis is an ongoing disease, more expressed on grafted arteries (progression of the disease more commonly found in segments bypassed with venous rather than arterial grafts [5]), this phenomenon obviously was not specific to CCBG. Moreover, recent studies have demonstrated that the most important factor in long-term results was the selection of the conduit rather than the progression of the coronary disease (Discussion in Nottin and colleagues [4]). These results have confirmed that the capability of CCBG plays an important role in solving some difficult problems in coronary surgery (ie, patients with porcelain aorta or a heavily calcified ascending aorta, arch and supra-aortic branches, or patients with an inadequate length of available graft material). In these patients, proximal and distal anastomoses can be achieved either between two segments of the same coronary artery or between two different coronary arteries.
In our patient there was no proximal stenosis on the large LAD running well over the cardiac apex, thus we decided to use only a short segment of the radial artery to perform a coronary-coronary bypass for the single, distal stenosis for the LAD. We emphasized that an IMA graft would not have been long enough to give a segment for the LAD, and then to arrive at the marginal branch, unless it was detached at its origin. Finally, the radial artery was our graft of choice because it had better mid-term [6] and long-term [7] patency than the venous grafts, thus leaving both the IMA for an eventual redo procedure in this "young" patient. We only believe that a termino-terminal anastomosis (completely excluding the "sick" part of the native coronary artery, thus eliminating the potential site of thrombosis) is possibly a better solution in CCBG if there are no important branches originating from these segments of the coronary artery.
Coronary-coronary, LAD to LAD bypass (as single graft for the LAD) has been reported only in 4 patients (2 with a segment of the left IMA, 1 with a right IMA segment, and 1 with VSM) in the largest series of CCBG [4]. Tixier and colleagues [8] have presented excellent angiographic and clinical results with radial artery as coronary to coronary conduit for the right coronary artery. We believe that the coronary-coronary bypass for the LAD with the radial artery has not yet been reported in the literature.
In our opinion this technique may occasionally be an attractive approach for bypassing very distal lesions of large coronary arteries (combined with regular arterial or venous grafting of the target artery if proximal stenosis is also present).
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References
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- Effler DB, Favarolo RG, Groves LK. Coronary artery surgery utilizing saphenous vein graft techniques: clinical experience with 224 operations. J Thorac Cardiovasc Surg. 1970;59:147–153[Medline]
- Barboso G, Rusticali F. Proximal internal mammary in situ graft and distal coronaro-coronary graft to revascularize left anterior descending coronary artery. Tex Heart Inst J. 2000;27:70–71[Medline]
- Biglioli P, Almanni F, Antona SC, Sala A, Susini G. Coronary-coronary bypass: theoretical basis and techniques. J Cardiovasc Surg. 1987;28:333–335[Medline]
- Nottin R, Grinda JM, Anidjar S, Folliguet T, Detroux M. Coronary-coronary bypass graft: an arterial conduit-sparing procedure. J Thorac Cardiovasc Surg. 1996;112:1223–1230[Abstract/Free Full Text]
- Manninen HI, Jaakkola P, Suhonen M, Rehnberg S, Vuorenniemi R, Matsi PJ. Angiographic predictors of graft patency and disease progression after coronary artery bypass grafting with arterial and venous grafts. Ann Thorac Surg. 1998;66:1289–1294[Abstract/Free Full Text]
- Amano A, Hirose H, Takahashi A, Nagano N. Coronary artery bypass grafting using the radial artery: midterm results in a Japanese Institute. Ann Thorac Surg. 2001;72:120–125[Abstract/Free Full Text]
- Acar C. Radial artery grafting: clinical results. Guo-Wei HE. Arterial grafts for coronary artery bypass surgery. Singapore Pte Ltd: Springer-Verlag; 1999. p. 257–260
- Tixier DB, Acar C, Carpantier A. Coronary-coronary bypass using the radial artery. Ann Thorac Surg. 1995;60:693–694[Abstract/Free Full Text]
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Abstract
Introduction
