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J Thorac Cardiovasc Surg 2004;127:1810-1812
© 2004 The American Association for Thoracic Surgery
Brief communication |
ko G. Ne
i
, MD, PhD, FETCSa,*evi, MD, BCha
irkovi, MDa. Ne
kovi, MD, DEAAa, MDakovi, MD, PhD, FACC, FESCaa Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia and Montenegro, Yugoslavia
Received for publication November 24, 2003; accepted for publication December 16, 2003.
* Address for reprints: Duko Nei MD, PhD, FETCS, Chief, Department of Cardiac Surgery, Dedinje Cardiovascular Institute, M. Tepia 1, 11040 Belgrade, Serbia and Montenegro, Yugoslavia
nezic{at}EUnet.yu
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We describe a case in which the patient's large left anterior descending coronary artery (LAD) had proximal and distal stenosis. We speculated that a pedicled internal thoracic artery (ITA) graft would not have enough length for sequential bypass. Although the effects of skeletonization of the ITA on its long-term patency has not been established, we decided to use a free, short segment of pedicled left ITA as coronary-coronary bypass over a distal lesion on the LAD. The proximal remnant of left ITA was used as an in situ graft to bypass the proximal stenosis on the LAD. In our opinion, this technique may occasionally be an attractive approach when pedicled ITA is not long enough to be used for sequential bypass grafting.
Clinical summary
A 61-year-old man was admitted with progressive angina (New York Heart Association functional class III on admission). Hypertension, smoking, hypercholesterolemia, diabetes mellitus, and family history were all risk factors for coronary artery disease. Cardiac catheterization and angiocardiography revealed good left ventricular function (ejection fraction 0.60) with severe double-vessel disease. There was stenosis (80%) in the mid third of the right coronary artery, 70% stenosis of the proximal LAD, and long (3 cm in length) stenosis as great as 85% on the border zone between mid and distal thirds of the large LAD (Figure 1).
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The patient's postoperative course and convalescence progressed without any difficulty, and he was discharged with no angina. A predischarge check angiogram done on ninth postoperative day showed patency of the in situ left ITA graft and the coronary-coronary free ITA graft over the distal stenosis on the LAD (Figure 2). The patient has been receiving regular follow-up for 3 months and is in New York Heart Association class I.
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The pedicled ITA graft is the criterion standard conduit for coronary artery bypass surgery, with its superiority as a direct result of its high resistance to atherosclerosis.1 A 20-year follow-up study with angiographic confirmation in 90% of survivors demonstrated an 89% patency rate for pedicled ITA grafts.2 Although total arterial myocardial revascularization is gaining popularity, skeletonization of ITA has recently been advocated to increase the number of arterial anastomoses. Additional advantages of skeletonized ITA are increased available graft length for enhanced sequential grafting, greater blood flow in the early postoperative period, and preservation of collateral blood flow to the sternum.1,3 Nonetheless, skeletonization of the ITA may induce mechanical and physical damage to the vessel wall, loss of the vasa vasorum (which may cause ischemia in the outer layer of the media), and loss of draining vein and lymphatic capillaries, which may induce stasis end edema in the vessel wall as well as accumulation of metabolism waste products. Development of significant atherosclerotic lesions secondary to these waste deposits may not be detected for years.1 Theoretically, skeletonization of the ITA might adversely affect its long-term resistance to atherosclerosis and subsequently the patency rate. Calafiore's group4,5 reported on this problem in two occasions. Midterm results4 showed the same patency rate for both pedicled and skeletonized ITA grafts. However, angiographic follow-up was obtained for 15.8% of patients with skeletonized ITA conduits (133 of 842), with a mean of only 7.6 ± 2.3 months for this group. Long-term5 patency rate of skeletonized ITA was reported to be greater than 99%, but angiographic control was limited to 5% of the patients (88 of 1737 survivors, follow-up 33.4 ± 24.7 months) at a mean of only 17.5 ± 18.4 months. Because there are long-term studies of pedicled ITA patency at 15 to 20 years available, and available studies of skeletonized ITA long-term patency are not conclusive enough, we consider the effect of skeletonization on long-term patency of the ITA graft has not yet been established.
In our case there were two stenoses (one proximal and one very distal) on the large LAD, running well over the cardiac apex. We usually hesitate to use skeletonized ITA because of our previously mentioned doubts. Although pedicled left ITA graft is sometimes too short to perform sequential bypass in cases of distal stenosis on the LAD, we used a free, short segment of pedicled left ITA for coronary-coronary bypass grafting over that distal LAD stenosis. Biglioli and colleagues6 have confirmed the physiologic restoration of coronary blood flow after coronary-coronary bypass grafting. Furthermore, progression of coronary disease at the site of proximal anastomosis (the most critical point of this technique) has never been observed in the largest series (143 patients, total of 148 coronary-coronary grafts) of coronary-coronary bypass grafting (Nottin and coworkers7 with a maximum follow-up of 7 years). The in situ remnant of left pedicled ITA was used to bypass the proximal LAD stenosis. A few cases have been reported with the same approach to the problem of double LAD stenosis.8 In that series, only 2 of 6 patients underwent follow-up angiography (3 and 8 years after surgery), and ITA grafts were patent (in situ as well as on coronary-coronary position).
We strongly believe that this technique may occasionally be an attractive approach when pedicled ITA is not long enough to be used for sequential bypass grafting.
References
This article has been cited by other articles:
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  D. Nezic Reply J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 800 - 801. [Full Text] [PDF]
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M. H. Aazami The difference is meaningful: Anatomic coronary-coronary bypass or physiologic coronary-coronary bypass? J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 799 - 800. [Full Text] [PDF]
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