HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract 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 Author home page(s): Joseph R. Elbeery Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Elbeery, J. R. Articles by Chitwood, W. R. Search for Related Content PubMed PubMed Citation Articles by Elbeery, J. R. Articles by Chitwood, W. R., Jr Related Collections Related Articles

Ann Thorac Surg 1997;64:1840-1842
© 1997 The Society of Thoracic Surgeons

---

How To Do It

Intraoperative Catheterization of the Left Internal Mammary Artery via the Left Radial Artery

Division of Cardiothoracic Surgery, East Carolina University School of Medicine, Greenville, North Carolina

Accepted for publication August 27, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Results Comment References

 
Minimally invasive coronary artery bypass grafting involving anastomosis of the left internal mammary artery to the left anterior descending coronary artery has become popular in the last year. Critics of this technique infer lower graft patency rates and increased cardiac morbidity. Therefore a technique is described that allows intraoperative selective left internal mammary arteriography to be performed by the surgeon to ensure graft patency before leaving the operating room.

	Introduction

Top Footnotes Abstract Introduction Technique Results Comment References

 
See also page 1842.

Minimally invasive direct coronary artery bypass grafting (MIDCABG) is an operation involving the anastomosis of the left internal mammary artery (LIMA) to the left anterior descending (LAD) coronary artery through a small left anterior thoracotomy. The anastomosis is performed on the beating heart without the use of cardiopulmonary bypass. Although MIDCABG appears to offer several advantages over traditional bypass grafting including reduced hospital length of stay, recovery time, and costs, skeptics suggest decreased graft patency and increased perioperative cardiac morbidity. Clearly the importance of the LIMA-to-LAD graft on survival [1] mandates that patency rates of MIDCABG anastomoses must be as good or better than those obtained with traditional coronary artery bypass grafting. The technique described allows selective angiography of the LIMA graft via the left radial arterial catheter site to assure an adequate anastomosis before chest closure. This procedure can be performed by the surgeon and should allow for a 100% early graft patency rate.

See also page 1725 and 1835.

	Technique

Top Footnotes Abstract Introduction Technique Results Comment References

 
Invasive monitoring is performed as per the surgeon's protocol with an arterial pressure catheter placed in the left radial artery using sterile technique. The patient is positioned with the left arm extended. Sterile preparation and draping of the chest should include the left arm. The operation is performed in standard fashion. It is important that the pedicle be placed in its expected final position before angiography because anastomotic problems have been found related to pedicle kinking [2].

Attention is now turned to arterial access. The previously placed left radial arterial catheter is exchanged for a 4F pediatric arterial sheath (Daig Corp, Minnetonka, MN). This is accomplished by disconnecting the pressure tubing from the radial artery catheter and inserting a 0.021-inch guidewire through the catheter into the radial artery. The guidewire is included in the arterial sheath kit and should pass through virtually any size radial artery line. The previously placed catheter is discarded and the enclosed dilator is placed through the 4F sheath and inserted over the guidewire after a small skin nick is made. The sheath and dilator should pass with gentle pressure into the radial artery. The guidewire is removed and the sheath is aspirated and flushed with heparinized saline solution. The side port of the sheath can be reconnected to the arterial pressure tubing for continued monitoring.

A 4F internal mammary artery (IMA) catheter (Cordis Europa NV, the Netherlands) is prepared. The catheter is flushed with 0.03% papaverine solution and a standard 0.035-inch, 145-cm guidewire (Cook Corp, Bloomington, IN) is passed into the catheter. The papaverine theoretically reduces radial artery spasm during catheter insertion. The wire is pulled just inside the distal tip of the IMA catheter, which is then inserted into the sheath. The left arm is now moved on the arm board toward the patient's left side to allow the fluoroscopy unit to be positioned. Our institution has used the OEC 9400 unit (OEC Medical Systems Inc, Salt Lake City, UT), but any fluoroscopic unit is adequate to confirm graft patency. The guidewire is advanced under fluoroscopic guidance until it enters the aorta, at which point the end of the wire will resume its natural curled position. The IMA catheter is advanced over the wire until the end drops into the aorta as well. The guidewire should be withdrawn as the catheter is advanced to avoid its crossing the aortic valve. As the wire is withdrawn, the IMA catheter resumes it natural "hook" configuration.

