Ann Thorac Surg 2002;74:700-703
© 2002 The Society of Thoracic Surgeons
Original article: cardiovascular
Coronary artery bypass surgery by the transdiaphragmatic approach1
Kenji Takahashi, MD*a,
Masahito Minakawa, MDa,
Norihiro Kondo, MDa,
Shigeru Oikawa, MDa,
Masaharu Hatakeyama, MDa
a Department of Cardiovascular Surgery, Aomori Rousai Hospital, Hachinohe, Japan
Accepted for publication May 9, 2002.
* Address reprint requests to Dr Takahashi, Department of Cardiovascular Surgery, Aomori Rousai Hospital, 1 Minamigaoka, Shirogane, Hachinohe, Aomori, 031-0822, Japan
e-mail: takaken{at}aomorih.rofuku.go.jp
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Abstract
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Background. The transdiaphragmatic approach is useful for reoperative coronary artery bypass grafting involving the right coronary artery because it does not require median sternotomy or cardiopulmonary bypass.
Methods. Twenty-one patients underwent coronary artery bypass surgery by the transdiaphragmatic approach. The ratio of first operations to reoperations was 7:14. The cause of reoperation was occlusion of a saphenous vein graft in 4 patients, right gastroepiploic artery graft failure in 3 patients, and a new sclerotic lesion in the right coronary artery in 7 patients. When the radial artery or saphenous vein was used, grafting extended from the origin of the gastroduodenal artery to the right coronary artery.
Results. None of the patients died during surgery. The sites of anastomoses were as follows: right coronary artery in 11 patients, right posterior descending artery in 9 patients, and the atrioventricular node artery in 1 patient. The following types of grafts were used: right gastroepiploic artery in 17 patients, saphenous vein in 2 patients, and radial artery in 2 patients.
Conclusions. When reoperative coronary surgery involving the right coronary artery is necessary, the transdiaphragmatic technique is effective because it does not damage patent grafts placed during the primary operation.
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Introduction
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The transdiaphragmatic approach is an effective technique for performing reoperative coronary artery bypass grafting (CABG) involving the right coronary artery (RCA) because it does not damage a patent graft placed during the primary operation. Unlike conventional CABG, which employs a median sternotomy, the transdiaphragmatic approach uses a median abdominal incision. The use of the present approach in reoperative CABG makes it possible to reach the RCA through the diaphragm while for the most part leaving intact the rest of the wound after the primary CABG. This allows surgeons to perform reoperative surgery without worrying about damaging patent grafts placed during primary CABG. Although the right gastroepiploic artery (GEA) is often used in CABG, when the GEA has been excised by gastrectomy or is not graftable, the saphenous vein (SV) or radial artery (RA) can be grafted from the gastroduodenal artery to the RCA, right posterior descending artery (RPD), and atrioventricular node artery (AVN).
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Patients and methods
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The study group consisted of 21 patients who underwent CABG by the transdiaphragmatic approach between October 27, 1996, and October 31, 2001 (Table 1).
The age of these patients ranged from 50 to 81 years, with an average age of 66.9 years. There were 15 men and 6 women. Whereas 7 patients underwent CABG for the first time (primary CABG), the remaining 14 patients underwent this bypass surgery for the second time (reoperative CABG). The reasons for reoperative CABG were as follows: obstruction of a vein graft placed during the primary CABG in 4 patients, GEA graft failure in 3 patients, and formation of a new sclerotic lesion in the RCA in 7 patients. Also, 1 patient (case 15) had undergone subtotal gastrectomy for the treatment of gastric cancer. The breakdown of patent grafts placed during the previous operation was as follows: right internal thoracic artery (RITA) to left descending artery (LAD) running at an oblique angle at the median sternotomy wound in 9 patients, left internal thoracic artery (LITA) to circumflex (Cx) in 7 patients, LITA to first diagonal branch (D1) in 2 patients, LITA to LAD in 1 patient, ascending aorta to LAD:SV in 2 patients, and ascending aorta to D1:SV in 1 patient.
Each patient was placed in the supine position and after inducing anesthesia a pillow was placed between the patient’s back and the operating table so that the back arched about 10 cm from the table at the level of the liver. An approximately 10-cm median incision was performed from the xiphoid process to open the abdomen. Excision of the xiphoid process at this stage of surgery facilitates a better visual field. A Kent’s retractor was then positioned at the left and right costal arches and when the retractor was pulled in the cranial direction a large gap was created between the liver and the diaphragm thus allowing the surgeons to view the abdominal side of the diaphragm (Fig 1). Next, a transverse incision of approximately 4 cm was made along the upper margin of the left hepatic lobe on the central tendon of the diaphragm and the pericardium to expose the heart. At this point, the root region of the RPD could be seen at the periphery of the RCA (Fig 2).
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Fig 1. A large space between the liver and the diaphragm was obtained. Kent’s retractor was placed to the right and left costal arches to raise the ribs in the cranial direction.
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Fig 2. The right posterior descending artery (RPD) was visible after an approximately 4-cm transverse incision of the diaphragm.
