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Ann Thorac Surg 1997;63:1284-1287
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Simultaneous Subclavian Artery Reconstruction in Coronary Artery Bypass Grafting

Department of Surgery II, Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan

Accepted for publication November 11, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Subclavian artery occlusive lesion, although rare, is sufficiently important to consider before coronary artery bypass grafting because it can cause not only symptoms of the lesion per se, but also the postoperative coronary–subclavian steal phenomenon.

Methods. Four patients undergoing coronary artery bypass grafting received simultaneous reconstruction of the subclavian artery. During aortic cross-clamping, an 8-mm ring-reinforced polytetrafluoroethylene graft was attached to the aorta perpendicularly. The prosthetic graft was led to the proximal segment of the axillary artery through the second intercostal space and anastomosed to the inferior surface of the artery.

Results. Three patients received unilateral reconstruction of the subclavian artery, whereas another received bilateral reconstruction. There were no complications related to the subclavian reconstruction procedure. Postoperative angiograms revealed excellent patency of the prosthetic grafts. All of the patients have been asymptomatic with follow-up periods ranging from 9 to 50 months.

Conclusions. To perform simultaneous subclavian artery reconstruction along with coronary artery bypass grafting, the aortoaxillary bypass procedure using an 8-mm polytetrafluoroethylene graft may be the method of choice because it has lower potential for complications and is less technically demanding.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The incidence of peripheral arterial occlusive disease is considered to be high in patients with coronary artery disease. Among the arterial occlusive lesions, subclavian artery occlusion is relatively rare compared with aortoiliac occlusive disease.

The subclavian occlusive lesion, however, has a special meaning in coronary artery bypass surgery. The development of a focal occlusion of the subclavian artery proximal to the internal thoracic artery (ITA) before or after ITA–coronary artery anastomosis can result in the so-called coronary–subclavian steal syndrome, in which a steal from the coronary artery with flow reversal in the ITA into the subclavian artery causing myocardial ischemia can occur. Need for an awareness of the presence of the subclavian occlusive lesion in patients undergoing coronary artery bypass grafting has been emphasized [1–7].

Currently, we have experienced 4 patients with coronary artery disease with a concomitant subclavian occlusive lesion proximal to the ITA successfully treated with simultaneous coronary artery bypass grafting and aortoaxillary bypass. In the midterm follow up, excellent clinical and angiographic results were obtained.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Among the 350 consecutive patients who underwent coronary artery bypass grafting, there were 4 (1.1%; 2 men and 2 women) who underwent simultaneous reconstruction of the subclavian artery either unilaterally or bilaterally (Table 1). All of them exhibited an upper arm pressure difference greater than 20 mm Hg. Symptoms of vertebrobasilar insufficiency were observed in 2 patients, whereas the other 2 complained of upper extremity ischemia. Diagnosis was confirmed by angiography of the arch vessels performed along with the preoperative coronary angiography. All patients had significant occlusive lesions of the subclavian artery proximal to the ITA. Less than 50% stenosis with irregularity of the ipsilateral carotid artery was observed in 2 patients. All patients had triple-vessel coronary artery disease, and 2 of them received emergency operation for unstable angina.

During a single aortic cross-clamp period, after completion of the proximal anastomoses of the vein grafts, another 10-mm transverse incision was made on the anterior aortic wall superior to the vein graft attachment. An 8-mm ring-reinforced polytetrafluoroethylene graft was attached to the aorta perpendicularly by a 4-0 continuous polypropylene suture. After the aorta was unclamped, the prosthetic graft was led to the axillary artery with forceps through the incision made at the level of the second intercostal space by way of the pleural cavity, and anastomosed to the inferior surface of the artery. On passing the graft through the intercostal space, the fascia and muscles were manipulated digitally to loosen the hole to prevent pinching of the graft. Care was taken not to injure the intercostal vessels when leading the prosthetic graft to the axillary artery and to avoid compression on the axillary vein.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Three patients received unilateral reconstruction of the subclavian artery, whereas another received bilateral reconstruction. Triple coronary artery bypass grafting was performed in 3 patients and quadruple bypass in 1, using the ITA and the saphenous veins. In 2 patients whose subclavian involvment was left-sided, the right ITA was anastomosed to the left anterior descending coronary artery (Table 2). All patients were weaned from respiratory support within 12 hours postoperatively. There were no complications related to either the subclavian reconstruction procedure or coronary artery bypass grafting. Symptomatic relief was obtained in all patients, and the upper arm pressure difference disappeared. The postoperative angiograms taken after 5 to 33 months in 3 patients revealed excellent patency of all the prosthetic grafts (Figs 1–3). All of the patients have been in stable condition with follow-up periods ranging from 9 to 50 months.