A 10-mL syringe is filled with contrast material (Isovue-370; E.R. Squibb, New Brunswick, NJ), deaired, and connected directly to the IMA catheter, which is aspirated until free of air. The catheter must be filled with contrast medium to be visible once the guidewire is removed. The hook of the catheter is directed at the patient's feet and slowly withdrawn into the subclavian artery. Small contrast infusions of 1 or 2 mL are given for orientation. In most patients, the LIMA arises inferiorly from the proximal subclavian and is easily cannulated. As the catheter is withdrawn across the LIMA orifice the catheter tip will fall into the ostium, which is manifest by a change in configuration of the catheter end to a more acute angle (Fig 1). The location is confirmed by an injection of 3 or 4 mL of contrast medium.

View larger version (60K): [in this window] [in a new window]   Fig 1. . Fluoroscopic image of catheter with straightened tip in subclavian artery (upper) and characteristic curve (lower) when ostium of left internal mammary artery is engaged.

View larger version (128K): [in this window] [in a new window]   Fig 2. . Fluoroscopic image of completed left internal mammary artery-to-left anterior descending artery anastomosis.

	Results

Top Footnotes Abstract Introduction Technique Results Comment References

	Comment

Top Footnotes Abstract Introduction Technique Results Comment References

 
Intraoperative angiography of MIDCABG operations can affirm patency of LIMA anastomoses before the patient leaves the operating room. If an inadequate anastomosis is detected, it can be revised or the procedure converted to a standard coronary artery bypass grafting operation. Thus no patient is left with an inadequate revascularization at the conclusion of the procedure.

Most surgeons have some rudimentary experience with postoperative angiography in peripheral vascular operations as well as intraoperative cholangiograms and therefore are familiar with fluoroscopy. We have no training in cardiac catheterization and have found the described technique to be simple and quick, adding no more than 10 or 15 minutes to each case. A cardiology consultant may be helpful on the first 1 or 2 cases, but most surgeons will be impressed with the ease at which the LIMA can be cannulated through the left arm approach.

This procedure offers several advantages over routine postoperative cardiac catheterization before hospital discharge. For example, the results are obtained immediately. Therefore, a return trip to the operating room and a second operation are not experienced by the patient or family members as is the case with "prior to hospital discharge" catheterization as advocated by others [3]. Same-day catheterization has also been described [2]. This necessitates transfer of the patient from the operating room to a cardiac catheterization suite, adds significant time to the procedure, and assumes immediate availability of cardiology personnel. In most institutions this is not practical. Furthermore, routine postoperative catheterization adds cost to the MIDCABG procedure and may not be seen by third-party payers as "medically indicated."

The major disadvantage of intraoperative catheterization involves the somewhat inferior quality of the images obtained. Mobile cardiac C-arm units are becoming commercially available (OEC Medical Systems) and may improve intraoperative image quality to the level of a formal cardiology study.

Minimally invasive cardiac surgery will play an increasing role in the future management of cardiovascular diseases. It is incumbent upon surgeons to see to it that the quality of an operation is not compromised by enthusiasm for a new technique. The described procedure affords the surgeon the greatest control over the early outcome of the MIDCABG operation and should eliminate concerns about the technical adequacy of this exciting alternative to standard coronary artery bypass grafting.

	Footnotes

Top Footnotes Abstract Introduction Technique Results Comment References

 
Address reprint requests to Dr Elbeery, Division of Cardiothoracic Surgery, East Carolina University School of Medicine, 600 Moye Blvd, Greenville, NC 27858-4354.

