Eur J Cardiothorac Surg 2002;21:953-954
© 2002 Elsevier Science NL
Retrocaval route for the right internal mammary artery
Luc Noyez*
Department of Thoracic and Cardiac Surgery – 414, Heartcenter, University Nijmegen Medical Center, St. Radoud, 6500 HB Nijmegen, The Netherlands
Received 11 December 2001;
accepted 18 February 2002.
* Tel.: +31-24-3614744; fax: +31-24-3540129
e-mail: l.noyez{at}thorax.umcn.nl
I read with interest the How-to-do-it article by Ramandan et al. [1], but I have two remarks. First, Pliam and Zapolanski described this technique in 1993 [2]. My second remark, however, concerns the last part of the final ‘conclusion’: "the RIMA (right internal mammary artery) is well hidden behind the vena cava which can be considered as an advantage in redo surgery by further avoiding RIMA damage". I agree that the place and covering the IMA pedicle during the primary operation is essential to avoid damage to this graft during redo surgery [3]. A lot of surgeons reject the ante-aortic route to cross the midline with a right IMA graft, and the reason is possible damage to this graft during resternotomy for reoperation (RECABG). However, damage may also occur during the dissection of the IMA-graft, necessary for manipulation of the heart, and eventually clamping the IMA-graft. If a RIMA is crossing the midline, it is important to have a good access to the proximal part of the RIMA-graft, because by reopening the chest by sternotomy, it is this part that needs more length. By spreading the two sternum parts, the distance between the ostium of the right IMA in the subclavian artery and the midline is increasing. Therefore, meticulous dissection of this part of the right IMA is important to avoid damage to this pedicle. Above all, if we have an IMA-graft passing through the transverse sinus, to a circumflex coronary artery, and we have to reach the lateral side of the heart during RECABG, the dissection of this IMA can give us a lot of problems. Even the part of this IMA-graft under the aorta must be dissected free, to avoid damage during aortic cross-clamping.
Besides the fundamental discussion is it opportune to cross the midline with an IMA-graft? In my personal opinion, the ante-aortic route is a safe and the most practical way to bring a right IMA to the left heart side. The pedicle must, however, always be covered by pericardium or thymic fat, to avoid direct adherence with the internal sternal table. Use of the retrocaval route allows additional length to the RIMA, and the placement of the IMA-graft through the transverse sinus avoids lesions during resternotomy as stated by the authors [1]. However, IMAs placed in this way are more difficult to handle during RECABG. With the increasing number of RECABG, with patent IMA-grafts [4], not only placement and covering of IMA grafts are necessary to avoid damage during RECABG, but also the possibility to manipulate these grafts during RECABG becomes important.
In conclusion, the retrocaval route to bring the right IMA to the left heart side is useful in a selected number of patients.
References
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Ramadan R., Al Attar N., Lessana A., Nataf P. Retrocaval in situ RIMA for distal marginal arteries grafting. Eur J Cardiothorac Surg 2001;20:1235-1236.[Abstract/Free Full Text]
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Pliam M.B., Zapolanski A. Retrocaval routing of the right internal thoracic artery. Ann Thorac Surg 1993;56:181-182.[Abstract]
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Noyez L., van Eck F.M., Skotnicki S.H., Brouwer R.M.H.J. Coronary reoperations in patients with a patent internal mammary artery. Cardiovasc Surg 2001;9:179-183.[Medline]
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van Eck F.M., Noyez L., Verheugt F.W.A., Brouwer R.M.H.J. Changing profile of patients undergoing redo-coronary artery surgery. Eur J Cardiothorac Surg 2002;21:205-211.[Abstract/Free Full Text]
