Ann Thorac Surg 2007;83:1911-1912
© 2007 The Society of Thoracic Surgeons
How To Do It
Total Arterial Coronary Revascularization Using Arterial Bypass Circle With Multiple Inflows
Reida M. El Oakley, MD*,
Hamad F. Al Habib, MBBS
Department of Cardiac Surgery, Prince Salman Heart Center, Riyadh, Kingdom of Saudi Arabia
Accepted for publication June 23, 2006.
* Address correspondence to Dr El Oakley, National University of Singapore, Prince Salman Heart Center, King Fahad Medical City, PO Box 59046, Riyadh, 11525 Kingdom of Saudi Arabia (Email: surrmo{at}nus.edu.sg).
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Abstract
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Coronary artery bypass techniques, currently applied to maximize the benefits of multiple arterial coronary conduits, render the newly constructed myocardial flow dependent on a single source "inflow" of blood. We describe a technique for total arterial coronary revascularization with multiple inflows; the distal end of the pedicled right internal thoracic artery is anastomosed to the distal end of a free radial artery, and the other end of the radial artery is then connected to the ascending aorta. This vascular circle, passed in a retro-cardiac fashion, is used to revascularize the inferio-lateral surface of the heart using multiple side-to-side anastomoses. The "sacred" left internal thoracic artery is reserved to revascularize the anterior wall of the myocardium, independent of the arterial circle.
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Introduction
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Arterial bypass conduits are the grafts of choice for myocardial revascularization, because of their excellent long-term patency that is translated into better short- and long-term survival [1]. A number of ingenious techniques were devised to achieve total arterial revascularization, including the right internal thoracic artery (RITA) or the radial artery (RA) connected to the left internal thoracic artery (LITA) as a T-graft [2], Y-graft [3], K-graft [4], and 
-graft [5]. All these techniques have an inherent limitation where the newly constructed coronary flow is dependent on a single graft, namely the LITA. Furthermore, many surgeons consider the LITA as a "sacred" graft, the long-term patency of which should not be compromised by adding other grafts before or after it has been anastomosed to the left anterior descending coronary artery [6]. We describe a new technique for total arterial revascularization, with multiple inflows combined with an independent LITA to left anterior descending coronary artery.
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Technique
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Pedicled LITA, RITA, and a free RA are dissected as previously described [7, 8]. The free distal end of the RA is then anastomosed end-to-end to the pedicled RITA. This RITA-RA composite is passed in a retro-cardiac fashion along the inferio-lateral surface of the heart. On-bypass or off-bypass, a partial occlusion clamp is applied to the aorta and the proximal end of the RA is anastomosed to the aorta to create the bypass circle. Thus giving a second inflow to the circuit in addition to the primary flow from the RITA (Fig 1). This coronary artery bypass circle is used to revascularize the diseased coronary arteries on the inferio-lateral surfaces of the heart using multiple side-to-side anastomosis. To avoid miscalculating the length of the graft, it is advisable that the planned sites of the coronary bypass are marked, using a permanent marker pen, together with the corresponding point on the coronary artery bypass circle while the heart is full. The "sacred" LITA is then anastomosed to the left anterior descending coronary artery or diagonals, or both, to supply the anterior surface of the heart. This technique can be applied using on-pump or off-pump surgery.
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Fig 1. An artist impression of the coronary artery bypass circle, a composite right internal thoracic artery (RITA) to the radial artery (RA) connected by end-to-end anastomosis, in which the other end of the RA is connected to the aorta. Thus, giving a second inflow to the circuit in addition to the primary flow from the RITA. The left internal thoracic artery (LITA) is used to revascularize the anterior wall of the heart, independent of the arterial circuit. (A) The left internal thoracic artery. (B) The right internal thoracic artery. (C) The radial artery.
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The coronary artery bypass circle technique with independent LITA to left anterior descending coronary artery was applied in 3 patients; they had an average of four arterial-to-coronary anastomoses each. All patients recovered well without major complications and were discharged 7, 8, and 10 days after surgery. Cardiac computed tomographic angiography of the first case using the General Electric Lightspeed Pro 16 Slices (General Electric) 3 months after surgery showed patent (A) LITA, (B) RITA, and (C) RA (Fig 2).
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Fig 2. Three-dimensional reconstruction of cardiac computed tomographic angiography of the first case using the General Electric Lightspeed Pro 16 Slices (General Electric, New York, NY) 3 months after surgery, showed patent (A) left internal thoracic artery, (B) right internal thoracic artery, and (C) radial artery.
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Comment
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The coronary artery bypass circle technique described here offers multiple arterial conduits that are dependent on dual sources of blood flow without compromising the LITA to left anterior descending coronary artery graft. Having multiple inflows in the coronary artery bypass circle may enhance coronary artery flow reserve, particularly during diastole. However, dual inflow can lead to competitive flow between both sources if the coronary bed (ie, run off) is not adequate. Hence the theoretical risk of thrombosis of either inflow limbs.
Apart from being technically challenging, the main potential limitation of this technique is the initial concern regarding the length of the circuit. Full mobilization of the right internal thoracic artery (beyond the bifurcation), the radial artery (from the proximal palmar crease up to the posterior inter-ossius branch just distal to the cubital fossa) and complete division of the adventia surrounding the radial artery, and semi-skeletonization of the right internal thoracic artery, will almost always ensure adequate length of the circuit.
Other potential configurations of this circuit concept include:
- 1 (LITA-Radial-Aorta) circle to graft the left anterior descending artery/other coronaries on the left side of the heart.
- 2 (RITA-Radial-Aorta) circle.
To avoid miscalculating the length of the graft it is highly recommended that the planned sites of coronary bypass are marked together with the corresponding point on the coronary artery bypass circle using a permanent marker pen while the heart is full.
The impact of this technique on the short-term and long-term patency of total arterial coronary revascularization can only be ascertained in further studies, including detailed in-vivo physiological evaluation of graft-flow throughout the cardiac cycle, and most importantly, the analysis of long-term graft patency.
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Acknowledgments
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We acknowledge the contribution of Dr Nageeb Ghanem and his team in the department of radiology, who performed and analyzed the cardiac computed tomographic angiography. We also wish to thank Dr Ayman Al Khadra and Dr Mostafa Youssef for their critical appraisal of this manuscript.
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References
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Abstract
Introduction
