Ann Thorac Surg 2004;78:1081-1082
© 2004 The Society of Thoracic Surgeons
Case report
Application of cabrol technique to off-pump coronary artery bypass grafting using radial artery
Won-Min Jo, MDa,
Chan-Young Na, MD, PhD*,a,
Man-Jong Baek, MD, PhDa,
Sam-Sae Oh, MDa
a Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Sejong Heart Institute, Bucheon, Kyonggi-do, South Korea
Accepted for publication July 3, 2003.
* Address reprint requests to Dr Na, Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, 91-121 Sosa Bon 2-dong, Sosa-ku, Bucheon-shi, Kyonggi-do 422-232, South Korea.
koreaheartsurgeon{at}hotmail.com
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Abstract
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We present the case of a Cabrol-type proximal anastomosis technique in off-pump coronary artery bypass. The patient was a 64-year-old man with significant stenoses on the left main, left anterior descending, and proximal right coronary artery. The obtuse marginal and right coronary arteries were anastomosed with both ends of a radial artery. For the proximal anastomosis during this procedure, we applied the Cabrol-type looping interposition technique. In selected patients, we suggest that this technique allows the effective use of graft length and can reduce a number of ascending aortic manipulations.
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Introduction
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In coronary artery bypass grafting, multiple proximal anastomosis may increase the risk of cerebral embolism and aortic dissection or pseudoaneurysm. Therefore to reduce these morbidities, ascending aortic manipulation should be minimized [1, 2].
For this previously described purpose, we applied the Cabrol technique to proximal anastomosis off-pump coronary artery bypass grafting. In the Cabrol technique, an interposed graft is looped between both coronary ostia, and then the loop is attached to the ascending aortic composite valve graft by side-to-side anastomosis in ascending aortic disease [3].
The graft used was a radial artery. Nowadays the radial artery is revived as an adequate graft for coronary artery bypass grafting [4]. We considered that the radial artery was acceptable to our procedure, because the radial artery has the appropriate diameter for proximal anastomosis and can obtain the appropriate length for bypass in stenotic left and right coronary arterial lesions. Besides, radial artery has no intraluminal one-way valve, such as the saphenous vein, so bidirectional flow is possible.
A 64-year-old man was admitted for unstable angina. He had a history of hypertension for 10 years. Coronary angiogram showed 70% stenosis of the left main artery, 90% stenosis of the left anterior descending artery, and 75% stenosis of the proximal right coronary artery. He was infused nitroglycerine and heparin preoperatively due to unstable angina. He received an urgent operation. Coronary artery bypass grafting was conducted with an off-pump technique. After systemic heparinization, the Medtronic Octopus tissue stabilizer (Medtronic Inc, Minneapolis, MN) was used for stabilization. The left anterior descending artery was bypassed with the left internal thoracic artery using an 8-0 Prolene continuous suture (Ethicon, Somerville, NJ). The obtuse marginal branch was bypassed with the distal end of the radial artery graft by end-to-side anastomosis using an 8-0 Prolene continuous suture (Ethicon) and proximal anastomosis between the ascending aorta and an appropriate radial artery was performed by side-to-side maneuver using a 6-0 Prolene continuous suture (Ethicon) under partial clamping of the ascending aorta. An aortic clamp was released to an open state of proximal end of radial artery graft so that air and debris in the ascending aorta lumen could be removed through the proximal opening of the radial artery graft. After sufficient air was removed from the ascending aorta lumen, the proximal part of the radial artery was clamped. Then the proximal end of the radial artery graft was bypassed to the mid-right coronary artery by end-to-side maneuver using a 7-0 Prolene continuous suture (Ethicon). The schematic diagram is shown in Figure 1. Heparin was reversed with protamine sulfate. The patient had an uneventful postoperative course. Postoperative follow-up coronary angiogram was performed on postoperative day 4 (Fig 2).
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Fig 1. Schematic diagram of Cabrol technique applied to off-pump coronary artery bypass grafting. (LAD = left anterior descending artery; LITA = left internal thoracic artery; OM = obtuse marginal artery; RA = radial artery; RA to p-OM = end-to-side anastomosis between radial artery and proximal obtuse marginal artery; RA to p-RCA = end-to-side anastomosis between radial artery and proximal right coronary artery; RCA = right coronary artery.)
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Fig 2. Postoperative coronary angiogram of Cabrol technique applied to off-pump coronary artery bypass grafting. (OM = obtuse marginal artery; RA = radial artery; RA to p-RCA = end-to-side anastomosis between radial artery and proximal right coronary artery; RCA = right coronary artery.)
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Comment
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We conclude that this technique of the Cabrol-type proximal anastomosis in off-pump coronary artery bypass grafting allows the effective use of grafted radial artery length and also reduces the number of ascending aorta manipulations. Therefore this technique can be applied to selected patients more safely.
However, this technique has a greater limitation of the use of the radial artery to reach more distal coronary artery branches. Therefore, we consider that the "I" composite graft using the right internal thoracic artery or saphenous vein graft with the radial artery using the Cabrol proximal anastomosis would provide more appropriate graft length.
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References
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- Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med. 1996;335:1857–1863[Medline]
- Hammon JW Jr, Stump DA, Kon ND, et al. Risk factors and solutions for the development of neurobehavial changes after coronary artery bypass grafting. Ann Thorac Surg. 1997;63:1613–1618[Abstract/Free Full Text]
- Cabrol C, Pavie A, Mesnildrey P, et al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg. 1986;91(1):17–25[Abstract]
- Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg. 1992;54:652–660[Abstract/Free Full Text]
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Abstract
Introduction
