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J Thorac Cardiovasc Surg 2004;128:800-801
© 2004 The American Association for Thoracic Surgery

Letter to the Editor

Reply

Duko Nei, MD, PhD, FETCS

Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia and Montenegro

Reply to the Editor:

I read with great interest the comments of Dr Aazami about the article my colleagues and I recently published in The Journal of Thoracic and Cardiovascular Surgery..¹

We absolutely agree that the physiologic benefit (ie, diastolic blood flow closer to physiologic norms) of coronary-coronary bypass (CCB) grafting can be achieved only when the origin and initial segment of the targeted coronary artery are free of atherosclerotic lesions. In such a case we can use this region as a site of proximal anastomosis in a CCB graft procedure, thus using the advantages of the coronary prompting effect of sinuses of Valsalva.^2,3

We were able to use these advantages in 2 patients with multivessel coronary artery disease, including single distal stenosis on a large left anterior descending artery (LAD) running well over the cardiac apex. These distal LAD lesions were bypassed with the CCB grafting technique by using a short segment of the left internal thoracic artery⁴ and a short segment of the radial artery, respectively.⁵

There are very few articles in the literature discussing the CCB graft technique. In our article,¹ Biglioli and colleagues² were cited to assure the readers that such an approach had been tested and that normal or natural (physiologic rather than anatomic) flow could be expected in the distal third of the bypassed LAD (supported, of course, in this case with mid-LAD flow from the in situ left internal thoracic artery). From our point of view, this CCB is rather an imitation of the normal LAD vascular bed (especially if anastomoses were created in a terminoterminal fashion) than prolongation of an in situ left internal thoracic artery graft.

In our opinion, neither the procedure of Biglioli and colleagues² nor that of Nottin and coworkers⁶ is able to imitate pure physiologic coronary flow. With the proximal anastomosis of CCB grafting (in both procedures) at the origin of the right coronary artery (RCA; Figure 1 in Nottin and coworkers⁶), there is at least an artificially created new double orifice, causing blood flow turbulence and thus affecting the physiology of natural blood flow and distribution.

I would go even beyond the guidelines, suggesting that CCB grafting is a possible solution for low-grade stenosis (50%-60%) of the RCA, of course in the presence of significant multivessel coronary artery disease. It is very widely known that such an RCA stenosis represents a real challenge for the cardiac surgeon. All the grafts (arterial and venous) that have been used have had the worst patency rate in such conditions.^7,8 Perhaps CCB grafting (with the RCA region free of lesions below the orifice as a site of proximal anastomosis, even in a terminoterminal fashion) would be a good choice.

Finally, we have just refreshed the idea of Dr Barboso and Dr Rusticali (they were cited in our article), and therefore they deserved Dr Aazami's congratulations for the innovation.

	References

Top References

 

1. Nei DG, Kneevi AM, irkovi MV, Nekovi V, Vukovi PM, Nekovi AN. The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery. J Thorac Cardiovasc Surg.2004;127:1810-1812.[Free Full Text]
   
2. Biglioli P, Almanni F, Antona SC, Sala A, Susini G. Coronary-coronary bypass: theoretical basis and techniques. J Cardiovasc Surg.1987;28:333-335.[Medline]
   
3. Nishida H, Grooters RK, Endo M, Koyanagi H, Merkley DF, Thieman KC, et al. Flow study of coronary-coronary bypass grafting. Cardiovasc Surg.1993;1:296-299.[Medline]
   
4. Nei D, Kneevi A, Borovi S, irkovi M, Milojevi P. Coronary-coronary free internal thoracic artery graft on a single, distal, left anterior descending artery lesion. J Thorac Cardiovasc Surg.2004;127:1517-1518.[Free Full Text]
   
5. Nezic D, Cirkovic M, Knezevic A, Mangovski LJ. Coronary-coronary radial artery graft for single, distal LAD lesion. Ann Thorac Surg...2004;78:1078-80..
   
6. Nottin R, Grinda JM, Anidjar S, Folliguet T, Detroux M. Coronary-coronary bypass graft: an arterial conduit-sparing procedure. J Thorac Cardiovasc Surg.1996;112:1223-1230.[Abstract/Free Full Text]
   
7. Tatoulis J, Buxton B, Fuller J. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg.2004;77:93-9101.[Abstract/Free Full Text]
   
8. Shah P, Gordon I, Fuller J, Seevanayagam S, Rosalion A, Tatoulis Jet al. Factors affecting saphenous vein graft patency: clinical and angiographic study in 1402 symptomatic patients operated on between 1977 and 1999. J Thorac Cardiovasc Sur.2003;126:1972-1977.[Abstract/Free Full Text]
   

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