	References

Top Footnotes Abstract Introduction Technique Results Comment References

 

1. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6.[Abstract]
2. Schaff HV, Casle DG, Rihal CS, et al. Minimal thoracotomy for coronary artery bypass: value of immediate post procedure graft angiography [Abstract]. Circulation 1996;94(Suppl):151.[Abstract/Free Full Text]
3. Subramanian VA, Sani G, Benetti FJ, Calafiore AM. Minimally invasive coronary bypass surgery: a multi center report of preliminary clinical experience [Abstract]. Circulation 1995;92(Suppl):1645.

This article has been cited by other articles:

				P. K. Hol, E. Fosse, R. Lundblad, S. Nitter-Hauge, P. Due-Tonnessen, K. Vatne, and H.-J. Smith The importance of intraoperative angiographic findings for predicting long-term patency in coronary artery bypass operations Ann. Thorac. Surg., March 1, 2002; 73(3): 813 - 818. [Abstract] [Full Text] [PDF]

				J. C. Lin, D. L. Fisher, M. F. Szwerc, and J. A. Magovern Evaluation of graft patency during minimally invasive coronary artery bypass grafting with Doppler flow analysis Ann. Thorac. Surg., October 1, 2000; 70(4): 1350 - 1354. [Abstract] [Full Text] [PDF]

				T. A. Vassiliades Jr, E. W. Rogers, J. L. Nielsen, and J. L. Lonquist Minimally invasive direct coronary artery bypass grafting: intermediate-term results Ann. Thorac. Surg., September 1, 2000; 70(3): 1063 - 1065. [Abstract] [Full Text] [PDF]

				W. R. Chitwood Jr, C. L. Wixon, J. R. Elbeery, N. A. Francalancia, and R. M. Lust Minimally invasive cardiac operation: adapting cardioprotective strategies Ann. Thorac. Surg., November 1, 1999; 68(5): 1974 - 1977. [Abstract] [Full Text] [PDF]

				M. J. Mack, J. A. Magovern, T. A. Acuff, R. J. Landreneau, D. M. Tennison, E. J. Tinnerman, and J. A. Osborne Results of graft patency by immediate angiography in minimally invasive coronary artery surgery Ann. Thorac. Surg., August 1, 1999; 68(2): 383 - 389. [Abstract] [Full Text] [PDF]

				L. K. Han, E. Jacobsohn, and S. Aronson Intraoperative Echocardiography for the Patient Undergoing Minimally Invasive Heart Surgery Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 98 - 108. [Abstract] [PDF]

				M. B. Izzat, K. S. Khaw, W. Atassi, A. P. C. Yim, S. Wan, and M. H. El-Zufari Routine Intraoperative Angiography Improves the Early Patency of Coronary Grafts Performed on the Beating Heart Chest, April 1, 1999; 115(4): 987 - 990. [Abstract] [Full Text] [PDF]

				R. R. Lazzara and F. E. Kidwell Minimally invasive direct coronary bypass versus cardiopulmonary technique: angiographic comparison Ann. Thorac. Surg., February 1, 1999; 67(2): 500 - 503. [Abstract] [Full Text] [PDF]

				M. B. Izzat, M. H. El-Zufari, and A. P.C. Yim Intraoperative "direct" LIMA angiography for beating heart operations Ann. Thorac. Surg., October 1, 1998; 66(4): 1431 - 1432. [Abstract] [Full Text] [PDF]

				J. R. Elbeery, P. M. Brown, and W. R. Chitwood Jr Intraoperative MIDCABG arteriography via the left radial artery: a comparison with doppler ultrasound for assessment of graft patency Ann. Thorac. Surg., July 1, 1998; 66(1): 51 - 55. [Abstract] [Full Text] [PDF]

This Article Abstract 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 Author home page(s): Joseph R. Elbeery Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Elbeery, J. R. Articles by Chitwood, W. R. Search for Related Content PubMed PubMed Citation Articles by Elbeery, J. R. Articles by Chitwood, W. R., Jr Related Collections Related Articles