Ann Thorac Surg 2008;85:1108-1109. doi:10.1016/j.athoracsur.2007.04.040
© 2008 The Society of Thoracic Surgeons
How To Do It
Patch Aortoplasty for Proximal Anastomosis of Coronary Artery Bypass Grafts in Patients With Complex Aortic Pathology
Amit Korach, MD,
Praveen Menon, MD,
Oz M. Shapira, MD*
Department of Cardiothoracic Surgery, Boston Medical Center, Boston, Massachusetts
Accepted for publication April 13, 2007.
* Address correspondence to Dr Shapira, Department of Cardiothoracic Surgery, Suite B-402, Boston Medical Center, 88 East Newton St, Boston, MA 02118 (Email: oz.shapira{at}bmc.org).
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Abstract
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Proximal anastomosis of conduits to the ascending aorta in patients undergoing coronary artery bypass grafting may be hazardous or impossible in the presence of complex aortic pathology. We describe a technique of the excision of a segment of the diseased aortic wall, reconstruction with a bovine pericardial patch, and attachment of the grafts to the patch. The technique was used successfully in 2 patients (ie, 1 patient with Takayasu’s disease and the other with a heavily calcified aorta).
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Introduction
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The ascending aorta is the most frequently used site for proximal anastomosis of "free" grafts used for coronary artery bypass grafting. However, in the presence of severe aortic root pathology, such as Takayasu’s disease or atheromatous aorta, attachment of grafts may be technically difficult and associated with significant complications such as systemic embolization, acute thrombosis, and increased incidence of anastomotic stenosis or occlusion [1–3]. We describe a technique of the excision of a segment of the diseased aortic wall, reconstruction with a bovine pericardial patch, and attachment of the grafts to the patch.
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Technique
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Patient 1
A 19-year-old woman presented with new onset angina. She was diagnosed with Takayasu’s disease 1 year prior to this admission and underwent stenting of the abdominal aorta. A treadmill stress test was positive for anterior wall ischemia. Aortography and cardiac catheterization showed a narrow ascending aorta, total occlusion of the left subclavian artery, 70% ostial left main coronary artery stenosis, and 60% ostial right main coronary artery stenosis.
An operation was performed using cardiopulmonary bypass and cardioplegic arrest with a single aortic cross clamping. Distal anastomoses of three reversed segments of the saphenous vein to the left anterior descending coronary artery, the circumflex marginal artery (OM), and the right coronary arteries were constructed first. Attempts to create holes in the ascending aorta for proximal anastomoses failed due to severe thickening (8 mm) and fibrosis of the aortic wall. Therefore, a segment of the disease aortic wall (3-cm in diameter) was excised. The defect in the aortic wall was reconstructed with a bovine pericardial patch (Peri-Guard; Synovis, St. Paul, MN) sutured in place using a continuous 5-0 polypropylene suture. Two holes were created in the patch using a standard "punch" instrument (Teleflex DP; Teleflex Medical, Research Triangle Park, NC), and the vein grafts to the left anterior descending coronary artery and right coronary artery were attached to the patch using continuous 6-0 polypropylene sutures (Fig 1). The vein graft to the OM was anastomosed to the left anterior descending coronary artery graft in an end-to-side fashion, creating a "Y" graft (Fig 1). The patient recovered uneventfully and is asymptomatic 2 years after the operation.
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Fig 1. Attachment of two saphenous vein grafts to a bovine pericardial patch used to reconstruct a severely diseased ascending aorta in a patient with Takayasu’s disease. A third saphenous vein graft was anastomosed in an end-to-side fashion creating a "Y" graft. (Ao = aorta; P = patch; SVG = saphenous vein graft.)
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Patient 2
A 78-year-old man with a past medical history of hypertension, diabetes mellitus, and hyperlipidemia presented with acute non-ST-segment elevation myocardial infarction and post-infarction angina. Cardiac catheterization revealed severe three-vessel disease not amenable to percutaneous intervention. Plain film of the chest x-ray revealed heavily calcified aortic arch, but a normal ascending aorta. The patient was referred for coronary artery bypass grafting with planned grafts to the left anterior descending coronary artery, OM, and right posterior descending coronary artery.
An epiaortic ultrasound performed after opening the pericardium showed a large atheromatous plaque in the anterior wall of the proximal ascending aorta as well as the aortic arch and the innominate artery. A short segment of the distal ascending aorta was free of calcifications and allowed arterial cannulation and cross clamping. During a single period of aortic cross clamping and cardioplegic arrest three distal anastomoses were constructed (ie, the left internal mammary artery [LIMA] to the left anterior descending coronary artery, and saphenous vein grafts to the OM and the posterior descending coronary artery).
