Ann Thorac Surg 2006;82:69-73
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Coronary Artery Bypass Grafting Using an Abdominal Artery as an Inflow
Kenji Takahashi, MD
*
,
Kazuyuki Daitoku, MD,
Masahito Minakawa, MD,
Norihiro Kondo, MD,
Kazuhiro Naito, MD,
Shigeru Oikawa, MD
Department of Cardiovascular Surgery, Aomori Municipal Hospital, Aomori, Japan
Accepted for publication October 31, 2005.
* Address correspondence to Dr Takahashi, Department of Cardiovascular Surgery, Aomori Municipal Hospital, Katta 1-14-2, Aomori City, 030-0821, Japan (Email: takaken{at}r66.7-dj.com).
 |
Abstract
|
|---|
BACKGROUND: In multiple bypass surgery, when the ascending aorta cannot be used as an inflow, it is sometimes necessary to use an abdominal artery. This technique is useful when a re-median sternotomy might damage a patent graft in patients undergoing reoperations or when the gastroepiploic artery is unsuitable for use as a graft.
METHODS: The subjects were 17 patients in whom an abdominal artery was used as an inflow. In these 17 patients, 9 underwent surgery for the first operation, while 8 underwent surgery for the reoperation. As an inflow, the gastroduodenal artery was used in 8 patients, the common hepatic artery in 4 patients, the left gastric artery in 3 patients, the right gastric artery in 1 patient, and the middle colic artery in 1 patient. The target coronary artery was the right posterior descending artery in 13 patients, the atrioventricular artery in 2 patients, and the circumflex artery in 4 patients. Sequential bypass was performed on 2 patients.
RESULTS: None of the patients died during surgery. Symptoms disappeared postoperatively in all patients; postoperative angiography showed that all grafts were patent.
CONCLUSIONS: The present technique is useful when the ascending aorta cannot be used as an inflow or when a bypass to a region with a large perfusion area is needed in multiple bypass surgery.
|
Introduction
|
|---|
We have utilized an abdominal artery as an inflow as one of the options when the ascending aorta cannot be used as an inflow due to porcelain aorta, a reoperation is needed in patients in whom the left gastroepiploic artery (GEA) has already been used as a graft, or the GEA is unusable as a graft. We report the usefulness of the present technique.
|
Patients and Methods
|
|---|
The subjects were 17 patients treated between December 1, 1998 and May 1, 2005. There were 13 men and 4 women, ranging in age from 46 to 80 years with an average age of 69.5 years (Table 1
). All patients underwent off-pump coronary artery bypass grafting (OPCAB). Also, while 9 patients underwent bypass grafting for the first operation, 8 patients underwent bypass grafting for the second operation (Table 1). The time lapse from the first to second surgery ranged from 2 years and 3 months to 9 years and 3 months, with an average of 6 years and 6 months. In order to secure the inflow of an abdominal artery, first the attachment between the diaphragm and the left hepatic lobe was severed using an electrocautery instrument, enabling the movement of the left hepatic lobe to the left or right direction. With this step, a broad visual from the diaphragm to the small curvature of the stomach and the entire lesser omentum was obtained. When utilizing the gastroduodenal artery as an inflow, by raising the descending leg from the bulbar region of the duodenum in the left direction (Kocher's maneuver), the bifurcation of the common hepatic artery into the proper hepatic artery and the gastroduodenal artery could be observed. The gastroduodenal artery was slightly detached in the distal direction to secure enough space for anastomosis. Also, the common hepatic artery was detached in the proximal direction from the bifurcation with the gastroduodenal artery, and anastomosis was carried out at a location where the graft length would be at its shortest without any bending. Because the common hepatic artery is surrounded by nerve plexus and narrow vessels, detachment can sometimes be difficult due to bleeding. In this case detachment can be done with less bleeding by using the Harmonic Scalpel II (Ethicon Endo-Surgery Co, Ltd, Cincinnati, OH). A thick left artery before the bifurcation with the cardiac branch could be reached by following the smaller curvature branch along the small curvature of the stomach in the proximal direction. In bypass the graft was first anastomosed to the coronary artery, and then a small hole was made in the diaphragm in order to place the graft into the abdominal cavity with the shortest distance to the target abdominal artery while minimizing bending. The graft was placed between the lesser omentum and the left hepatic lobe. The graft was anastomosed to the abdominal and coronary arteries carried out using 7-0 polypropylene string, and while interrupted sutures were initially used, continuous sutures have been used in recent years (n = 15).
