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Ann Thorac Surg 2005;79:e17-e18
© 2005 The Society of Thoracic Surgeons

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Case report

Endovascular Control of Patent Internal Thoracic Artery Graft in Aortic Valve Surgery

^a Department of Cardiothoracic Surgery, Reims, France
^b Department of Cardiology, Hôpital Robert Debré, Reims, France

Accepted for publication September 2, 2004.

^* Address reprint requests to Dr Fuzellier, Department de Chirurgie Cardiothoracique. Hospital Robert Debré, Ave du General Koenig, 51100 Reims, France; (E-mail: jffuzellier{at}aol.com).

	Abstract

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Aortic valve replacement in patients who underwent previous coronary artery bypass with a patent internal thoracic artery is often a challenge because of the risk of graft injury during dissection or difficulties to obtain optimum myocardial protection. Different approaches to myocardial protection or internal thoracic graft dissection and control have been described. Endovascular control of the internal thoracic graft by an angioplasty balloon catheter positioned in the operating room before the operation can be a safe and simple alternative. We report the case of a patient who underwent this technique for aortic valve replacement.

	Introduction

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Internal thoracic artery (ITA) is widely used for coronary artery bypass grafting with excellent long-term patency. Among patients who underwent coronary artery bypass grafting, a percentage will subsequently have aortic valve disease develop, which requires another cardiac procedure. Aortic valve replacement remains a difficult challenge in this subsection of patients. Various strategies have been described. The common approach involves clamping of the ITA graft during aorta cross-clamping to obtain an optimal myocardial protection. An injury of the graft can occur affecting the outcome.

We propose a safe alternative with an endovascular control of the ITA graft flow by an angioplasty balloon positioned in the operating room before the operation.

A 63-year-old man was referred to our hospital for aortic valve replacement for an important aortic insufficiency 3 years after undergoing a triple coronary artery bypass graft, left ITA to left anterior descending artery, and sequential saphenous graft on the diagonal and marginal arteries. Preoperative coronary angiography showed a patency of all the grafts.

In the operating room, after the patient's intubation and during complete monitoring by the anesthesiologist, catheterization of the ITA graft was performed by an interventional cardiologist. The left transradial approach was considered after an Allen's test confirmed the presence of adequate collateral circulation. Artery puncture was realized using an 18-gauge short needle, and a 5-French introducer sheath inserted over a short wire with a flexible tip (Terumo, Tokyo, Japan). A vasodilator (verapamil, 3 mg) and heparin (3,000 IU) solution was then injected through the sheath. Under fluoroscopy guidance with a mobile roentgenogram device and arterial pressure monitoring, a large lumen 5-French guided catheter (mammary artery 0.58 inch inner diameter catheter [Medtronic, Minneapolis MN]) selectively cannulated the ostium of the ITA graft. Then a guidewire (Galeo floppy, [Biotronik, Berlin, Germany]) was slightly moved in the graft far to the left anterior descending coronary artery to obtain an effective stability of the whole during the surgical time. The bypass graft diameter was assessed during vessel opacification with contrast dye. Then a 2.0 mm diameter rapid-exchange balloon catheter was placed in the body graft 2 cm far from the subclavian artery, and a low pressure inflation (less than 4 atm) was performed to ensure the complete occlusion of the graft confirmed by using contrast dye injection. The balloon catheter was left deflated in the graft before the surgical time began and the patient's arm was not mobilized to avoid the migration of the balloon.

The operation was performed by a median sternotomy. Minimal dissection of the heart was performed. Only the ascending aorta and a small part of the right atrium were dissected to allow the insertion of an arterial cannula and a two-stage single venous cannula. No other segment of the heart was dissected, in particular the ventricle. Normothermic cardiopulmonary bypass was initiated and the aorta was cross-clamped. The aorta was opened and an intermittent antegrade warm blood cardioplegia was injected by a selective perfusion of coronary ostia and the proximal anastomosis of the saphenous vein graft with a simultaneous occlusion of the ITA graft flow by angioplasty balloon was inflated to the pression level allowing complete occlusion at the previous inflation test.

Aortic valve replacement was performed with a bi-leaflet mechanical prosthesis using standard surgical techniques. During aortic cross-clamping, any cardiac electrical activity was noted. Total aortic cross-clamping and ITA graft occlusion times were 40 minutes with a spontaneous defibrillation. Total cardiopulmonary bypass time was 50 minutes.

The postoperative course was uneventful. Cardiac enzymes were normal (serum cardiac troponin I concentration: 3.3 ng/mL) and electrocardiogram was not modified. Seven days later, echocardiography showed a cardiac function similar to the preoperative function, and the patient was discharged from the hospital.

