Eur J Cardiothorac Surg 2007;32:65-68. doi:10.1016/j.ejcts.2007.03.046
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Should axillary artery to coronary artery bypass be part of the cardiac surgeon's armamentarium?
Ahmad M. Tarakji*,
Michael C. Sinclair
Lehigh Valley Hospital, Allentown, PA, United States
Received 15 September 2006;
received in revised form 28 February 2007;
accepted 27 March 2007.
* Corresponding author. Address: Lehigh Valley Hospital, Department of Surgery, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556, United States. Tel.: +1 610 402 1296; fax: +1 610 402 1667. (Email: sally.lutz{at}lvh.com).
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Abstract
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Background: The axillary artery has been used as an alternate inflow source for revascularization of the lower extremities for four decades. Since 1997, there have been several reports of axillary artery to coronary artery bypass. Methods: All cases of axillary artery to coronary artery bypass at our institution from 1997 through 2003 were reviewed. PubMed was queried for publications on this subject and all pertinent reports were reviewed. Results: Thirty-eight patients underwent axillary artery to coronary artery bypass at our hospital. Most (34) of the operations were performed without cardiopulmonary bypass. Saphenous vein (37) or radial artery (1) grafts were placed to one or more coronary arteries from either the left (36) or right (2) axillary artery. Twenty patients underwent sternotomy, and 18 had either a left (16) or right (2) minimally invasive direct coronary artery bypass (MIDCAB) procedure performed. Most of the sternotomies were for primary myocardial revascularization and most of the MIDCABs were reoperations. There were three deaths—all from non-cardiac causes, one myocardial infarction, and one transient brachial plexus injury. Doppler ultrasound, angiographic, and clinical follow-up were limited, but graft patency has been demonstrated up to 9 years. Conclusion: Axillary artery to coronary artery bypass should be part of the armamentarium of surgeons who perform myocardial revascularization operations.
Key Words: Axillary artery to coronary artery bypass • Myocardial revascularization • Extra-anatomic coronary bypass grafting • Coronary bypass grafting • Anterior thoracotomy • Redo MIDCAB
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1. Introduction
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The use of the axillary artery as an inflow source for revascularization of the lower extremities was reported by Blaisdell and Hall in 1962 [1]. Though the long-term patency rate of axillary–femoral bypass grafts is less than that of aorto-femoral grafts, this method of extra-anatomic revascularization has a defined role in peripheral vascular surgery. In 1997, Coulson and Bakhshay [2] described a case of axillary artery to left anterior descending coronary artery bypass. Since then there have been many single case reports and several small series of axillary artery to coronary bypass grafts [3–10]. The most common indication for using the axillary artery as an inflow source for myocardial revascularization has been a reoperation performed through a redo minimally invasive direct coronary artery bypass (redo MIDCAB) procedure. In a few instances the axillary artery was used for the proximal anastomosis when the aorta was found to be extensively diseased, the so-called ‘untouchable’ aorta, after sternotomy. Patient follow-up has been limited. There have been few human anatomic and/or animal laboratory studies regarding axillary artery–coronary artery bypass grafting [11,12].
Our early experience, like that of others, has demonstrated the technical feasibility and apparent safety of this type of extra-anatomic coronary bypass grafting [7]. It is time to look at the available evidence and try to answer a fundamental question—should axillary artery to coronary bypass grafting be abandoned or should it be part of the cardiac surgeon's armamentarium?
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2. Methods
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This is a retrospective review. Hospital records and, where available, office charts of all patients, who underwent surgical myocardial revascularization using bypass grafts from either axillary artery to one or more coronary arteries at the Lehigh Valley Hospital (LVH) in Allentown, Pennsylvania, USA, from 1997 through 2004, were reviewed.