|
Results
|
|---|
None of the patients died during surgery. As an inflow, the GDA was used in 8 patients, the common hepatic artery (CHA) in 4 patients, the left gastric artery (LGA) in 3 patients, the right gastric artery (RGA) in 1, and the middle colic artery in 1 patient. As a graft, a vein graft was used in 7 patients, a radial artery (RA) graft in 5 patients, a free right internal thoracic artery (FRITA) graft in 4 patients, and a free left internal thoracic artery (FLITA) graft in one patient. Sequential bypass was done in 2 patients. The target coronary artery was the right posterior descending artery (PDA) in 13 patients, the atrioventricular artery in 2 patients, and the circumflex artery (Cx) in 4 patients. Sequential bypass was performed on 2 patients.
Among the patients who underwent bypass grafting for the first time, the present technique was employed because of the following: the GEA was occluded in 1 patient (patient 3); the GEA was severed due to gastric cancer surgery in 1 patient (patient 2); the amount of blood flow in the GEA would have been insufficient due to central constriction of the RCA in 4 patients (patients 1, 4, 6, and 7); the amount of blood flow in the GEA would have been insufficient for sequential bypass in 2 patients (patients 5 and 8);and the GEA was injured in 1 patient (patient 9). Among the patients who underwent bypass grafting for the second time, the present technique was employed because of the following: the GEA had already been used as a graft and had become occluded in 1 patient (patient 12), and the vein graft connecting the ascending artery and right coronary artery (RCA) had become occluded, and a re-median sternotomy could have damaged the patent graft in 5 patients (patients 10, 11, 12, 15, and 16). In patient 17, the vein graft anastomosed to Cx was patent but new RCA and left descending artery (LAD) lesions caused angina. In patient 14 the left internal thoracic artery was patent, but due to new RCA and Cx lesions angina often occurred, thus requiring reoperation. In this patient, a subtotal gastrectomy had been performed due to gastric cancer and the stomach had been reconstructed by a Billroth IIb method. Furthermore, because porcelain aorta was seen from the ascending aorta to the abdominal aorta and the iliac artery, it was determined that bypass from the aorta would be impossible; as a result, we decided that an abdominal artery would be used as an inflow. However, due to marked intestinal tract adhesion it was difficult to expose the GDA or CHA and as a last resort the transverse colic artery was used as an inflow artery. Because the intestinal tract adhered markedly and broadly, we thought that it would be possible to avoid strangulation ileus by the graft. As for the approach to the heart, a mediansternotomy + laparotomy was performed on all patients who underwent bypass grafting for the first time. Among the patients who underwent bypass grafting for the second time, the transdiaphragmatic approach [1] was employed in 6 patients, the transdiaphragmatic approach + a left thoracotomy in one patient, and a left thoracotomy + laparotomy in one patient. In all 17 patients the anginal symptoms disappeared and postoperative contrast radiography showed that the grafts were patent (see Figs 1–3).
View larger version (137K):
[in this window]
[in a new window]
|
Fig 1. Patient 13: Postoperative angiography; bypass from the gastroduodenal artery (GDA) to right coronary artery (RCA) using the free right internal thoracic artery (FRITA).
|
|
View larger version (146K):
[in this window]
[in a new window]
|
Fig 2. Patient 14: Postoperative angiograph; sequential bypass from middle colic artery to right coronary artery (RCA) and circumflex (Cx) using the saphenous vein (SV).
|
|
View larger version (130K):
[in this window]
[in a new window]
|
Fig 3. Patient 16: Postoperative angiography: bypass from right gastric artery (RGA) to right coronary artery (RCA) using radial artery (RA).