View larger version (135K): [in this window] [in a new window]   Fig 1. . Angiogram of a 70-year-old man 12 months postoperatively. The left subclavian artery, along with the internal thoracic artery (small arrow), is opacified through the polytetrafluoroethylene graft (large arrow).

View larger version (148K): [in this window] [in a new window]   Fig 2. . Angiogram of a 60-year-old woman 5 months postoperatively. Bilateral subclavian arteries are opacified through the polytetrafluoroethylene graft (arrows).

View larger version (130K): [in this window] [in a new window]   Fig 3. . Angiogram of a 62-year-old woman 33 months postoperatively. An arrow indicates the left internal thoracic artery.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

The subclavian occlusive lesion has a special meaning in coronary artery bypass surgery. The development of a focal occlusion within the proximal segment of the subclavian artery before or after myocardial revascularization can result in so-called coronary–subclavian steal synrome, ie, a devastating steal from the coronary artery with flow reversal in the ITA into the subclavian artery causing myocardial ischemia. Prevention of the steal syndrome is best accomplished by a careful examination of the patients and appropriate arteriography before operation. At our hospital, when the coronary angiography in progress indicates the possibility of a bypass operation, the physicians routinely opacify the ITAs semiselectively during the same catheterization procedure, making small hand injections of contrast medium to visualize the proximal segment of the subclavian artery. Coronary–subclavian steal is uncommon but sufficiently important to think of before coronary artery bypass grafting.

When the presence of a symptomatic subclavian lesion proximal to the ITA is detected before a coronary artery operation, the ITA of the affected side should not be used as a bypass conduit unless the subclavian lesion is corrected preoperatively or intraoperatively. Although it may be possible to perform carotid–subclavian bypass or transposition electively before coronary artery bypass to make the ITA of the affected side usable, fear of perioperative myocardial ischemia may always remain a major problem. It is preferable to reconstruct the subclavian artery simultaneously. Under these circumstances, the methods of choice include carotid–subclavian bypass and the aortoaxillary bypass procedure that is reported herein.

As a simultaneous procedure in the open heart operation, aortoaxillary bypass may have some advantages. In aortoaxillary bypass, the site of anastomosis is very accessible. It does not require manipulation of the carotid artery. Further, the area around the subclavian artery is a "busy place." The phrenic nerve, the recurrent laryngeal nerve, the vagus nerve, the brachial plexus, the cervical sympathetic chain, and the thoracic duct on the left side are always encountered in the vicinity of the subclavian artery. In contrast, only the nerves of the brachial plexus lie deep to the proximal part of the axillary artery. Accordingly exposure of the subclavian artery in the supraclavicular region has the possibility of several kinds of postoperative complications, although most of them are transient in nature [9–12]. In the aortoaxillary bypass procedure, the graft is easily led to the axillary artery without any fear of kinking through the intercostal space, and the distal anastomosis can be performed on the axillary artery without difficulty. This can be performed even in emergency situations as in our cases.

As the postoperative angiograms clearly show that the smooth flow pattern observed from the ascending aorta to the proximal axillary artery through the polytetrafluoroethylene graft appears sufficient, aortoaxillary bypass provides a more direct connection and straightforward blood supply to the subclavian artery. Although our experience is in a small series, excellent long-term patency can be expected.

In our current series, we abondoned the use of the ITA on the affected side for coronary revascularization. The use of the ipsilateral ITA for a graft to the coronary artery had not received general acceptance yet, because the pattern of blood flow in the ITA after aortoaxillary bypass could not be foreseen before the bypass graft was constructed.

On the other hand, there have been many reports on coronary–subclavian steal being successfully treated with carotid–subclavian bypass [1–7]. This evidence indicates that the ITA that receives blood through the bypass graft can afford to perfuse the coronary artery sufficiently. Accordingly, the aortoaxillary bypass graft, like the carotid–subclavian bypass graft, may be able to give sufficient blood flow to the ITA to work as a graft to the coronary artery. As a matter of fact, as is shown in the figures, the left ITA was clearly visualized as having a normal shape by the contrast medium injected in the polytetrafluoroethylene graft. Thus, the establishment of aortoaxillary bypass before dissection of the ITA can provide the possibility of using the ITA. When adequate blood flow is obtained from the free end of the ITA after the aortoaxillary bypass graft is completed, it could be used as a bypass conduit. Should the bypass graft fail, another opportunity for subclavian reconstruction by the extrathoracic procedure may follow.

In conclusion, subclavian artery occlusive lesion, although rare, is sufficiently important to consider before coronary artery bypass grafting. When performing simultaneous subclavian artery reconstruction along with coronary artery bypass grafting, the aortoaxillary bypass procedure may be the method of choice in such a special condition.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Ochi, Department of Surgery II, Cardiovascular Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113, Japan.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ochi, M. Articles by Tanaka, S. Search for Related Content PubMed PubMed Citation Articles by Ochi, M. Articles by Tanaka, S.