	Comment

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Aortic valve replacement in patients with patent ITA grafts remain a surgical challenge because of the possibility of injury to ITA graft [1] and inadequate myocardial protection. Different strategies have been described. The common technique consists of surgical dissection of the ITA graft to stop the flow during aortic cross-clamping for optimal myocardial protection. Prevalence of ITA graft injury is between 9% and 5% [1–3] associated with a mortality rate of 8.6% and a perioperative myocardial infarction rate of 40% in patients with ITA graft injury, despite supplemented saphenous vein graft [1]. Kuralay and colleagues [4] described a supraclavicular control of ITA graft with lower risk of injury of the ITA graft (4.2%). A second strategy involves deep hypothermia circulatory arrest with the known deleterious effects. Another approach is to leave the ITA graft open during aortic cross-clamping time. However, a patent ITA graft may cause an inadequate myocardial protection due to cardioplegia washout. Different myocardial protections are mandatory as associated deep hypothermia with cardiac arrest by cold cardioplegia [3] or continuous retrograde cardioplegia. Some authors have proposed beating-heart with aortic cross-clamping and continuous antegrade [5] or retrograde coronary perfusion [6]. These methods have advantages in terms of avoidance potential damages to a patent ITA graft. However, both of these methods have drawbacks such as an encumbered operative field by cannulas or an obscured operative field by backflow from the coronary ostia due to an open ITA graft and retrograde perfusion. Endovascular control of the ITA graft seems to be safe and simple. This technique allows control of blood flow of the ITA graft during aortic cross-clamping without the risk of injuring the graft. Moreover, it offers the advantage of secure myocardial protection with a uniformity of this protection. The operation is not complicated by deep hypothermia or by continuous perfusion in a beating heart. Another advantage of this technique is the avoidance of a larger dissection of the heart with its deleterious effects. In our patient, the dissection was limited to the aorta and the right atrium.

This procedure is easily feasible and reproducible by an interventional cardiologist accustomed in selective catheterization of the ITA and in percutaneous transluminal coronary angioplasty of the ITA graft through the radial route. Because angioplasty tools are only used to ensure temporary occlusion of the graft, a mobile roentgenogram device is sufficient to obtain an adequate fluoroscopic control. Therefore the whole catheterization procedure can be easily performed in the operating room immediately before the surgical time, thus limiting the migration of the balloon during the patient's mobilization from the catheterization laboratory.

The risks of endothelial damage with potential long-term consequences of endoluminal occlusion are unknown. However some reports concerning angioplasty of the ITA graft with dilatation of anastomotic sites or of the ITA graft itself have good results with high primary success rates and low incidences of re-stenosis [7]. The risk of endothelial damage can be minimized by the choice of the correct size of the balloon adapted to the size of the ITA graft (assessed by previous opacification) and the minimal pressure inflation of the balloon ensuring the complete occlusion of the graft with previous inflation test.

Endovascular clamp of a patent ITA graft during aortic valve replacement is a safe and simple method. This technique allows to have a secure myocardial protection without the risk of the ITA graft, and it seems to be helpful in these challenging surgical procedures.

	References

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1. Gillinov AM, Casselman FP, Lytle BW, et al. Injury to a patent left internal thoracic artery graft at coronary reoperation Ann Thorac Surg 1999;67:382-386.[Abstract/Free Full Text]
2. Odell JA, Mullany CJ, Schaff HV, Orszulak TA, Daly RC, Morris JJ. Aortic valve replacement after previous coronary artery bypass grafting Ann Thorac Surg 1996;62:1424-1430.[Abstract/Free Full Text]
3. Byrnes JG, Karavas AN, Filsoufi F, et al. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts Ann Thorac Surg 2002;73:779-784.[Abstract/Free Full Text]
4. Kuralay E, Cingoz F, Gunay C, et al. Supraclavicular control of patent internal thoracic artery graft flow during aortic valve replacement Ann Thorac Surg 2003;75:1422-1428.[Abstract/Free Full Text]
5. Savitt MA, Singh T, Agrawal S, Choudhary A, Chaugle H, Ahmed A. A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft Ann Thorac Surg 2002;74:1269-1270.[Abstract/Free Full Text]
6. Bar-El Y, Kophit A, Cohen O, Kertzman V, Milo S. Minimal dissection and continuous retrograde cardioplegia for aortic valve replacement in patients with a patent left internal mammary artery bypass graft J Heart Valve Dis 2003;12:454-457.[Medline]
7. Hearne SE, Davidson CJ, Zidar JP, Philips HR, Stack RS, Sketch Jr MH. Internal mammary artery graft angioplasty: acute and long-term outcome Cathet Cardiovasc Diagn 1998;44:153-156.[Medline]

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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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fuzellier, J.-F. G. Articles by Saade, Y.-A. Search for Related Content PubMed PubMed Citation Articles by Fuzellier, J.-F. G. Articles by Saade, Y.-A. Related Collections Valve disease