Using the same technique, a calcified part of the anterior wall of the aorta (3-cm in diameter) was excised and reconstructed with a bovine pericardial patch. The saphenous vein graft to the OM was attached to the pericardial patch and the posterior descending coronary artery graft was anastomosed to the OM graft in an end-to-side fashion creating a "Y" graft. The patient recovered uneventfully and is doing well 1 year after the operation.
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Comment
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The optimal source for graft inflow in patients with complex aortic root pathology who require multivessel coronary artery bypass grafting remains controversial. Direct anastomosis of the grafts to the ascending aorta under epiaortic ultrasound guidance is an option that is associated with lower, albeit still significant incidence of systemic embolization and graft occlusion [1–3]. Graft occlusion in these circumstances frequently occurs at the ostia of the grafts secondary to extension of the disease from the adjacent aortic wall into the graft [1–3].
Another common approach is to construct a "T," "Y," or other type of composite arterial graft using the left internal mammary artery or the right internal mammary artery as the sole source of blood flow to the heart [4]. Although an attractive option, the use of even a single "in-situ" internal mammary artery was not feasible in patient 1 due to total occlusion of the left subclavian artery and is considered by many surgeons to be contraindicated in patients with Takayasu’s disease [2, 3]. Composite arterial grafts are associated with several potential disadvantages. Bilateral internal mammary artery harvest is associated with increased incidence of sternal wound infection, particularly in the elderly diabetic patients, such as our second patient. These grafts are more technically demanding and are more vulnerable to errors. Finally, in as many as 1% to 2% of cases, the blood flow through a single internal mammary artery is not sufficient to perfuse all territories, creating myocardial ischemia (ie, "hypoperfusion syndrome") [4]. Other sources for graft inflow (such as the right gastroepiploic artery, splenic artery, and superior mesenteries artery) are much more complex, require violation of other body cavities, and have been used only anecdotally [5]. The use of visceral arteries in patient 1 was not feasible due to involvement of the abdominal aorta.
Patch aortoplasty is a simple technique that avoids many of the previously mentioned pitfalls. It affords a smooth healthy surface to which the grafts can be easily and precisely sutured. Excision of part of the aortic wall allows augmentation of the aorta and removes a significant load of atheroma, decreasing the risk of future embolization such as in patient 2. The presence of a margin of foreign inert tissue between the native diseased aorta and the ostia of the grafts decreases the risk of long-term ostial graft stenosis due to extension from the adjacent aorta. In this regard, use of autologous live pericardium may be adequate in patients with atherosclerotic aorta, but it should probably be avoided in patients with Takayasu’s disease because of the autoimmune nature of the latter [2, 3, 5, 6]. Use of pericardium to augment the aorta has been shown to be safe without aneurysm formation for as many as 15 years after the operation [7]. Impregnated Dacron (DuPont, Wilmington, DE), polytetrafluoroethylene, or other prosthetic patches might be also used, but these are stiffer, less pliable, and more vulnerable to late infections.
In summary, patch aortoplasty with a bovine pericardial patch is a safe and effective technique that should be included in the armamentarium of techniques of managing complex aortic pathology in patients requiring multivessel coronary artery bypass grafting. Long-term follow-up is indicated to further assess the effectiveness of this technique.
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References
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- Endo M, Tomizawa Y, Nishida H, et al. Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis J Thorac Cardiovasc Surg 2003;125:570-577.[Abstract/Free Full Text]
- Amano J, Suzuki A. Coronary artery involvement in Takayasu’s arteritis J Thorac Cardiovasc Surg 1991;102:554-560.[Abstract]
- Tector AJ, Amundsen S, Schmahal M, Kress DC, Peter M. Total revascularization with T grafts Ann Thorac Surg 1994;57:33-39.[Abstract]
- Yamaguchi A, Endo H, Adachi H, Kawahito K, Ino T. Off-pump coronary artery bypass in patients with Takayasu’s disease Ann Thorac Surg 2004;77:2186-2188.[Abstract/Free Full Text]
- Matteucci MLS, Iascone M, Gamba A, et al. Left main patch plasty and aortic root homograft in Takayasu’s disease Ann Thorac Surg 2004;77:314-317.[Abstract/Free Full Text]
- Piehler JM, Danielson GK, Pluth JR, et al. Enlargement of the aortic root or annulus with autogenous pericardial patch during aortic valve replacement: long-term follow up J Thorac Cardiovasc Surg 1983;86:350-358.[Abstract]
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Ann. Thorac. Surg.,
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86(6):
2023 - 2023.
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Abstract
Introduction
