Eur J Cardiothorac Surg 2005;27:515-517
© 2005 Elsevier Science NL
Left subclavian artery free graft as a salvage technique after failed coronary artery transfer in arterial switch operation
Si Chan Sung,
Yun Hee Chang*,
Hyoung Doo Lee,
Jong Soo Woo
Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, 1-10, Ami-dong, Seo-gu, Busan 602-061, South Korea
Received 26 August 2004;
received in revised form 17 November 2004;
accepted 22 November 2004.
* Corresponding author. Tel.: +82 51 240 7267; fax: +82 51 243 9389. (E-mail: drcrista{at}empal.com).
 |
Abstract
|
|---|
Coronary artery transfer in transposition of the great arteries with single coronary artery or intramural coronary artery is still a technically demanding procedure. We present a technique of left coronary bypass using a free graft of left subclavian artery for the management of failed coronary artery transfer of left intramural coronary artery.
Key Words: CHD • Arterial switch • Coronary artery bypass graft
|
1. Introduction
|
|---|
The most critical step in arterial switch operation is the reimplantation of coronary arteries. More attention should be paid to coronary transfer when the patient has complex coronary anatomy such as single coronary artery or intramural coronary artery. However, surgeons may face a very difficult situation if the coronary artery is transferred inadequately even though it is infrequent. This difficult problem could be solved through revision of the coronary artery buttons, which is not always successful because of lack of enough cuff tissue of the coronary buttons or because of unavoidable torsion or kinking. In the situation in which revision of the coronary artery buttons is not possible or not successful, coronary artery bypass operation should be considered as a rescue procedure.
|
2. Technique
|
|---|
The left subclavian artery is mobilized following aortic arch exposure and harvested with enough length (about 12mm) after applications of multiple clips or ligations at the proximal and distal ends of the vessel. A longitudinal incision is made at the left main coronary artery. One end of the left subclavian artery segment is anastomosed to the incision with continuous 8-0 polypropylene suture. Two vertical incisions are then made respectively at the corresponding sites of the divided proximal main pulmonary artery and the left subclavian artery segment, and they are anastomosed with each other. After Lecompte maneuver, neoaortic reconstruction is performed by making anastomosis between the divided distal ascending aorta and the proximal main pulmonary artery incorporating the left subclavian artery free graft connected to the left coronary artery. The neopulmonary reconstruction is subsequently followed (Fig. 1).
|
3. Patients and results
|
|---|
This procedure was applied in two patients having typical intramural left coronary artery with juxtacommissural origin from right facing sinus. The first patient was a 22-day-old neonate presenting in our early experience of arterial switch operation with complete transposition of great arteries and ventricular septal defect. Inadvertent injury of the intramural left coronary artery occurred during its mobilization and he underwent left coronary artery bypass using left subclavian artery free graft as described above after reimplantation of the right coronary artery. The second patient was a 7-day-old neonate, diagnosed as having complete transposition of great arteries with intact ventricular septum. The patient underwent double button technique for the coronary transfer of the left intramural coronary artery. However, the patient had progressive deterioration of left ventricular contractility with color change. Left coronary bypass using left subclavian artery free graft was performed as a rescue procedure. Both patients had uneventful postoperative recovery even though both required delayed sternal closure. They were discharged home 15 and 34 days after surgery, respectively and both had normal ventricular function on echocardiography at discharge. There was no newly developed ventricular dysfunction after follow-up of 75 and 22 months, respectively. The coronary angiographies of both patients taken 70 and 20 months after operation, respectively showed patent left coronary artery systems (Fig. 2).
|
4. Discussion
|
|---|
There were some reports describing successful coronary artery bypass using the internal thoracic artery or left subclavian artery as a rescue operation for myocardial ischemia after arterial switch operation [1–6]. However, the use of the internal thoracic artery in coronary artery bypass as a rescue procedure after neonatal arterial switch operation has some limitations. The mobilization of the internal thoracic artery in the neonates is technically demanding and a time consuming procedure in the emergent situation such as cardiopulmonary weaning failure. Moreover, the artery may be too small to be grafted safely in the neonatal period.
