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J Thorac Cardiovasc Surg 1998;116:1087
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

The route of choice for the axillocoronary bypass graft

Reply to the Editor:

We would like to thank Dr Tovar for his comments on our article. His argument that compression of the axillocoronary bypass by the intercostal muscles might be a problem is understandable. Graft occlusion by intercostal compression can be suspected but is not proved in 1 case report in the literature. ¹

Before the first clinical applications of axillocoronary bypass grafting we undertook a feasibility study in the human cadaver ² and found that an incision closer to the anterior axillary fold was technically easier than exposure of the axillary artery in the infraclavicular region, as described by other authors. ^3-6 After the bypass graft had been sutured to the axillary artery caudal to the insertion of the pectoralis minor muscle, entrance into the pleural cavity via the adjacent intercostal space was very straightforward. Crossing of the pectoralis major muscle, which might constrict the bypass graft, can also be avoided by using this route.

Clinically, we have taken special care that a large hole in the intercostal space was created to allow a loose and compression-free course of the graft. Intraoperative flow measurements and postoperative duplex scans, both performed during forced respiration in our patients, have shown no changes in bypass flow. Our own concerns regarding a trans– intercostal muscle course are directed more toward development of neointimal hyperplasia at the rib crossing site, and partial rib resection can be debatable in some cases. We agree that the ideal course of the axillocoronary bypass graft still needs to be determined, but we regard the method as a useful adjunct for the management of a severely atherosclerotic ascending aorta in coronary artery bypass grafting.

Johannes Bonatti, M.D.
Division of Cardiac Surgery
University Clinic of Surgery
Anichstrasse 35
Innsbruck A-6020, Austria

12/8/93300

References

1. Yaryura R, Vardhan R, Springer AJ, Cooley DA. A 66-year-old man with severe angina and previous coronary artery bypass. Lancet 1996;349:396.
   
2. Bonatti J. Ladurner R, Hangler H, Katzgraber F. Anatomical studies concerning technical feasibility of minimally invasive axillocoronary bypass grafting. Eur J Cardiothorac Surg 1998;14 (Suppl I):570-4.
   
3. Coulson AS, Bakhshay SA. Subclavian artery origin for a coronary bypass graft. Contemp Surg 1997;50:65-6.
   
4. Knight WL, Baisden CE, Reiter CG. Minimally invasive axillary–coronary artery bypass. Ann Thorac Surg 1997;65:304-5.
   
5. Tovar EA, Blau N, Borsari A. Axillary artery–coronary bypass grafting. J Thorac Cardiovasc Surg 1998;115:242-3. [Free Full Text]
   
6. Michiraju VR, Culig MH, Heppner RL, Minella RA, O'Toole JD. Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures. Ann Thorac Surg 1998;65:625-7.[Abstract/Free Full Text]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Johannes Bonatti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bonatti, J. Search for Related Content PubMed Articles by Bonatti, J.