Ann Thorac Surg 2004;78:1103-1104
© 2004 The Society of Thoracic Surgeons
How to do it
The mammary loop: How to do an adjustable "Y" graft with the left internal thoracic artery
Lucian Stoica, MD, PhD*,a,
Sidney Chocron, MD, PhDa,
Pierre-Emmanuel Falcoz, MDa,
Djamel Kaili, MDa,
Joseph-Philippe Etievent, MDa
a Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, Besançon, France
Accepted for publication August 1, 2003.
* Address reprint requests to Dr Stoica, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Bd Fleming, Besançon, France 25000
l.stoica{at}voila.fr
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Abstract
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We present a technique that permits the grafting of two vessels with the left internal thoracic artery when a sequential graft cannot be performed. The left internal mammary artery is anastomosed to itself resulting in a loop that will be cut open at the time of the coronary anastomosis.
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Introduction
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Sequential grafting permits the use of one conduit to bypass two vessels. Anatomical features restrict the use of this technique. We present here the mammary loop technique as an alternative to sequential graft when the topography of the arteries is not favorable. The end of the left internal thoracic artery (LITA) is anastomosed to the proximal LITA into a loop. The latter is then cut open into a "Y" graft in order to bypass two vessels. This technique enables the accurate determination of the lengths of the two "Y" branches just before anastomosis [1].
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Technique
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The LITA is mobilized in a skeletonized way from the left subclavian vein to its bifurcated end in order to get maximum length. The loop is performed by anastomosing "end-to-side," the spatulated distal end of the LITA on an arteriotomy made on the proximal part of the LITA at the level of the pericardial reflection on the left side of the aorta. This loop will be cut open to obtain an adjustable "Y" graft at the time of the coronary anastomosis (Fig 1, Fig 2). We put a textile pad under the LITA at the time of the loop anastomosis for making the operating field more stable. All the time we preserve the branch made with the proximal part of the LITA for the left anterior descending artery, and we use the other branch for the other left coronary vessel. This technique permits us to bypass the left anterior descending artery and a distant diagonal artery or the left anterior descending artery and an intermediate branch or an upper obtuse marginal artery. However, in the case of a distal obtuse marginal or the circumflex arteries, the use of the right internal mammary artery is still required [2, 3].
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Fig 1. The right internal mammary artery (dotted arrow) is skeletonized to bypass the right coronary artery; the left mammary loop (solid arrow) is prepared to bypass the left anterior descending artery and an upper obtuse marginal artery.
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Fig 2. The construction of the mammary loop and the "Y" graft made only with the left internal thoracic artery (LITA). The LITA clamped at the origin with an atraumatic clamp that is not represented. (1) Arteriotomy on the proximal part of the LITA at the level of the pericardial reflection on the left side of the aorta. (2) 45° spatulated LITA end. (3) End-to-side anastomosis. (4) The loop is cut at the desirable level. (5) Proximal LITA branch to left anterior descending artery. (6) Distal LITA branch to diagonal, intermediate branch or upper marginal artery.
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Results
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We started to use this technique in April 2003 and we performed it for five patients with triple-vessel disease. In all of the cases we grafted the right coronary artery with the skeletonized right internal thoracic artery and the left anterior descending artery and the intermediate branch or the left anterior descending artery and an upper obtuse marginal artery with an adjustable "Y" graft made with the mammary loop technique. One patient also had an aortic valve replacement. There were three procedures performed with cardiopulmonary bypass and two off-pump procedures. All of the patients had an uneventful early postoperative recovery. The troponin I levels at 6 and 24 postoperative hours were studied as for all the others patients in our center; we found similar levels with the other coronary revascularized patients.
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Comments
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The two goals of this technique are (1) to make a "Y" graft using only LITA for the patients who need a two-vessel left coronary bypass and in whom the coronary vessel topography is inappropriate for a sequential graft with LITA; and (2) to spare the right internal thoracic artery for grafting other vessel(s).
The advantages of this technique are (1) only one arterial conduit is needed to finally make a "Y" graft; (2) the "Y" anastomosis is much easier to perform before the distal anastomoses are done; (3) the two legs of the graft have the right length, which prevents tractions or distortions of the "Y" graft; and (4) the technique can also be performed for beating heart surgery.
The two technical features that can be used to obtain the maximal length available are (1) harvesting the LITA in a skeletonized fashion from the second rib down to its bifurcation, and (2) the division of the mediastinal tissue of the left pleura and the pericardial reflection on the left side of the aorta to improve the LITA's entrance into the surgical field.
We do not have angiographic follow-up with our first 5 patients. Our policy is to control the grafts only when ischemic symptomatology is present or when the troponin I level is postoperatively high. We have been performing this technique for 3 months and further evaluation is required.
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References
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- Athanasiou T, Casula R, Glenville B, Stanbridge R. A new method of grafting the circumflex through lateral MIDCAB with the use of the radial loop technique. Inter Cardiovasc Thorac Surg. 2003;2:97–98[Abstract/Free Full Text]
- Chocron S, Etievent JP, Schiele F. The Y graft: myocardial revascularization with both internal thoracic arteries. Evaluation of eighty cases with coronary angiographic assessment. J Thorac Cardiovasc Surg. 1994;108(4):736–740[Abstract/Free Full Text]
- Tector AJ, Kress DC, Schmahl TM, Amundsen S. T-graft: a new method of coronary arterial revascularization. J Cardiovasc Surg (Torino). 1994;35(6 Suppl 1):19–23[Medline]
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Abstract
Introduction
