Ann Thorac Surg 2000;70:309-310
© 2000 The Society of Thoracic Surgeons
How to do it
Reoperative "off-pump" circumflex revascularization via left thoracotomy: how to prevent graft kinking
Marco Ricci, MD, PhDa,
Hratch L. Karamanoukian, MDa,
Giuseppe D’Ancona, MDa,
Tomas A. Salerno, MDa,
Jacob Bergsland, MDa
a Division of Cardiothoracic Surgery and the Center For Minimally Invasive Cardiac Surgery, Kaleida Health System and State University of New York at Buffalo, Buffalo, New York, USA
Address reprint requests to Dr Karamanoukian, Division of Cardiothoracic Surgery, The Buffalo General Hospital, 100 High St, Buffalo, NY 14203
e-mail: lisbon5{at}yahoo.com
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Abstract
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Reoperative circumflex revascularization can be performed through a left thoracotomy approach, with or without cardiopulmonary bypass. In such cases, establishing the appropriate length of coronary grafts connecting the descending thoracic aorta to one of the marginal branches of the circumflex coronary artery may be problematic. In fact, if these grafts are too long they may kink, whereas if left too short they may be injured by respiratory excursions of the left lower lobe of the lung. In this report we describe a technique that can prevent these potential complications.
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Introduction
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Reoperative coronary artery bypass grafting (CABG) is associated with morbidity and mortality rates substantially greater than those of primary coronary operations [1]. Technical aspects that are generally thought to increase operative risk and adversely affect outcomes are represented by, but are not limited to, sternal reentry, injury to patent coronary grafts supplying graft-dependent areas of the myocardium, injury to the heart or great vessels during dissection of adhesions, and embolization to patent coronary grafts [2]. As a result, the left thoracotomy approach has been introduced as an alternative strategy in reoperative coronary operation for atherosclerotic disease involving the circumflex system [2, 3]. Based on recent technical advances in "off-pump" coronary exposure and epicardial mechanical stabilization, this approach may be undertaken to avoid the use of cardiopulmonary bypass (CPB) [4, 5].
When using this approach, after the distal anastomosis on one of the marginal branches of the circumflex coronary artery is constructed on the beating heart, the proximal end of the vein graft is connected to the descending thoracic aorta. Establishing the optimal length of the coronary graft, however, may be particularly problematic. If the graft is too long, kinking or twisting may occur, whereas if left too short, it may be exposed to injury and unwanted stretching caused by downward displacement of the left lower lobe of the lung during inspiration. This may occur with increased frequency in patients with severe chronic obstructive pulmonary disease, as a result of lung hyperinflation.
Based on these considerations, we herein describe the details of a technique that prevents these potential complications from occurring.
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Technique
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The left chest is entered via left posterior thoracotomy on the fifth intercostal space (Fig 1A). The left lung is collapsed and the pericardium is exposed. Anterior extension of the incision to a full posterolateral thoracotomy may be useful to harvest the left internal mammary artery for revascularization of the left anterior descending coronary artery. The inferior pulmonary ligament is then dissected, avoiding injury to the inferior pulmonary vein, to gain additional exposure. The pericardium is opened just posterior to the left phrenic nerve, and the marginal branches of the circumflex coronary artery are identified. Once the target vessel is exposed, and a suitable segment of long saphenous vein has been harvested, preparations are made for coronary grafting on the beating heart. The patient is heparinized (150 U/kg). The marginal branch of the circumflex coronary artery is stabilized using a mechanical stabilizer connected to a CTS retractor (Cardio Thoracic Systems, Cupertino, CA). A 4-0 Prolene snare is placed around the coronary artery to temporarily interrupt blood flow while the arteriotomy is performed. An intracoronary shunt is placed. The distal anastomosis is constructed using 7-0 Prolene in a running fashion. Upon completion, the descending thoracic aorta above the diaphragm is dissected to perform the proximal anastomosis.
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Fig 1. (A) The operation is performed through a left thoracotomy approach. (B) The modification to the original technique, which consists of bringing the coronary graft from the circumflex system to the descending thoracic aorta above the inferior pulmonary vein. The graft is placed in a tunnel made between the superior and inferior pulmonary veins, underneath the left lower lobe of the lung. (C) The original technique, which consists of bringing the coronary graft to the descending thoracic aorta around and below the inferior pulmonary vein.
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The technique recently adopted in 2 of our patients consists of bringing coronary grafts to the descending thoracic aorta through a tunnel made between the inferior and superior pulmonary veins, underneath the left lower lobe of the lung (Fig 1B). This technique is in contrast to the one used previously, in which the newly constructed coronary grafts were brought posteriorly to the descending thoracic aorta around and below the inferior pulmonary vein (Fig 1C). By using the recent modification, coronary grafts to the circumflex system are allowed to lay in a straight line, and are not affected by respiratory excursions. Subsequently, proximal anastomoses on the descending aorta are constructed in the usual manner, after lateral-occlusion clamping has been accomplished. Graft patency is confirmed by the Doppler-based technique transit time flow measurement. Once ventilation is resumed, the grafts are inspected for confirmation of proper positioning and avoidance of kinking or stretching.
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Comment
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As the left internal mammary artery is used with increasing frequency for left anterior descending coronary artery revascularization in the setting of primary coronary operations, a small but significant number of patients present with recurrent anginal symptoms as a result of isolated ischemia in the circumflex coronary artery territory. These patients may be effectively managed by circumflex revascularization without CPB using a left thoracotomy approach, obviating the hazards related to sternal reentry [2]. We have used the left thoracotomy approach in this setting for many years, initially with CPB [3], and more recently without CPB. Although the technical modification described herein has been used in only 2 patients, we believe that this technical detail has proved useful in preventing troublesome complications because of kinking or stretching of coronary grafts.
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References
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Accepted for publication January 12, 2000.
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Abstract
Introduction
