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J Thorac Cardiovasc Surg 1998;116:1086-1087
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

The route of choice for the axillocoronary bypass graft

To the Editor:

I read with great interest the recent article by Bonatti and colleagues, "Axillocoronary Bypass for Severely Atherosclerotic Aorta in Coronary Artery Bypass Grafting." ¹ Their approach seems to be an excellent solution to prevent cerebral embolization during the construction of proximal anastomoses while performing coronary bypass operations in patients with a severely atherosclerotic ascending aorta. Of concern, however, is the course they chose to tunnel the graft into the thoracic cavity which, in turn, may limit its patency and the application of this procedure.

Several routes have been previously reported to tunnel axillocoronary grafts into the chest cavity: a subcutaneous course, ² a subfascial plane, ³ a tunnel through the bed of the second costal cartilage, ⁴ or a tunnel through the intercostal muscles. ⁵ Bonatti and colleagues ¹ chose the last one.

During quiet, deep, and forced respiration, the external intercostal muscles raise the ribs. During forced respiration the internal intercostal muscles lower the ribs. The combined action of the external and internal intercostal muscles draws the ribs together. This can be felt during insertion of chest tubes while performing digital examination of the pleural cavity when patients suddenly cough. It is no surprise that a patient, reported to have undergone an axillocoronary bypass with tunneling of the graft through the intercostal muscles, died suddenly 3 weeks after the operation. ⁵

Before using the axillary artery as a source of inflow to revascularize the coronary arteries, I realized that there was no natural passage to reenter the chest cavity. ⁶ Therefore I decided to remove the anterior portion of the first rib, which transformed the proximal portion of the axillary artery into an intrathoracic structure (Fig. 1). This surgical step requires expertise usually acquired while treating patients with thoracic outlet syndrome, and care has to be taken to avoid injury to the neurovascular bundle. Its performance, however, allows a sound and protected course for the axillocoronary graft. Another option I have used, although technically demanding, is to access the subclavian artery through an extrathoracic supraclavicular approach just distal to the internal thoracic artery, routing the graft parallel to this vessel into the adjacent parietal pleura. This should not be considered an axillocoronary but a subclaviocoronary bypass. Anatomically, it is not possible to access the distal portion of the subclavian artery through an infraclavicular approach unless the anterior portion of the first rib has been removed. Likewise, although the distal portion of the subclavian artery can be accessed through a supraclavicular approach, the clavicle makes the axillary artery inaccessible.

View larger version (20K): [in this window] [in a new window]   Fig. 1 A, Top view of the thoracic outlet. B, Observe how, by removing the anterior portion of the first rib, the proximal portion of the axillary artery becomes an intrathoracic structure.

Eduardo A. Tovar, MD
Department of Cardiothoracic Surgery
St Jude Medical Center
100 E Valencia Mesa Dr, Suite 301
Fullerton, CA 92835

12/8/93301

References

1. Bonatti J, Hangler H, Antretter H, Muller L. Axillocoronary bypass for severely atherosclerotic aorta in coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:956-7. [Free Full Text]
   
2. 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]
   
3. Knight WL, Baisden CE, Reiter CG. Minimally invasive axillary–coronary artery bypass. Ann Thorac Surg 1997;63:1776-7. [Abstract/Free Full Text]
   
4. Coulson AS, Bakhshay S. Axillary-coronary bypass. Ann Thorac Surg 1998;65:304. [Medline]
   
5. Yaryura R, Vardhan R, Springer AJ, Cooley DA. A 66-year-old man with severe angina and previous coronary artery bypass. Lancet 1997;349:396. [Medline]
   
6. Tovar EA, Blau N, Borsari A. Axillary artery-coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:242-3.[Free Full Text]
   

This article has been cited by other articles:

				H. Yasuda and N. Sakagoshi A technique to protect an axillo-coronary bypass graft Ann. Thorac. Surg., September 1, 2002; 74(3): 941 - 942. [Abstract] [Full Text] [PDF]

				J. A. Magovern, T. J. Hunter, and P. D. Yoon Clinical results with left axillary to left anterior descending coronary artery bypass Ann. Thorac. Surg., February 1, 2001; 71(2): 561 - 564. [Abstract] [Full Text] [PDF]

				J. Bonatti, H. Hangler, D. Oturanlar, L. Posch, L. C Muller, W. Voelckel, B. Schwarz, and G. Bodner Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S18 - S23. [Abstract] [Full Text] [PDF]

This Article 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): Eduardo A. Tovar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tovar, E. A. Search for Related Content PubMed PubMed Citation Articles by Tovar, E. A.