Eur J Cardiothorac Surg 1999;16:S18-S23
© 1999 Elsevier Science NL
Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting
Johannes Bonatti
a
,*,
Herbert Hangler
a
,
Derya Oturanlar
a
,
Lydia Posch
a
,
Ludwig C Müller
a
,
Wolfgang Voelckel
b
,
Birgit Schwarz
b
,
Gerd Bodner
c
a Innsbruck University Hospital, University Clinic of Surgery/Cardiac Surgery, Anichstrasse 35, A-6020 Innsbruck, Austria
b University Clinic of Anesthesiology and General Intensive Care, Innsbruck, Austria
c University Clinic of Radiodiagnostics, Innsbruck, Austria
* Corresponding author. Tel.: +43-512-504-3806/2529; fax: +43-512-504-2528 (Email: johannes.o.bonatti{at}uibk.ac.at).
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Abstract
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Objectives: Cannulation and clamping of a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) can lead to cerebral embolization of atheromatous debris and should therefore be avoided whenever possible. A variety of surgical techniques including performance of extraanatomical coronary bypass conduits has been described to solve this problem. We report on a preliminary series of four patients in whom the axillary artery was used as an inflow vessel for venous coronary artery bypass grafts which were performed on the beating heart in order to achieve an aortic no touch concept. Methods: The axillary artery was exposed between the pectoralis major muscle and the deltoid muscle via an infraclavicular incision. A saphenous vein graft of at least 40 cm in length was sutured to the axillary artery and then brought into the pericardial cavity following an intercostal and transpleural route. The graft was anastomosed to the target vessel using local coronary occlusion. The procedure was carried out via sternotomy in three patients who also received additional internal mammary artery in situ grafts for adequate coronary revascularization. In one high risk patient an isolated axillocoronary bypass was performed in a minimally invasive fashion via anterolateral minithoracotomy. Results: The procedure was completed without major technical difficulties in all four patients. The mean graft length required was 33.2±1.6 cm, postoperative ultrasonic duplex scans of the axillocoronary grafts revealed a mean flow of 62.5±23.6 ml/min. No stroke or brachial plexus injury occurred. Three patients are in angina class I (Canadian Cardiovascular Society Classification), one patient is in class II postoperatively. After a mean follow up of 11.5±6.6 months postoperatively all grafts remain patent. Conclusion: Axillocoronary bypass grafting can be easily performed for management of the untouchable ascending aorta. Straightforward surgical technique and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass grafts.
Key Words: Coronary artery bypass grafting • Beating heart coronary surgery • Ascending aorta • Atherosclerosis • Stroke • Axillary artery
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1. Introduction
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Encountering a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) represents a serious problem for the cardiac surgeon, as devastating cerebral damage by embolization of atheromatous debris may occur secondary to application of the aortic cross clamp. Strategies to overcome this problem have included performance of the coronary anastomosis on the beating [1] or fibrillating heart [2,3], single aortic crossclamping [4], endoluminal aortic occlusion [5], ascending aortic endarterectomy [6], ascending aortic replacement [7], and performance of extraanatomical bypass grafts to avoid proximal anastomoses to the ascending aorta. Several arteries have been used as inflow vessels for these extraanatomical coronary bypass variations. We have recently presented a case, in which the axillary artery was taken as the inflow vessel for an extraanatomical bypass in the management of a severely atherosclerotic ascending aorta [8], and herein report on additional experience gained with this technique.
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2. Methods
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Axillocoronary bypass grafting was performed in four patients with significant coronary artery disease who exhibited a severely atherosclerotic ascending aorta. Their demographic data are listed in Table 1
. Three procedures were carried out via median sternotomy, and one procedure was performed using a left anterior 5th intercostal space minithoracotomy. In two sternotomy cases supportive cardiopulmonary bypass was used.
2.1 Performance of the axillocoronary bypass
The axillary artery was exposed via an oblique infraclavicular skin incision between the pectoralis major and deltoid muscle distal to the pectoralis minor muscle. After applying vascular clamps the vessel was opened longitudinally and a saphenous vein graft of at least 40 cm in length was sutured in an end-to-side fashion to the axillary artery using 6/0 polypropylene (Prolene Ethicon Inc., Somerville, NJ). The ipsilateral pleura was incised and a large opening which allowed passage of two fingers was created digitally in the intercostal space adjacent to the axillary anastomosis. The blood filled and distally occluded vein graft was then pulled through the intercostal opening and brought transpleurally into the pericardial cavity. After target vessel occlusion an end-to-side coronary anastomosis was performed on the beating heart using 7/0 Prolene. For mechanical stabilization of the target vessel, the MINI-CABG system (USSC, Elancourt, France) was applied in two patients.
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3. Results
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Axillocoronary bypass grafting was successfully performed in all four patients. Exposure of the axillary artery and performance of the proximal bypass graft anastomosis was without any difficulties (Fig. 1). Intra and postoperative results are listed in Table 2
. A typical diastolic flow profile and adequate flow rates were detected in all grafts by ultrasonic duplex scans on discharge (Fig. 2).
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Fig. 1. Axillocoronary bypass grafting using a minimally invasive technique via an axillary and a thoracic mini-incision. The filled vein graft sutured to the axillary artery is pulled through the pleural space to reach the target vessel which is exposed via a 4th interspace anterolateral minithoracotomy (arrow).
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Fig. 2. Typical high diastolic pulsatile flow profile of an axillocoronary bypass graft visualized by pulsed Doppler ultrasound.