Han et al. [6] reported good short-term result of bypass grafting using left subclavian artery for rescuing the neonate from severe myocardial ischemia immediately after bypass weaning. They emphasized that this graft might be better than the internal thoracic artery in terms of its size and technical feasibility. We agree with them. However, we have great concerns about the tendency of the left subclavian artery to kink at its origin from the aorta and its inadequate length which can cause tension at the anastomotic site. Additionally, it cannot be ignored that the somewhat greater diameter and the long course of the graft may be more thrombogenic. These concerns prompted us to use the left subclavian artery as a short free graft. Our technique is relatively easy and can be done without tension or torsion of the graft. In addition, it can guarantee adequate blood flow if the distal anastomosis is well constructed. To our knowledge, this is the first report of neonatal myocardial revascularization using a left subclavian artery free graft.
In conclusion, left subclavian artery free grafting is a good salvage procedure in the event of coronary artery insufficiency after neonatal arterial switch operation. A long term follow-up is mandatory.
|
Appendix A. Conference discussion
|
|---|
Dr M. Hazekamp (Leiden, Netherlands): If you have two ostia from one single sinus, when exactly do you decide between the use of aortocoronary flap technique and use of a double ostium technique?
Dr Sung: I think that if there is a wide room between the orifices, it is possible to get enough cuff. But since we had two failures of the button technique, we have become somewhat reluctant to do that operation. As you see, we had two failures. So recently we prefer the aortocoronary flap technique to a double-button technique. However, many centers are using now the double-button technique.
Dr O. Ghez (Marseille, France): I would like to know if you have done any late angiography control on these patients?
Dr Sung: As I said, we did not perform the routine angiography, but we dealt with the patient only with the echocardiography. But in 3 patients, we did a coronary angiography. In patients who underwent the subclavian free graft technique, we took coronary angiography. And the other patient who have ventricle dysfunction, we checked the angiography.
Dr W. Mrowczynski (Poznan, Poland): I saw that there was a group of patients operated after the neonatal period, and I have a question. Did this age have impact on survival, or maybe you did a two-stage procedure?
Dr Sung: Two-stage? We don't have any two-stages, no.
Dr Mrowczynski: What was the impact of the late operation on the survival of your patients? Were there any patients operated after the neonatal period in your series?
Dr Sung: The median age was only 9 days.
Dr J. Comas (Madrid, Spain): I have a question related to the material for the flap. Are you using pericardial Gore-Tex to avoid compression from the PA?
Dr Sung: I think that that is a very important problem we are concerning now. We used the fresh pericardium in 4 cases, bovine pericardium in 2 cases, glutaraldehyde-treated autologous pericardium in 1 case. At our early experience, we used the fresh autologous pericardium. So we are concerning about the dilatation of the pouch. But until now, we cannot see any problem. There was no dilatations of the pouch so far; but we have to see the future.
|
Footnotes
|
|---|
☆ Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.
|
References
|
|---|
- Ebels T, Meuzelaar K, Gallandat Huet RC, Bink-Boelkens MT, Cromme-Dijkhuis A, Bams JL, Boeve WJ, Eijgelaar A. Neonatal arterial switch operation complicated by intramural left coronary artery and treated by left internal mammary artery bypass graft. J Thorac Cardiovasc Surg 1989;97:473-475.
- Rheuban KS, Kron IL, Bulatovic A. Internal mammary artery bypass after arterial switch operation. Ann Thorac Surg 1990;50:125-126.[Abstract]
- Serraf A, Roux D, Lacour-Gayet F, Touchot A, Bruniaux M, Sousa-Uva M, Planche C. Reoperation after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-899.[Abstract/Free Full Text]
- Nair KK, Chan KC, Hickey MS. Arterial switch operation: successful bilateral internal thoracic artery grafting. Ann Thorac Surg 2000;69:949-951.[Abstract/Free Full Text]
- Prifti E, Bonacchi M, Luisi SV, Vanini V. Coronary revascularization after arterial switch operation. Eur J Cardiothorac Surg 2002;21:111-113.[Abstract/Free Full Text]
- Han JJ, Lee YT, Park YK, Hong SN, Kim SH. Left subclavian artery bypass graft in complicated arterial switch operation. Ann Thorac Surg 1996;61:1523-1525.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
T. Miyamoto, K. Miyaji, K. Ohara, and T. Tashiro
Thermal coronary angiography in pediatric coronary artery bypass grafting
Interactive CardioVascular and Thoracic Surgery,
February 1, 2008;
7(1):
161 - 163.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Introduction