2.1 Techniques
The operative technique was described previously [7]. Since that report the technique has been slightly modified. The axillary artery is exposed through an oblique infraclavicular incision, splitting the pectoralis major in the direction of its fibers and retracting the pectoralis minor laterally. Using electrocautery, a large (e.g., 3 cm) opening is made through the first intercostal space directly caudad to the first part of the axillary artery. After heparinization the vein graft is anastomosed to the underside of the axillary artery and passed into the thoracic cavity. The graft is passed medial to the lung and the lung is manually hyperinflated to determine the length of the graft required to reach the target coronary artery.
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3. Results
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Thirty-eight patients, aged 54–83 years (mean age 73 years), underwent coronary bypass grafting using the axillary artery as the site of the proximal anastomosis. Fifteen of these patients were included in a prior publication from LVH [7]. The left axillary artery was used in the vast majority (36) of the cases. More than two-thirds of the patients were men (26 males, 12 females). In just over half of the cases (20), a median sternotomy was performed for myocardial revascularization. The remainder of the operations were either left (16) or right (2) anterior thoracotomies (MIDCAB). All but one of the thoracotomies were reoperations, and all but two of the sternotomies were first operations.
The most common reason for using the axillary artery as an inflow source was a diseased aorta (20) in the sternotomy group. The ascending aorta was considered unsuitable for proximal anastomosis, either because of extensive atherosclerosis (13) or a diameter too large for safe performance of a proximal anastomosis (7). In one patient in the latter group, the aorta was frankly aneurysmal. An external aneurysmorrhaphy was performed decreasing the aortic diameter with a wrap of bovine pericardium. The saphenous vein graft from axillary artery to two obtuse marginal arteries was patent at catheterization performed for ill-defined chest pain 6 months postoperatively (Fig. 1
). After 3 years, the patient is doing well with no further enlargement of the aorta and no recurrent angina.
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Fig. 1. (A, B) Saphenous vein graft from left axillary artery to two obtuse marginal arteries 6 months postoperative.
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Reoperation with an occluded LIMA graft to the LAD was the indication for using the axillary artery for a proximal anastomosis in 17 of 18 patients who underwent a reoperation using a redo MIDCAB. In the remaining patients who underwent a redo MIDCAB, the LIMA had not been used at the previous operation, but it was injured during harvesting.
The greater saphenous vein was the conduit used in all but one patient. The sole exception was an elderly man who had had two previous coronary bypass operations. He had no remaining venous conduits and the radial artery was used for an extra-anatomic redo MIDCAB. Thirty-four of the 38 procedures were performed without cardiopulmonary bypass.
Three patients died—all from non-cardiac causes. One patient died of mesenteric ischemia on the second postoperative day. One died of complications of heparin-induced thrombocytopenia on the 25th postoperative day. The third died of sepsis and multi-organ failure on the 54th postoperative day. One patient had a perioperative myocardial infarction. He had an anterior current of injury upon arrival in the intensive care unit. He was returned immediately to the operating room where the limb of a Y-graft which supplied the left anterior descending coronary artery was found to be occluded. The other limb which supplied the obtuse marginal artery was soft, pulsatile, and apparently patent. The limb of the graft to the left anterior descending artery was revised and the patient did well, though he had enzymatic and electrocardiographic evidence of an anterior myocardial infarction. No patients suffered from upper extremity ischemia, axillary artery dissection, or wound infections. One patient (previously reported) had a transient brachial plexopathy [7].
3.1 Doppler ultrasound
In our earlier report, the 13 patients in whom the vein graft was tunneled through the second intercostal space were followed for varying periods of time with Doppler ultrasound [7]. Since changing our technique to bring all grafts directly into the thorax through the first interspace, we have been unable to reliably visualize the grafts with the ultrasound probe and, therefore, Doppler ultrasound is no longer used to follow patients with axillary to coronary bypass grafts at our institution. However, one of the earliest patients was recently admitted 9 years postoperatively with an acute myocardial infarction and congestive heart failure, and Doppler ultrasound indicated that the axillary–coronary graft was patent.