|
|
|
Comment
|
|---|
In off-pump multiple coronary artery bypass grafting, several studies have documented the effectiveness of Y and T internal thoracic artery grafts [2–6] but we have not used these grafts due to problems with postoperative graft patency. It has been reported that the amount of blood supplied to the myocardium directly after surgery is insufficient. Also, the string phenomenon is caused by anastomosing a graft to a coronary artery with a peripheral runoff or a vascular resistance difference; most graft flow is diverted to a vessel with favorable runoff or a coronary artery with less vascular resistance [7–11]. Hence, at our institution, when multiple bypass is indicated we occasionally use the ascending aorta as an inflow. When utilizing the ascending aorta it is necessary to assess thoroughly the degree of aortal calcification and the presence of debris; thus, preoperative computed tomography is standard and intraoperative ultrasound is performed when necessary. However, if porcelain aorta of the ascending aorta is marked or if the risk for blockage is high due to debris, either the left axillary artery [12–14] or the descending aorta [15] is used as an inflow; an abdominal artery is another option [16–18]. Furthermore, the present technique is useful when a re-median sternotomy can damage a patent graft in patients undergoing reoperations, particularly when the RITA is anastomosed to the LAD, the GEA has been used or severed, or bypass to the RCA or Cx is needed but the GEA is occluded due to a sclerotic lesion or too narrow to be used as a graft.
Among earlier patients, the GDA was used as an inflow artery and the graft was placed in front of the anterior surface of the left hepatic lobe, and then led into the cardiac sac through a small hole placed in the central tendon of the diaphragm [1]. However, because the GDA and CHA exist on the dorsal side of the left hepatic lobe, when the graft was placed in front of the left hepatic lobe, the graft length was long and occasionally the graft was strongly bent by the lower margin of the liver or was compressed during breathing (patient 12). As a result, a change was made to place the graft on the left side of the left hepatic lobe. However, this arrangement also required a long graft. Subsequently, in recent cases the attachment between the left hepatic lobe and the diaphragm has been severed to enable the movement of the left hepatic lobe to the left or right direction, thus securing a sufficient visual between the small curvature of the stomach and the diaphragm. Also, a small hole is placed in the diaphragm in order to minimize the distance between the target coronary artery and the inflow artery, and the graft is placed on the dorsal side of the left hepatic lobe. Furthermore, in order to shorten the graft length the CHA has recently been used as an inflow, and if the LGA and RGA are large enough one of these arteries can be used as an inflow to shorten further the graft length.
While blockage of the GDA or CHA appears to induce ischemia of the liver and pancreas, the blood flow to the liver and pancreas is maintained by retrograde flow through the anterior and posterior pancreaticoduodenal artery arcades from the superior mesenteric artery; as a result, there is no time limitation for anastomosis. In fact, there were no abnormal postoperative increases in the level of liver and pancreatic enzymes such as asparate aminotransferase, alanin aminotransferase, and amylase. However, when utilizing the present technique, we believe that it is necessary to confirm the patency of the superior mesenteric artery.
The advantage associated with the present technique is that a sufficient graft flow can be obtained. If there is central stenosis of the RCA, or if stenosis is mild (
75%), use of the GEA as an arterial graft can result in insufficient blood flow and competition with the native artery, thus resulting in graft occlusion or the string phenomenon. The present method achieves a sufficient graft flow using a short graft, and as it is an effective technique when a bypass to the Cx or RCA with a large perfusion area is required, can be an alternative in such a case.
