J Thorac Cardiovasc Surg 1999;117:1229-1230
© 1999 Mosby, Inc.
Coronary artery bypass grafting with the descending branch of thelateral femoral circumflex artery used as an arterial conduit: Is arteriographicevaluation necessary before its use?
Bernard Faidutti, MD,
Afksendiyos Kalangos, MD, PhD
Clinic for Cardiovascular Surgery
University Cantonal Hospital ofGeneva
1211 Geneva 14, Switzerland
To the Editor:
We read with interest the recent paper by Schamun and associates
1 regarding the use of the descendingbranch of the lateral femoral circumflex artery (LFCA) as an arterial conduitfor myocardial revascularization 2 (Fig. 1). We thoroughly agree with them becauseour clinical experience correlates with theirs. Since October 1997, the descendingbranch of the LFCA has been used as graft material in 24 patients who underwentcoronary artery bypass grafting in our institution. In all cases, bilateralsaphenous veins either were absent owing to bilateral stripping or were notsuitable as graft material owing to varicose dilatation or fibrotic lesions.Twenty patients were men and 4 were women with a mean age of 65 ± 5years (range 52-81 years). One patient in whom the descending branch of theleft LFCA was used to revascularize the circumflex artery underwent redo coronaryartery bypass grafting 1 month later because of a significant stenosis distalto the anastomosis of the left internal thoracic artery (ITA) to the leftanterior descending artery (LAD). The descending branch of the right LFCAwas then used to revascularize the LAD distal to the stenosis. The descendingbranch of the LFCA was anastomosed on the right coronary artery in 10 cases,the first marginal branch of the circumflex artery in 5, the first diagonalbranch in 5, the LAD in 3, the intermediary artery in 1, and the posteriordescending artery in another case. In 21 cases, proximal anastomoses of thedescending branch of the LFCA were carried out on the ascending aorta, andin 4 cases they were carried out either on the pedunculated right ITA or leftITA, forming a Y-shaped graft. The average length of the descending branchof the LFCA was 16 cm (range 14-20 cm). Clinical follow-up was complete forall patients with a mean follow-up of 8 months (range 2-26 months). One patientwho was operated on on an urgent basis with an ejection fraction of 20% diedof irreversible left ventricular failure on the fifth postoperative day. Apostoperative coronary angiogram was repeated in 4 patients, and in only 1of them was the descending branch of the LFCA found to be occluded. The otherpatients continue to be followed-up by periodic treadmill tests and remainclinically free of symptoms. During the beginning of our experience with thedescending branch of the LFCA, we observed that this artery was unsuitablefor use in some cases. The presence of a poorly developed artery (Fig. 2A)and of macroscopic atheromatous lesions in the artery itself preclude itsharvesting. For these reasons, we considered itnecessary to perform bilateral femoral arteriography before surgery, duringcoronary angiography, for patients in whom the use of the descending branchof the LFCA might be justified. Arteriographic evaluation provided furtherinformation on the anatomic variations of this artery such as the LFCA arisingfrom the common femoral artery or a hypoplastic LFCA being sometimes replacedby small branches taking their origin from the deep or superficial femoralarteries. The anatomy of the LFCA can be different between the right and leftsides in the same person. Moreover, radiologic evaluation allows the detectionof some occlusive or stenotic lesions of the superficial femoral arteriesfor which the descending branch of the LFCA contributes to the collateralcirculation of the limb (Fig. 2B). Histopathologic examination of theharvested descending branches of the LFCA revealed that this artery can containmacroscopically occult atheromatous lesions, sometimes even with microscopiccalcified deposits, which could result in earlier occlusion of the graft afterthe operation.
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Fig. 1 Bilateral femoral arteriographyshowing the adequately developed descending branch of the lateral femoralcircumflex artery on both sides (black arrows).
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Fig. 2A. The poorly developed descendingbranch of the left lateral femoral circumflex artery (white arrowheads).
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Fig. 2B. The well-developed descendingbranch of the left lateral femoral circumflex artery (black arrows) contributing to the collateral circulation of thelimb in the presence of occlusive lesions of the left superficial femoralartery and the deep femoral artery after the origin of the lateral femoralcircumflex artery.
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In conclusion, although we totally agree with the conclusions reportedby the authors regarding this new arterial conduit, we would like to emphasizethe importance of a preoperative bilateral arteriographic evaluation of thefemoral arteries and that of LFCAs, as we systematically do for thoracic arteries.We believe that this evaluation can avoid useless attempts at harvesting.Attractiveness of the descending branch of the LFCA as an arterial conduitwill depend on its patency rate in the long term and the enthusiasm of surgeonsto use it.
12/8/97601
References
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Schamun CM, Duran JC, Rodriguez JM, etal. Coronary revascularization with the descending branch of the lateral circumflexartery as a composite arterial graft. J Thorac Cardiovasc Surg 1998;116:870-1.[Free Full Text]
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Tatsumi TO, Tanaka Y, Kondoh K, et al.Descending branch of lateral femoral artery as a free graft for myocardialrevascularization: a case report. J Thorac Cardiovasc Surg 1996;112:546-7.[Free Full Text]
