Eur J Cardiothorac Surg 2004;26:839-841
© 2004 Elsevier Science NL
Arterial graft extension with radial artery: a method of total arterial revascularization
Rafael García Fustera,*,
Jordi Estornellb,
Oscar Gila,
José Anastasio Monteroa
a Department of Cardiac Surgery, University General Hospital of Valencia, Av. Tres Cruces s/n, 46014, Valencia, Spain
b Department of Radiology, University General Hospital of Valencia, Av. Tres Cruces s/n, 46014, Valencia, Spain
Received 15 March 2004;
received in revised form 15 June 2004;
accepted 2 July 2004.
* Corresponding author. Address: C/Artes Gráficas n° 4, esc. izda, pta 3, 46010, Spain. Tel.: +34-96-3622216; fax: +34-96-3862982. (E-mail: rgfuster{at}terra.com).
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Abstract
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A method of total arterial revascularization is presented. This technique is based on the extension of a semi-skeletonized right internal thoracic artery graft with an entire radial artery in an end to end fashion. A complete arterial revascularization is achieved with a bilateral in situ internal thoracic artery strategy preserving the left internal thoracic artery to the left anterior descending artery bypass as an isolated graft. In our experience, this pattern of revascularization has been especially important in patients with atheromatous disease of the ascending aorta, a difficult situation in which a ‘no-touch technique’ is mandatory.
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1. Introduction
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Bilateral internal thoracic artery (ITA) grafts allow better long-term survival and decreased cardiac events [1]. In situ method may have superior patency compared with free ITA grafts and it is often considered the gold standard for arterial conduits. But in situ right internal thoracic artery (RITA) grafting of the circumflex is not always possible because of a limitation in length [2]. This report presents a technique based on the extension of RITA with a radial artery (RA) in an end to end fashion to obtain a total arterial revascularization with bilateral in situ ITA grafts preserving left internal thoracic artery to left anterior descending (LITA-to-LAD) as an isolated conduit. In our early experience we have used this technique in patients with severe atheromatous disease of the ascending aorta.
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2. Technique
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The procedure is performed via median sternotomy and both ITAs are harvested in a semi-skeletonized fashion [3]. Simultaneously, the nondominant RA is dissected and its entire length is used to plan a sequential grafting strategy. After heparinization, the RITA is transected at the middle portion. The proximal edge of the RA is anastomosed end to end to the stump of the in situ RITA. Both conduits are spatulated and anastomosed meticulously with two independent running 8/0 polypropylene sutures: one at the heel and the other completing the toe. Both sutures are tightened and tied during dilation of graft with blood to avoid a purse-string effect. The RITA-RA graft can be placed through the transverse sinus (avoiding tension or kinking) or, more easily, crossing the midline anterior to the aorta covering it with a mediastinal fat pad in order to diminish the risk of damage during reoperation. Then the RA is anastomosed to one or more branches of circumflex artery in a sequential pattern in parallel side-to-side anastomoses. The end anastomosis is performed last and usually to the posterior descending artery, preferably, in a parallel end-to side fashion and in an antegrade direction with respect to the flow in the recipient artery. The LITA is always anastomosed to the LAD. Appropriate diagonal arteries are grafted with parallel side-to-side anastomoses with LITA or with other supplemental arterial grafts (distal RITA, LITA or RA) connected as a Y graft to the main composite conduit. This pattern of revascularization is reflected in Fig. 1.
We have operated on five patients with atheromatous disease of the ascending aorta and severe peripheral vascular disease by means of an off-pump strategy. All patients received intravenous nitroglycerine intraoperatively and for the first 24h and, thereafter, amlodipine (5–10mg orally daily for 6 months) was used routinely. All received two antiplatelet drugs (aspirin 100mg plus clopidogrel 75mg) daily for the first 3 months and commencing on the first postoperative day. Thereafter, aspirin was maintained indefinitely. Postoperative recovery was uneventful and all the grafts were patent on 3D coronary images from a multislice helical CT scanner (16 Light Speed CT GE®) within 6 months postoperatively (Fig. 2). Two-dimensional axial imagery, three-dimensional reconstruction with volume rendering and maximum intensity projection (MIP) were used to interpret the images. All grafts were patent without evidence of disease or suboptimal anastomoses (more than 50% stenosis). Routine postoperative coronary angiography was not performed in these patients because of their higher vascular risk.
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Fig. 2. Bilateral in situ ITA grafting using interposed RA during OPCAB surgery in a patient with aortic atheromatous disease. Intraoperative photographs (A) and postoperative multislice helical CT scanner images (B). Arrow: RITA-RA end-to-end anastomosis.
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3. Comment
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Composite lengthened arterial conduits have seldom been studied and only when related to selected patients if the length of conduit is not enough. Particularly, extended grafts from ITAs have been described with good results [4–7]. LITA elongation with inferior epigastric artery was reported by Calafiore et al. [4]. The RITA stump for the proximal RA anastomosis using an end-to-end technique was described by Pitsis et al. [5] with excellent angiographic results.
We have introduced some refinements. The elongation graft has been usually constructed with a short segment of radial or epigastric arteries and only for an isolated distal anastomosis. We have used the RA in its full length anastomosed at the middle third of a semi-skeletonized RITA to obtain a longer composite graft. Then, this graft is employed for multiple sequential anastomoses. The crucial end-to-end anastomosis can be performed comfortably between sternal edges and checked by free flow measurement. From Vitolla's study [6] it was evident that the end to end anastomosis between two arterial conduits was not a weak point of the strategy.
We have explored this technique to achieve a double objective: a total arterial revascularization based on two inflows (in situ ITAs) and the preservation of LITA to LAD as an isolated graft. This strategy has several advantages. The whole revascularization is originated in two independent inflows avoiding proximal anastomoses in the ascending aorta and free ITA-to-coronary artery grafts. Secondly, the pedicled LITA-to-LAD is maintained as an isolated graft avoiding composite grafts which may compromise the integrity of the best arterial conduit (LITA) to the most important coronary artery (LAD).
To the best of our knowledge, this is the first report of multiple sequential anastomoses with an extended RITA with an entire RA. This technique may be especially important in patients with atheromatous disease of the ascending aorta, a difficult situation in which a ‘no-touch technique’ is mandatory. In our patients OPCAB has been an excellent option. But several limitations must be taken into account: the atheromatous involvement of RA or small ITAs. Anyway, we precise a longer clinical-angiographic follow-up to demonstrate the utility of this technique in a more routine basis.
In conclusion, the reported technique is safe and should be considered in selected patients to obtain a complete arterial revascularization depending on bilateral in situ ITA grafting that preserves LITA-to-LAD bypass as an isolated graft.
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References
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- Calafiore AM, Teodori G, Di Giammarco G, Vitolla G, Contini M, Maddestra N, Paloscia L, Iaco A, Gallina S. Left internal mammary elongation with inferior epigastric artery in minimally invasive coronary surgery. Eur J Cardiothorac Surg 1997;12:393-396.[Abstract]
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Abstract
1. Introduction