In the present patients, vein grafts, RA grafts, FLITA, and FRITA grafts were used, and postoperative patency was favorable. As a result, the present technique appears to be useful when a bypass to either a coronary artery leading to a Cx or a RCA with a large perfusion area is needed.
|
References
|
|---|
- Takahashi K, Minakawa M, Kondo N, et al. Coronary artery bypass surgery by the transdiaphragmatic approach Ann Thorac Surg 2002;74:700-703.[Abstract/Free Full Text]
- Tector AJ, McDonald ML, Kress DC, et al. Purely internal thoracic artery graftsoutcomes. Ann Thorac Surg 2001;72:450-455.[Abstract/Free Full Text]
- Tector AJ, Amundsen S, Schmahl TM, et al. Total revascularization with T grafts Ann Thorac Surg 1994;57:33-38.[Abstract]
- Calafiore AM, Contini M, Vitolla G, et al. Bilateral internal thoracic artery graftinglong-term clinical and angiographic results of in situ versus Y grafts. J Thorac Cardiovasc Surg 2000;120:990-998.[Abstract/Free Full Text]
- Iaco AG, Teodori G, Di Giammarco G, et al. Radial artery for myocardial revascularizationlong-term clinical and angiographic results. Ann Thorac Surg 2001;72:464-469.[Abstract/Free Full Text]
- Calafiore AM, Di Giammarco G, Luciani N, et al. Composite arterial conduits for a wider myocardial revascularization Ann Thorac Surg 1994;58:185-190.[Abstract]
- Sakaguchi G, Tadamura E, Ohnaka M, et al. Composite arterial Y graft has less coronary flow reserve than independent grafts Ann Thorac Surg 2002;74:493-496.[Abstract/Free Full Text]
- Hosono M, Shimizu Y, Takanashi S, et al. Early angiographic and clinical results of branch conduits attached proximally to left internal thoracic arteries Ann Thorac Cardiovasc Surg 2002;8:145-150.[Medline]
- Nakamura Y, Kobayashi J, Tagusari O, et al. Early results of complete off-pump coronary revascularization using left internal thoracic artery with composite radial artery Jpn Thorac Cardiovasc Surg 2003;51:10-15.[Medline]
- Gaudino M, Aleassandrini F, Pragliora C, et al. Composite Y internal thoracic artery-saphenous vein graftsshort-term angiographic results and vasoreactive profile. J Thorac Cardiovasc Surg 2004;127:1139-1144.[Abstract/Free Full Text]
- Markwirth T, Hennen B, Scheller B, et al. Flow wire measurements after complete arterial coronary revascularization with T-grafts Ann Thorac Surg 2001;71:788-793.[Abstract/Free Full Text]
- Minakawa M, Takahashi K, Kondo N, et al. Left thoracotomy approach in reoperative off-pump coronary revascularizationbypass grafting from the left axillary artery or descending thoracic aorta. Jpn J Thorac Cardiovasc Surg 2003;51:582-587.[Medline]
- Bodner G. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting Eur J Cardiothorac Surg 1999;16(Suppl 2):S18-S23.[Abstract/Free Full Text]
- Bonatti J, Hangler H, Antretter H, et al. Axillocoronary bypass for severely atherosclerotic aorta in coronary artery bypass grafting J Thorac Cardiovasc Surg 1998;115:956-957.[Free Full Text]
- Mack MJ, Dewey TM, Magee MJ. Facilitated anastomosis for reoperative circumflex coronary revascularization on beating heart through a left thoracotomy J Thorac Cardiovasc Surg 2002;123:816-817.[Free Full Text]
- Kondo N, Takahashi K, Minakawa M, et al. Coronary artery bypass via diaphragmatic approach with free graft Ann Thorac Surg 2002;74:939-940.[Abstract/Free Full Text]
- Aufderheide AC, Henke BW, Parker EH. Granulomatous coronary arteritis (Takayasu's disease) Arch Pathol Lab Med 1981;105:647-649.[Medline]
- Yamaguchi A, Endo H, Adachi H, et al. Off-pump coronary artery bypass in patients with Takayasu's disease Ann Thorac Surg 2004;77:2186-2188.[Abstract/Free Full Text]
Related Article
-
Invited commentary
- Michael A. Savitt and Alfred J. Tector
Ann. Thorac. Surg. 2006 82: 73.
[Extract]
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
M. A. Savitt and A. J. Tector
Invited commentary.
Ann. Thorac. Surg.,
July 1, 2006;
82(1):
73 - 73.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
