Ann Thorac Surg 2005;79:1068-1069
© 2005 The Society of Thoracic Surgeons
How to do it
How to Tailor A "
" Graft for Complex Myocardial Revascularization: A Variant of the Mammary Loop Technique
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 December 2, 2003.
* Address reprint requests to Dr Stoica, Department of Thoracic and Cardiovascular, Surgery, Hôpital Jean Minjoz, 3 Bd. Fleming, Besançon 25000, France
l.stoica{at}voila.fr
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Abstract
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We present a new pattern for tailoring the "
" graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a "Y" graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a "" graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis.
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Introduction
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Complex use of the two internal thoracic arteries (ITAs) allows complete arterial revascularization of the heart. Different techniques offer a rational use of the length of the two ITAs: the "Y" graft [1] or the "T" graft [2], and more recently the "" graft [3]. The latter is a complex technique used to construct a composite conduit with only the two skeletonized ITAs. This technique allows complete left-heart revascularization, but requires additional extension with the radial artery to bypass the right heart as well. In the original technique [3], the lower two-thirds of the right ITA is anastomosed end-to-side to the proximal part of the left ITA to obtain a "Y" or "T" graft. The left ITA is divided at the level of the anastomosis on the left anterior descending artery and the distal remnant part of the left ITA is anastomosed end-to-side to the right ITA at a level that allows the obtaining of a branch that can bypass the diagonal artery, the intermediate branch, or the obtuse marginal arteries. If a right-heart bypass is required, the proximal third of the in situ right ITA is extended with the free radial artery [3].
We recently reported the left mammary loop technique [4] that allows the making of an adjustable "Y" graft using only the left ITA. The distal end of the left ITA is anastomosed end-to-side to the proximal part of the left ITA to make a loop, which is severed at the appropriate level at the time of coronary anastomosis. We used the advantages of the mammary loop technique to construct a "" graft. The first step was to construct a "Y" graft by anastomosing the free right ITA to the left ITA. The distal end of the left ITA was then anastomosed to the proximal part of the right ITA to make a loop between the two ITAs. When the left anterior descending artery was anastomosed, the loop was severed at the required level.
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Technique
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The two ITAs are skeletonized from the subclavian vein to the bifurcated end. The entire length of the right ITA is preserved as a free graft. The mediastinal tissue is separated from the left pleura, and the pericardial reflection on the left side of the aorta is divided vertically to improve the access of the left ITA into the surgical field. An arteriotomy is done on the left ITA at the level of the pericardial reflection on the pulmonary trunk. The proximal part of the free right ITA is anastomosed end-to-side at 45° to obtain a "Y" graft (Fig 1). The distal end of the left ITA is spatulated and anastomosed end-to-side to an arteriotomy done on the right ITA to obtain a loop. The level of this anastomosis is variable (ie, on the proximal third for the intermediate branch and on the middle third for the obtuse marginal or the circumflex artery). This anastomosis is performed extrathoracically. The loop is severed when the left anterior descending artery is anastomosed. The result is a "" graft with three branches: (1) a left branch made with the proximal left ITA, (2) a middle branch made with the distal left ITA, and (3) a right branch made with the right ITA (Fig 2). The proximal part of the loop made with the left ITA is always used to bypass the left anterior descending artery. The middle branch is the distal part of the loop, which becomes a reversed conduit and can bypass one or more lateral wall vessels. The part of the right ITA distal to the loop anastomosis is long enough to bypass the posterior descending artery or the left ventricular branch of the right coronary artery. Sequential anastomoses can be performed on the left ventricular vessels under the appropriate conditions.
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Results
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We performed this technique in July, 2003 on a patient with triple-vessel disease. The arteries bypassed were the proximal part of the left anterior descending artery with the left "" branch, the intermediate branch artery, and an obtuse marginal artery with the middle branch of the "" graft in sequential, and the left ventricular branch of the right coronary artery with the right "" branch. The patency of the whole construction was controlled postoperatively by coronarography (Fig 3).
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Comment
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This modification of the original "" graft technique presents certain advantages: (1) The mammary loop technique allows the determination of the level of the left ITA transection with precision for a more rational use of the length of the left ITA. (2) The middle branch anastomosis of the "" graft, performed extrathoracically, is much easier with the mammary loop technique. (3) Using the entire length of the right ITA allows a bypass of the right vessels with the "" graft to avoid harvesting the radial artery as in the original "" graft technique.
The "" graft is a complex technique that should only be used in selected patients. Our modification of the original "" graft technique offers a more rational use of the two ITAs and the possibility to do a right coronary artery bypass with the ITA. Further experience is needed to determine the long-term patency of this "" graft.
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Acknowledgments
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The authors thank Nancy Richardson-Peuteuil for her editorial assistance.
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References
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- Chocron S, Etievent JP, Schiele F, et al. 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]
- Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the "" graft. Ann Thorac Surg. 2002;73:1990–1992[Abstract/Free Full Text]
- Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JPh. The mammary loop — or how to do an adjustable "Y" graft with the left internal thoracic artery. Ann Thorac Surg 2004;78:1103–4
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Abstract
Introduction