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Graft patencies are shown in Table 2. Follow-up duplex scans showed reduction from 60 to 23 ml/min in the first patient. Graft angiography revealed a patent graft with narrowing at the coronary anastomotic site, probably due to neointima formation, whereas the course of the graft revealed no pathological findings. Duplex scans of the three other grafts during the first postoperative months detected stable flow rates with mild signs of intimal thickening at various sites throughout the graft course before entrance into the thoracic cavity.
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4. Discussion
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This small clinical series shows the feasibility and proper short term postoperative function of a new extraanatomical coronary bypass graft variation that uses the axillary artery as the inflow source. During the early phases of minimally invasive coronary artery bypass grafting we have investigated the axillary artery as a potential site for the proximal anastomosis of coronary vein grafts [9]. Minimally invasive axillocoronary artery bypass grafting was at that time described in several case reports of difficult reoperative situations [10–12] or unusable internal mammary arteries during minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures [13,14]. As extraanatomical bypass conduits are an essential part of managing a severely atherosclerotic ascending aorta during CABG, we have transferred the axillocoronary bypass concept into a therapeutic strategy for this problem.
4.1 Patient selection
Presently we take beating heart axillocoronary bypass grafting into consideration if a diseased ascending aorta with protruding atheroma or severe calcification is found on epiaortic scanning or palpation. Less severe findings would be handled on cardiopulmonary bypass with a single aortic cross clamp technique [4].
4.2 Operative technique
We have exposed the axillary artery via an oblique infraclavicular incison distal to the insertion of the pectoralis minor muscle. Although a more proximal site has been recommended for axillofemoral bypass grafts [15], we chose this location because it proved more straight forward in our preceeding human cadaver study [9], and because following this route compression by the pectoralis major muscle is avoided [16]. Using the proximal part of the axillary artery is advised for the axillofemoral bypass because anastomotic disruption during certain upper extremity movements is of some concern [15]. We did not observe reduction of graft flow or undesired graft tension on duplex scan with arm elevation in any patient. The problem of rib resection to guarantee a compression free course of the graft has been recently discussed [16]. We think that in the case of a narrow intercostal space this is clearly indicated. In none of the patients in this series, however, was compression of the graft in the intercostal space a problem.
A minimally invasive variation of the procedure via left anterolateral minithoracotomy was performed once in this series. It was indicated because of the considerable patient risk profile in this acute redo procedure. Although a questionable compromise we chose to carry out a distal end to end anastomosis to an old, patent, but proximally stenosed aortocoronary vein graft to the left anterior descending artery, and left the other (occluded) branches of the coronary artery system unrevascularized. The patient recovered well with no more complaints of angina, but with residual signs of congestive heart failure. A follow-up angiography revealed a patent graft without anastomotic lesions and flow rates on follow-up duplex scan were satisfactory.
4.3 Postoperative aspects and comparison with other extraanatomical bypass conduits
Although no trends can be delineated from this preliminary series, it seems noteworthy that no postoperative neurologic deficit occurred in these high risk patients. Brachial plexus injury is a rare complication in axillofemoral bypass grafting, and was not a problem in our initial experience with axillocoronary bypass grafting.
Already during the early phases of CABG, the innominate artery has been described as an inflow site for coronary bypass conduits in cases of ascending aortic atherosclerosis [17]. An advantage is its close location to the ascending aorta and that no additional incisions are required for performance of innominate artery to coronary artery bypass grafting. The innominate artery is, however, frequently involved in the atherosclerotic process [18], and cerebral ischemia or embolization may occur during placement of a partial occluding clamp on this vessel.
Anastomoses of coronary vein grafts to the subclavian artery either via sternotomy or via anterolateral thoracotomy have been reported as well [19,20]. Also with these methods no additional incisions are necessary, but exposure and clamping of the subclavian arteries via sternotomy is sometimes difficult. In addition, atherosclerosis of the vessel is frequently associated with ascending aortic atherosclerotic lesions [18].
The internal mammary artery is another possible inflow source for coronary bypass grafts if an ‘aortic no touch' concept is followed. Flow rates seem to be sufficient for adequate blood supply to several coronary arteries [21], and satisfactory performance of arterial Y- and T-grafts have been repeatedly demonstrated [22]. Nevertheless, we think that multiple arterial grafting using the above constructs or all arterial in situ conduits is technically demanding, especially when carried out on the beating heart. In some cases we regard multiple arterial coronary bypass grafting as time consuming, luxury surgical therapy for the often multimorbid patient population exhibiting an untouchable ascending aorta.
Mills and Everson have described vein grafts originating from the right gastroepiploic artery for management of the untouchable ascending aorta [23]. We think that an additional laparotomy is a major disadvantage of this technique. In addition problems may arise from the narrow lumen and frequently encountered spasm of the vessel.
4.4 Visualization of the axillocoronary bypass graft and potential long-term problems
Because of rare indications at single institutions, there is little information about patency rates of extraanatomical coronary bypass conduits. It can be speculated that due to the length of the axillocoronary bypass graft and due to crossing of several muscular and bony thoracic structures patency rates may be lower than in aortocoronary bypass grafts. As a special feature the axillocoronary bypass graft represents a conduit, which can be easily visualized by ultrasonic duplex scan. Besides the fact that patency can be assessed by this method important insights into the development of vein graft disease can be revealed. Knowledge about this pathological entity has been primarily derived from angiographic and pathological studies [24]. Our initial experience shows that focal wall thickening can be detected by ultrasound during the first postoperative months and potential development of graft atherosclerosis can be monitored non-invasively as well.
From this preliminary experience, we conclude that axillocoronary vein bypass grafting for management of a severely atherosclerotic ascending aorta is a straightforward procedure which follows an aortic no touch concept. Easy surgical handling and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass solutions.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3–5, 1998.
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Top
Abstract
1. Introduction
