Ann Thorac Surg 2005;79:700-701
© 2005 The Society of Thoracic Surgeons
Case report
Reinforcement of Saphenous Vein Graft With ePTFE Graft for Axillocoronary Bypass Grafting
Hiroyuki Nagahama, MD, PhDa,*,
Yasunori Fukushima, MD, PhDa,
Takahiro Hayase, MDa,
Makoto Yoshioka, MD, PhDa,
Toshio Onitsuka, MD, PhDb
a Department of Thoracic and Cardiovascular Surgery, Miyazaki Medical Association Hospital, Miyazaki, Japan
b Second Department of Surgery, Miyazaki Medical College, Miyazaki, Japan
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Nagahama, Department of Thoracic and Cardiovascular Surgery, Miyazaki Medical Association Hospital, 738-1 Funato Shin'Beppu, Miyazaki 880-0834, Japan
dokt05{at}cure.or.jp
 |
Abstract
|
|---|
Arteriosclerosis in the ascending aorta is widely accepted as a strong risk factor for the occurrence of stroke after coronary artery bypass grafting (CABG). The aortic no-touch technique, with a variety of modifications, has been used to reduce the risk of post-CABG stroke. Saphenous vein grafts (SVGs) have been used for axillocoronary bypass grafting, a modification of the aortic no-touch technique. However, kinking or compression often occurs with SVGs. We report here the successful application of an 8-mm expanded polytetrafluoroethylene graft, of the external bead support type, that was used to cover an SVG during axillocoronary bypass grafting.
|
Introduction
|
|---|
Axillocoronary bypass grafting is a very effective modification of the aortic no-touch technique [1] when the ascending aorta is severely atherosclerotic. However, use of saphenous vein grafts (SVGs) is problematic because this vessel often becomes kinked or compressed. We recently succeeded in overcoming these complications by covering the saphenous vein with an 8-mm expanded polytetrafluoroethylene (ePTFE) graft of the external bead support type (Boston Scientific/Medi-Tech, Wayne, NJ). The present report describes the beneficial use of an ePTFE graft for the reinforcement of an SVG graft.
An 83-year-old woman was admitted to our hospital with congestive heart failure and severe chest pain. Her cardiovascular risk factors included arterial hypertension and hypercholesterolemia. Coronary angiography showed the total occlusion of the proximal right coronary artery (RCA), 90% stenosis of the proximal left anterior descending artery, (LAD), and 75% stenosis of the proximal left circumflex artery (LCX). On hospitalization, she was immediately supported by an intraaortic balloon pump (IABP), and the decision was made to perform an emergency coronary artery bypass grafting (CABG) procedure.
As expected from her advanced age, arteriosclerosis in the ascending aorta was marked. We therefore chose to perform bypass grafting on the beating heart without cardiopulmonary bypass. Because the right internal thoracic artery was not long enough to replace the RCA, we conducted an axillocoronary bypass grafting procedure with an SVG to the RCA.
After median sternotomy, the pericardium was opened. When the ascending aorta was carefully inspected and palpated, diffuse calcifications were found. The decision was made to replace the RCA by an axillocoronary bypass with an SVG, while the LAD was replaced by the left internal thoracic artery (LITA) as an in situ graft to the LAD.
The LITA and the SVG were simultaneously dissected. The right axillary artery was exposed in the middle of the major pectoral muscle after the subclavicular incision. Under the systemic heparinization, the axillary artery was clamped and incised. The SVG was sutured to the axillary artery using 7-0 Prolene polypropylene (Ethicon, Inc, Somerville, NJ), and the right pleura cavity was opened. The SVG (about 20 cm) was inserted into an 8-mm ePTFE graft of the external bead support type (about 13 cm) and introduced into the pericardial cavity through the right thoracic cavity from the intercostal space so that the SVG would not be kinked or compressed. The artificial vessel protected the graft by 13 cm, leaving about 5 cm uncovered, from approximately 2 cm apart from the site of the axillo-SVG anastomosis to the pericardial cavity. The target vessel (the RCA) was opened longitudinally, the axillocoronary vein graft was trimmed to an adequate length, and an end-to-side anastomosis was performed on the beating heart using 7-0 Prolene sutures. The LITA was then sutured to the LAD as an in situ graft using 7.5 polypropylene sutures (Matsuda, Tokyo, Japan).
No significant complications occurred in the postoperative clinical course. The patient was weaned from the IABP on day 1 and extubated on day 2 after the operation. Coronary angiography on the 12th day after the operation revealed that both of the 2 bypass grafts were patent, and no kink or compression was evident in the axillocoronary bypass graft (Fig 1). The patient was discharged from the hospital on the 16th day after the operation. The postoperative follow-up for 2 years assured that she was in good condition as of the time this paper was submitted.
View larger version (145K):
[in this window]
[in a new window]
|
Fig 1. Images were taken from different directions to show the axillocoronary appearance. Angiogram for axillocoronary bypass graft is indicated by arrows (black and white), in which white arrows are used in dark fields. There was no apparent kink or compression, because of the protection of the saphenous vein graft with an 8-mm expanded polytetrafluoroethylene graft of the external bead support type.
|
|
|
Comment
|
|---|
Axillocoronary bypass grafting, a modification of the aortic no-touch technique, is a versatile method for the replacement of a severely atherosclerotic ascending aorta. Several routes have previously been examined to guide the axillocoronary graft into the chest cavity: a subcutaneous course [2], a subfascial plane [3], a tunnel through the bed of the second costal cartilage [4], and a tunnel through the intercostal muscles [1, 5]. However, an axillocoronary bypass graft is often compromised by kinks or compressions, regardless of the route selected. To avoid kinks or compressions, we inserted the SVG graft into an 8-mm ePTFE graft of the external bead support type to increase the durability of the SVG graft. The graft was thus protected by an artificial vessel from approximately 2 cm from the site of the axillo-SVG anastomosis to the pericardial cavity. These manipulations were completed without difficulty. Because the artificial vessel was of the external bead support type, it was possible to avoid compression of the graft in the thoracic cavity by the expanding lung during breathing as well as compression during the introduction of the graft through subcutaneous muscular layers or intercostal routes. This procedure was advantageous in avoiding kinks or compressions during axillocoronary bypass grafting and would be beneficial for patients.
|
Acknowledgments
|
|---|
We are indebted to Catherine C. Bryson for reading the manuscript. We also thank Hitoshi Takenaka, Department of Biochemistry I, Kyorin University School of Medicine, Tokyo, Japan, for his advice.
|
References
|
|---|
- Bonatti J, Hangler H, Antretter H, Muller L. Axillocoronary bypass for severely atherosclerotic aorta in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1998;115:956–957[Free Full Text]
- Machiraju VR, Culig MH, Heppner RL, Minella RA, O'Toole JD. Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures. Ann Thorac Surg. 1998;65:625–627[Abstract/Free Full Text]
- Knight WL, Baisden CE, Reiter CG. Minimally invasive axillary-coronary artery bypass. Ann Thorac Surg. 1997;63:1776–1777[Abstract/Free Full Text]
- Coulson AS, Bakhshay SA. Clinical concepts: subclavian artery origin for a coronary bypass graft. Contemp Surg. 1997;50:65–66
- Yaryura R, Vardhan R, Springer AJ, Cooly DA. A 66-year-old man with severe angina and previous coronary artery bypass. Lancet. 1997;349:396[Medline]
Top
Abstract
Introduction