3.2 Angiography
One patient underwent cardiac catheterization prior to discharge and the graft was patent. Twelve additional patients underwent cardiac catheterization because of chest pain at 1–52 months postoperatively (mean 30 months). Seven of the 12 axillary to coronary grafts were patent (Fig. 2
). The longest documented graft patency was 51 months. Two patients underwent percutaneous coronary interventions of native coronary arteries at 2.5 years and 4 years after axillary–coronary bypass grafting. In one instance, the graft was occluded, and in the other, the graft was patent and angioplasty was performed on another critically narrowed vessel.
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Fig. 2. (A–C) Saphenous vein graft from right axillary artery to right coronary artery 55 months postoperative.
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3.3 Clinical follow-up
Clinical follow-up was extremely variable. Five patients were lost to follow-up immediately after discharge from the hospital. Others have been followed for periods ranging from 1 to 104 months (mean 40.8 months). Three patients had myocardial infarctions which were treated medically. Six others developed recurrent angina and nine developed congestive heart failure. There are no other known deaths.
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4. Discussion
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Approximately 125 axillary artery to coronary artery bypass operations have been reported in the literature. The rates of perioperative mortality and complications are relatively low in this high-risk group of patients. We identified over 30 relevant publications which included a number of single case reports and letters to the editor. Seven articles plus our own prior publication contained three or more patients in whom axillary artery to coronary artery bypass had been performed [3–10]. Data from these seven publications and our current study are summarized in Table 1
.
Several authors reported angiographic visualization of the axillary–coronary bypass grafts prior to discharge from the hospital [5,8,10]. All grafts were patent. There has been no mention of technical difficulties in performing these anastomoses or problems with kinking or torsion of the grafts.
Medium- and long-term objective documentation of graft patency is lacking. Although Doppler ultrasound interrogation of grafts appeared to be a promising way to determine graft patency in some early reports [3,4,6,7], the difficulty in visualizing grafts which enter directly into the thorax through the first interspace makes this noninvasive method impractical in the majority of cases of axillary artery to coronary artery bypass.
Most of these operations were done in elderly or otherwise high-risk patients. The majority of these procedures were reoperations performed through an anterior thoracotomy (redo MIDCAB). In some instances, where the aorta was found to be unsuitable for proximal anastomosis at sternotomy, the axillary artery was selected as an alternate inflow source for one or more bypass grafts.
The operative mortality and morbidity rates for axillary artery to coronary artery bypass grafts are acceptable for the patient groups subjected to these procedures. These operations have most commonly been done without cardiopulmonary bypass. There were few reported complications—no strokes, no axillary artery injuries, no wound infections, and one transient brachial plexus injury. Follow-up is limited, but the fact that nearly half of the visualized grafts in our series were occluded suggests that the long-term patency of these extra-anatomic grafts is inferior to that of conventional aorto-coronary saphenous vein grafts. However, some grafts were patent as long as 9 years.
The axillary artery is relatively large and accessible. It is frequently free of atherosclerosis even in patients with diseased ascending aortas. Adequate axillary artery inflow can be assessed preoperatively by angiography or bilateral blood pressure measurement. The procedure is technically straightforward. Axillary artery to coronary artery bypass is a reasonable ‘bail out’ option in patients in whom the ascending aorta is diseased or inaccessible.
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5. Conclusion
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Axillary artery to coronary artery bypass should be part of the armamentarium of surgeons who perform myocardial revascularization operations.
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Acknowledgments
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We are grateful for the expert assistance of Sally Lutz, Editor, Scott Dornblaser, Photographer, and Mark Flamish and Matt Gierula, Multimedia Coordinators, of Lehigh Valley Hospital, Allentown, Pennsylvania.
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Footnotes
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\#9734; This paper was presented, in part, at the 2005 Delaware Valley Vascular Society Meeting, Philadelphia, Pennsylvania, USA, October 6, 2005.
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References
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Abstract
1. Introduction
