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J Thorac Cardiovasc Surg 1994;107:447-0449
© 1994 Mosby, Inc.

Surgery for Acquired Heart Disease

Proximal bypass to anomalous circumflex coronary artery

Duncan A. Killen, MD, Suchint Wathanacharoen, MD


Kansas City, Mo.

From the MidAmerica Heart Institute of Saint Luke's Hospital, Kansas City, Mo.

Received for publication March 25, 1993. Accepted for publication June 29, 1993. Address for reprints: D. A. Killen, MD, Medical Plaza II-50, 4320 Wornall, Kansas City, MO 64111.

Abstract

A technique for coronary artery bypass to the proximal segment of an anomalous circumflex coronary artery is described. This technique has been used in four patients. It is suggested that in some situations this would be the preferable approach for bypassing an anomalous circumflex coronary artery obstruction. (J THORAC CARDIOVASC SURG 1994;107:447-9)

Occasionally a critically obstructed, anomalously arising, circumflex coronary artery is encountered in patients undergoing coronary artery bypass. When the anomalous artery is of adequate size and supplies a significant myocardial mass, aorta-coronary bypass to this vessel is desirable. In some instances, the distal circumflex coronary artery and its branches are not suitable for direct anastomosis; however, when the offending lesion is in the initial segment of the artery it can be approached in its early course where a more proximal anastomosis may be feasible.

METHOD

After cold cardioplegic arrest, the proximal portion of the anomalous circumflex coronary artery is exposed by retracting the decompressed ascending aorta to the patient's left and the right atrium to the patient's right. Dissection is begun in the pericardial fat found at the junction of the right atrium and aortic root. The anomalous artery is identified and exposed distally behind the aorta until a soft vessel is found. The distal anastomosis is made in a routine fashion and the proximal anastomosis is made to the anterolateral aspect of the ascending aorta (Fig. 1).




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  		Fig. 1. View of proximal anomalous circumflex artery from right side of patient during construction of distal anastomosis (A) and after completion of bypass procedure (B). V, Vein; A,artery; R, right.

 
RESULTS

We have applied this technique in four patients with multivessel coronary artery occlusive disease in whom there was a significant obstruction in the proximal segment of an anomalously arising circumflex coronary artery (Fig. 2). One patient had undergone a quadruple coronary artery bypass some 14 years previously. Each patient had construction of multiple (two to four) bypasses, of which one was a saphenous vein bypass to the proximal anomalous circumflex coronary artery as described. The anastomosis to the circumflex artery was made just beyond the obstructing lesion where in each instance the artery accepted a probe of 1.5 mm or larger diameter.



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  		Fig. 2. Left anterior oblique arteriographic view of anomalous coronary artery, with long proximal stenosis (arrow), revascularized as described.

 
There were no complications related to the use of this technique and each patient has been a long-term survivor. There has been one known late complication of the circumflex artery bypass graft during a mean follow-up of 3.5 years. This complication was in a patient who was seen 6 years after operation with abrupt onset of unstable angina associated with acute occlusion (as evidence arteriographically by fresh thrombus in the distal graft) of the vein graft to the circumflex coronary artery.

DISCUSSION

Anomalous origin of the circumflex coronary artery from the right aortic sinus or the initial segment of the right coronary artery is a rather frequent anomaly being observed in approximately 0.5% of patients undergoing coronary arteriography.Go Go 1-3 It has been observed that an anomalous origin of the circumflex coronary artery increases its overall propensity to develop atherosclerotic lesions;Go 3 however, another study failed to confirm this.Go 1 The abnormal course (posterior to the aorta and main pulmonary artery) and hemodynamic stresses theoretically placed on the initial segment of the artery may increase the tendency for atherosclerotic plaques to be localized there.Go 4

When a proximally obstructed anomalous circumflex coronary artery is large, it may be exposed in the atrioventricular groove beneath the left atrial appendage or its distal epicardial branches may be used for performance of a distal anastomosis. However, the artery often is rather small or it branches as it courses behind the pulmonary artery, such that the distal vessel is not of adequate size for direct anastomosis. When these circumstances arise, coronary artery bypass to the more proximal portion of the artery may be feasible. The latter approach may be preferable even when the distal circumflex tree is suitable for a distal anastomosis, because use of a shorter bypass graft to a more proximal (and possibly larger) segment may have theoretic advantages as regards long-term patency. Also, this situation might be ideal for use of the right internal thoracic artery as a source graft for the bypass.

Exposure of the anomalous circumflex coronary artery requires tedious dissection, for the layer of epicardial fat may be rather thick. Palpation of the atherosclerotic lesion in the artery may be used as a guide to its exposure. The artery to the sinoatrial node often arises from the proximal right coronary artery and may be encountered in the field of dissection. The circumflex coronary artery is larger and more juxtaposed to the posterior aortic wall than the sinoatrial node artery. With retraction of the decompressed aorta and sharp dissection along the anomalous artery it can be exposed rather far distally.

CONCLUSION

We believe that this technique of performing bypass to the proximal portion of an anomalous circumflex coronary artery is one that sometimes is preferable to alternative approaches.

References

  1. Page HL, Engel HJ, Campbell WB, et al. Anomalous origin of the left circumflex coronary artery. Circulation 1974;50:768-73.[Abstract/Free Full Text]
  2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn 1990;21:28-40.[Medline]
  3. Click RL, Holmes DR, Vlietstra RE, et al. Anomalous coronary arteries: location, degree of atherosclerosis and effect on survival: a report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989;13:531-7.[Abstract]
  4. Silverman KJ, Bulkley BH, Hutchins GM. Anomalous left circumflex coronary artery: "normal" variant of uncertain clinical and pathologic significance. Am J Cardiol 1978;41:1311-14.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
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Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
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Right arrow Author home page(s):
Duncan A. Killen
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Right arrow Articles by Wathanacharoen, S.
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Right arrow PubMed Citation
Right arrow Articles by Killen, D. A.
Right arrow Articles by Wathanacharoen, S.

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