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One end of the surgical drape was sutured to the dorsal side of the pericardial incision and the other end of the drape was pulled in the caudal direction and adhered to the abdominal wall. This procedure pressed down the liver and the other abdominal organs to achieve a better visual field. In the reoperative cases adhesions formed after the primary CABG were kept intact to the extent possible, as such adhesions act as stabilizers. Among the seven primary CABG cases, in five cases either a 2-0 silk suture or a vessel loop was placed above and below the planned anastomosis site and then pulled slightly to stabilize the site, while Super Cab (a stabilizer produced by Baxter [Glendale, CA]) was used in the remaining two cases. Preconditioning was carried out by transiently blocking the blood flow above and below the planned anastomosis site (preconditioning was not necessary when anastomosing to RPD). An incision of approximately 5 mm was then made in the coronary artery to perform peripheral anastomosis. In the present series of patients we used interrupted sutures but this procedure could have been performed using continuous sutures. At this stage of surgery, as the surgical field is fairly deep, when suturing the dorsal side of the coronary artery such suturing should be performed while the graft and the coronary artery are separated. When a free RA or SV graft was used, after anastomosing the graft to the coronary artery the graft was led through the ventral or dorsal surface of the liver to reach the gastroduodenal artery. The blood flow in the gastroduodenal artery was blocked using a pediatric aortic partial clamp and after making an incision in the artery, end-to-side anastomosis was performed.
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Results
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None of the patients died during surgery. A graft was anastomosed to the RCA in 11 patients, to the RPD in 9 patients, and to the AVN in 1 patient. A GEA graft was used in 17 patients, a SV graft was used in 2 patients, and a RA graft was used in 2 patients. The two SV grafts were used because the GEA was too narrow in 1 patient (case 20) and in the other patient it had been excised during stomach cancer surgery (case 15). The RA artery was grafted from the gastroduodenal artery to a target coronary artery owing to GEA graft failure in 1 patient (case 16) and to narrow GEA in the other (case 21). Furthermore, 3 patients (cases 3, 4, and 11) also underwent minimally invasive direct coronary artery bypass grafting (MIDCABG) involving the LITA and LAD after left anterior small thoracotomy. One patient (case 5) underwent the anastomosis to the RCA after thromboendoarterectomy. One patient (case 13) also underwent bypass surgery in which a SV graft was performed from the descending aorta to Cx while simultaneously undergoing a left lower lobe resection for the treatment of lung cancer. Intraoperative changes in electrocardiograms were not seen in any of the patients, thus confirming that the hemodynamics of these patients were stable during surgery. Among 17 patients who underwent a single bypass by the transdiaphragmatic approach, the length of surgery time ranged from 90 to 180 minutes, with an average of 120 minutes. Blood transfusions were required in 3 of the 21 patients (14.2%) and the average duration of postoperative stay was 8.6 days. Postoperative contrast radiography confirmed the patency of every graft (Fig 3)
and symptoms disappeared in all patients.
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Fig 3. Postoperative angiography: the gastroepiploic artery (GEA) was anastomosed to the right coronary artery (RCA) after thromboendoarterectomy (case 5).
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Comment
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The mortality and morbidity associated with reoperative CABG are higher than those associated with primary CABG [1–4]. Also, the use of a median sternotomy in reoperative CABG may damage patent grafts placed during primary CABG [5–7]. The transdiaphragmatic approach can be characterized as follows: it does not damage the heart or a patent graft placed during primary surgery [5, 6]; grafting to the RCA or the RPD can be performed without markedly affecting the hemodynamics of patients; and even in reoperative cases, this surgery requires less time, postoperative management, and transfusion. At our institution the RITA is anastomosed to the LAD in a certain number of patients, and for these patients any damage to the graft could be lethal. Also, the effects of cardiopulmonary bypass on reoperative cases are great [8]. The outcomes for off-pump CABG, which does not require cardiopulmonary bypass, have stabilized in recent years and off-pump CABG now accounts for about 85% of the coronary artery bypass surgeries performed at our institution [9].
The transdiaphragmatic approach is an effective surgical technique for reoperative CABG because it does not require cardiopulmonary bypass nor does it markedly affect hemodynamics while ensuring the patency of grafts placed during primary CABG. The transdiaphragmatic approach is also effective for primary CABG in that if future grafting to another location becomes necessary, a median sternotomy can be safely performed. The two most important points in ensuring a favorable visual field using the transdiaphragmatic approach are the body position and the use of Kent’s retractors. In other words, after placing a patient in the supine position, a pillow is placed under the patient’s back to sufficiently arch the back and a Kent’s retractor is attached to the left and right costal arches and pulled in the cranial direction to create a large space between the diaphragm and the liver. This allows the RCA and the RPD to be clearly viewed. When feasible, it is safer to anastomose a graft to the RPD owing to its stable hemodynamics. Moreover, when the GEA has already been excised or is too narrow to serve as an effective graft it is possible to graft a free SV or RA graft from the gastroduodenal artery to the RCA or the RPD. In some RCA dominant cases, the use of a SV or RA graft is indicated over the use of a GEA graft.
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Footnotes
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1 This article has been selected for the open discussion forum on the CTSNet Web site:
http://www.ctsnet.org/doc/5499 
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References
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Abstract
Introduction
