Interactive Cardiovascular and Thoracic Surgery 2:97-98(2003)
© 2003 European Association of Cardio-Thoracic Surgery
A new method of grafting the circumflex through lateral MIDCAB with the use of the radial loop technique
Thanos Athanasiou*,
Roberto Casula,
Brian Glenville and
Rex DeL Stanbridge
Department of Cardiothoracic Surgery, St Mary's Hospital, 70 St Olaf's Road, Fulham, London SW6 7DN, UK
* Corresponding author. Fax: +44-207-886-1147
tathan5253{at}aol.com
Received June 16, 2002;
received in revised form November 11, 2002;
accepted November 19, 2002
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Abstract
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We report a technique that allows total arterial revascularization of the circumflex territory without cardiopulmonary bypass through limited thoracotomy with the radial as a composite graft. The technique includes anastomosis of the distal end of the radial artery to its more proximal part after the division of the conduit from the brachial artery. In this way we create an adjustable loop that can be divided and used as bifurcated conduit in two coronary targets according to the needs of revascularization.
Key Words: MIDCAB; Radial artery; Composite grafts; Arterial revascularization
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1. Introduction
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In the past grafting of the circumflex territory through thoracotomy has been used mainly in reoperations. The radial artery (RA) has been used effectively as simple or composite second conduit of choice after the internal thoracic arteries (ITAs) in conventional coronary artery bypass grafting (CABG) and more recently in beating heart surgery with excellent early and midterm clinical and angiographic outcome [1]. We describe a novel technique by using the radial artery as an adjustable loop that can be divided and used as bifurcated conduit according to the needs of revascularization. Advantages and future applications of the radial loop technique are highlighted.
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2. Technique
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We performed a lateral limited thoracotomy through the fifth intercostal space. Direct access to the obtuse marginal and posterolateral branches of the circumflex was achieved by retracting the lung towards the apex following division of the inferior pulmonary ligament and opening the pericardium posterior to the phrenic nerve.
The preparation of the loop includes the end to side anastomosis of the distal end to the proximal RA with an 8-0 prolene stitch (Fig. 1). The radial loop is divided at the time of grafting at a desirable point creating an adjustable composite graft (long and short leg). We create the ‘long leg’ by measuring the distance between the more distal target vessel and the proximal sites (descending aorta or ITA's). The rest of the radial length will be the ‘short leg’ of the radial loop, which will be anastomosed end to side to the proximal coronary target in a Y fashion.
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3. Discussion
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We perform surgical revascularization of the circumflex territory in case of single vessel disease when percutaneous transluminal coronary angioplasty (PTCA) has failed or when redo CABG is required.
MIDCAB thoracotomy in selected patients offers superior cosmetic results and reduces postoperative mortality, morbidity and length of stay especially in reoperations [2,3,4].
Very few reports emphasize the use of arterial and composite grafts to expand the ability for total arterial revascularization through incisions used for MIDCAB [5].
We believe that the radial loop technique in combination with MIDCAB incisions has several advantages: - With one conduit two distal anastomoses can be performed in a quick and safe manner.
- With this technique we perform two end to side anastomoses to the coronary targets which is technically less demanding compared to sequential grafting.
- It facilitates the performance of a totally endoscopic multivessel procedure allowing one anastomosis to be performed outside the chest.
- The radial artery as a pedicled conduit can be positioned on the descending aorta as a curved ‘y’ graft below the level of the hilum avoiding the potential kinking of a vein graft and compromising the long term patency.
Potential limitations of our method are: the potential kinking of the graft during the respiratory movement of the lung and the fact that flow velocity or angiographic studies were not performed to evaluate graft patency.
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Acknowledgements
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The authors would like to thank Chris Priest and the staff of the Department of Medical Illustration at the Chelsea and Westminster Hospital.
doi:10.1016/S1569-9293(02)00113-5
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References
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- Buxton B, Fuller J, Gaer J, Liu JJ, Mee J, Sinclair R, Windsor M. The radial artery as a bypass graft. Curr Opin Cardiol. 1996;11(6):591–598[Medline]
- Azoury FM, Gillinov AM, Lytle BW, Smedira NG, Sabik JF. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg. 2001;71(6):1959–1963[Abstract/Free Full Text]
- Dewey TM, Magee M, Edgerton J, Vela R, Prince SL, Acuff T, Mack MJ. Left mini-thoracotomy for beating heart bypass grafting: a safe alternative to high-risk intervention for selected grafting of the circumflex artery distribution. Circulation. 2001;104(12 Suppl1):I99–I101
- Fonger JD, Doty JR, Sussman MS, Salomon NW. Lateral MIDCAB grafting via limited posterior thoracotomy. Eur J Cardiothorac Surg. 1997;12(3):399–404[Abstract]
- Watanabe G, Misaki T, Kotoh K, Kawakami K, Yamashita A, Ueyama K. Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle. Ann Thorac Surg. 1999;68(1):131–136[Abstract/Free Full Text]
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Abstract
1. Introduction