J Thorac Cardiovasc Surg 1998;116:669-670
© 1998 Mosby, Inc.
Axillary artery–coronary artery bypass grafting in patients with atherosclerotic ascending aorta
Yukinori Moriyam,
Riichiro Tod,
Koichi Hisatom,
Akira Tair
Kagoshima, Japan
To the Editor:
We read with great interest the article by Bonatti and associates entitled "Axillocoronary Bypass for Severely Atherosclerotic Aorta in Coronary Artery Bypass Grafting" in the April 1998 issue of this Journal (1998;115:956-7). Atherosclerosis of the ascending aorta is a risk factor for the development of stroke in cardiac operations. The aortic no-touch technique, with a variety of modifications, has been used to avoid this complication and has substantially reduced the incidence of stroke.
1 The procedure described by Bonatti and colleagues seems to be a very useful method, and its successful applications have also been reported sporadically in cases in which off-pump coronary artery bypass grafting was done. 2,3
To date we have performed this procedure on 3 patients, 2 with a severely atherosclerotic ascending aorta, in whom we used cardiopulmonary bypass, and 1 who had off-pump coronary artery reoperation. All 3 patients survived without evidence of cerebrovascular accident or perioperative myocardial infarction. Postoperative angiography revealed all grafts to be patent, although, unfortunately, 1 patient was found to have a 70% stenosis in the left subclavian artery just distal to the origin of the internal thoracic artery (Fig l).
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Fig. 1. Postoperative coronary angiogram demonstrated a 70% stenosis (white arrow) in the left subclavian artery just distal to the origin of the internal thoracic artery. The left internal thoracic artery (*) and a saphenous vein graft (**) were widely patent.
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The patient was a 78-year-old man who had 2-vessel disease (a 99% stenosis of the left anterior descending artery and a 90% stenosis of the left circumflex artery) with a calcified ascending aorta. The blood pressures were almost equal in the upper extremities. A median sternotomy was applied and the left femoral artery was used for arterial perfusion. After harvesting of the left internal thoracic artery and systemic heparinization, the left axillary artery–left circumflex artery anastomosis was completed with a saphenous vein graft according to the procedure described by Bonatti and associates. The left internal thoracic artery was then attached to the left anterior descending artery as an in situ graft. During the operative procedure the presence of a stenotic subclavian artery was not noticed at all. In this case, however, no signs of myocardial or left arm ischemia were present after the operation.
For an untouchable aorta, various modifications in technique to avoid manipulation, cannulation, or clamping of the diseased aorta have been proposed; these include use of the femoral artery or aortic arch for cannulation, no aortic clamp under hypothermic circulatory arrest, placement of an in situ arterial graft, or use of the innominate artery or descending thoracic aorta as an inflow site for a free graft. 1,4,5 The axillary artery, which is easy to access, has been used as the blood supply for extra-anatomic reconstruction and may possibly have sufficient flow to supply the myocardium. Use of the saphenous vein to revascularize the coronary artery is technically easy as well. Taking these points into account, axillocoronary saphenous vein bypass is thought to be a valuable procedure for patients with severe atherosclerosis of the ascending aorta. On the basis of our own experience, we support the use of this procedure. However, particular attention must be paid to the coexistence or future development of atherosclerosis in the subclavian artery, although a number of ways are available to cope with this problem.
References
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Tovar EA, Blau N, Borsari A. Axillary artery–coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:242-3. [Free Full Text]
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Machiraju VR, Culig MH, Heppner RL, Minella RA, O'Toole JD. Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures. Ann Thorac Surg 1998;65:625-7. [Abstract/Free Full Text]
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Suma H. Innominate and subclavian arteries as an inflow of free arterial graft. Ann Thorac Surg 1996;62:1865-6. [Abstract/Free Full Text]
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Weinstein G, Killen DA. Innominate artery–coronary artery bypass graft in a patient with calcific aortitis. J Thorac Cardiovasc Surg 1980;79:312-3. [Abstract]
