Eur J Cardiothorac Surg 2002;22:443-444
© 2002 Elsevier Science NL
A simple distal coronary perfusion technique in off-pump coronary artery bypass
Toshiya Ohtsuka*,
Noboru Motomura,
Yoshihiro Suematsu,
Shinichi Takamoto
Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
Received 4 April 2002;
received in revised form 21 May 2002;
accepted 4 June 2002.
* Corresponding author. Tel.: +81-3-5800-8654; fax: +81-3-5684-3989
e-mail: toshimd{at}attglobal.net
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Abstract
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This communication describes the surgical technique and clinical outcomes of a simple coronary perfusion technique for use during off-pump coronary artery bypass grafting. An intra-coronary shunt tube connected to the graft conduit (saphenous vein or radial artery) with an arterial blood source (ascending aorta or right internal thoracic artery) was inserted distally via a coronary arteriotomy for temporary perfusion of six left anterior descending arteries and two right coronary arteries.
Key Words: Off-pump coronary artery bypass • Myocardial ischemia • Intra-coronary shunt tube
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1. Introduction
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In off-pump coronary artery bypass (OPCAB), a coronary perfusion device, i.e. an intra-coronary shunt tube or a perfusion catheter, has been employed in limited situations to lessen the degree of myocardial ischemia due to the coronary snaring maneuver [1–3]. We have been applying a simple technique for temporary coronary perfusion distal to the snaring site, using an intra-coronary shunt tube fixed to a bypass graft conduit with the arterial blood source. Here we describe the surgical technique and its clinical outcomes.
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2. Clinical materials and methods
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We studied eight male patients with a mean age of 68.2±6.5 years who underwent multiple coronary bypass grafting by the OPCAB method. The ten coronary arteries, including eight left anterior descending arteries (LAD) and two right coronary arteries (RCA), were subjected to the present technique.
An intravascular shunt tube (AnastaFLO, Baxter, Midvale, UT), US$50.00 each, was employed. Each shunt tube has an olive-shaped coronary occluder at each end, and a 3 cm long one with a 2 or 2.5 mm diameter olive was selected for the present technique. The shunt tube was connected to a coronary artery bypass conduit by inserting an olive into the distal end of the conduit and fixing each with a single tie (Fig. 1)
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Fig. 1. Photograph of an intra-vascular shunt tube (arrow: AnastaFLO, Baxter, Midvale, UT) connected to a saphenous vein graft from the ascending aorta (A). The picture on the top left shows a magnified view of the 3 cm long AnastaFLO with a 2 mm olive-shaped occluder.
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In our series, ten bypass conduits were utilized: six saphenous vein (SV) and three radial artery (RA) grafts from the ascending aorta and one composite graft, consisting of the RA conduit connected with the mobilized right internal thoracic artery (RITA) in situ. During distal perfusion with these conduits, the LAD was revascularized with the left internal thoracic artery and the RCA was bypassed with the RITA. Each bypass conduit employed for the present technique was used alternatively as a coronary artery bypass graft.
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3. Results
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In each patient, free blood flow through the shunt tube was measured just before insertion into the coronary artery. When the mean blood pressure, measured via the radial arterial line, was 67.4±10.6 mmHg, the average free blood flow through four SV and three RA conduits with the 2 mm shunt tube was 22.4 ml/min (range 20–24 ml/min) from the ascending aorta, and one RA conduit fixed with the 2 mm tube demonstrated an 18 ml/min flow from the RITA in situ. In two cases, SV grafts with the 2.5 mm shunt tube had greater flows (32 and 40 ml/min).
It was possible to introduce the 2 mm shunt tube in six (75%) of the eight target LADs, and the 2.5 mm tube in both RCAs. The blood flow through the bypass conduit, quantified using a transit time flow-meter probe (Medi-Stim Butterfly flowmeter, Medi-Stim AS, Oslo, Norway) during coronary anastomosis, ranged from 15 to 21 ml/min during perfusion of the six LADs (Fig. 2) , and was 28 and 30 ml/min during perfusion of the two RCAs. The average coronary snaring time was 17±4.5 min, during which none of the patients demonstrated significant detrimental changes on radial and pulmonary arterial monitors, significant ST-T segment changes on electrocardiography, or abnormal left ventricular motion on transesophageal echocardiography.
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Fig. 2. Intra-operative record of blood flow through a saphenous vein graft with a 2 mm AnastaFLO, measured with a transit time flow-meter probe (Medi-Stim Butterfly flowmeter, Medi-Stim AS, Oslo, Norway).
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4. Comments
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In the OPCAB procedure, a temporary brief coronary occlusion maneuver during anastomosis is tolerable in most of the target coronary arteries. In limited situations, however, i.e. bypass grafting to the large-sized LAD with a moderate stenotic lesion or the mid-portion of the RCA, ischemic signs are induced and an assistance tool for distal coronary perfusion may help accomplish a safe anastomotic maneuver. In such circumstances, use of an intra-coronary shunt tube or a coronary perfusion catheter with arterial inflow has been reported [1–3].
The intra-coronary shunt tube can be placed easily via a coronary arteriotomy, but its flow is not measurable. Although we have not compared both techniques in the clinical settings, the intra-coronary shunt flows supplied from the diseased proximal LAD seem to be less than the flows obtained from the present method. In the perfusion catheter technique, the femoral artery or ascending aorta is commonly used as the blood flow source. Particularly when the femoral artery — which is distant from the heart — is adopted, the flow through a puncture needle, extension line and perfusion catheter would be diminished significantly.
Our technique can be achieved simply by connecting an intra-coronary shunt tube to the coronary artery bypass conduit. Moreover, the blood flow, delivered via a bypass conduit into the shunt tube, can be monitored continuously simply by applying a flow probe to the graft conduit (Fig. 2). Through an SV or RA graft with a 2 mm shunt tube, LAD perfusion distal to the snaring site was 15–20 ml/min and the RCA perfusion rate reached 30 ml/min using a 2.5 mm tube.
In conclusion, coronary artery perfusion distal to the snaring site can be established using a prepared bypass conduit connected to an intra-coronary shunt tube with a 2 or 2.5 mm olive-shaped occluder. Although our experience is limited, we consider that this technique can be a simple, viable alternative within limited situations of OPCAB to ameliorate myocardial ischemia due to coronary arterial snaring.
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References
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- Arai H., Yoshida T., Izumi H., Sunamori M. External shunt for off-pump coronary artery bypass grafting: distal coronary perfusion catheter. Ann Thorac Surg 2000;70:681-682.[Abstract/Free Full Text]
- Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Katouzian A., Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-1658.[Abstract/Free Full Text]
- Lucchetti V., Capasso F., Caputo M., Grimaldi G., Capece M., Brando G., Caprio S., Angelini G.D. Intracoronary shunt prevents left ventricular function impairment during beating heart coronary revascularization. Eur J Cardiothorac Surg 1999;15:255-259.[Abstract/Free Full Text]
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Abstract
1. Introduction
