The Right Internal Thoracic Artery and Right Gastroepiploic Artery: Alternative Sites for Proximal Anastomosis in Patients with Atherosclerotic Calcified Aorta
Background: Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using off-pump coronary artery bypass (OPCAB) with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism. When the aorta is calcified and cannot serve as a safe site for proximal anastomosis, this anastomosis can be performed on the proximal segment of the right internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). Four such cases are described.
Methods: In 2 patients, the proximal right ITA was used as the site for proximal saphenous vein graft (SVG) anastomosis. Chronic obstructive lung disease in one patient and insulin-dependent diabetes in the other precluded performance of OPCAB with bilateral ITA. In addition, positive Allen test precluded performance of composite T-graft with radial artery (RA) on ITA. Both SVGs were anastomosed distally to the posterior descending artery. In 2 other patients, RA was connected end-to-side to the proximal segment of the RGEA. Both of these patients had repeat operations. The distal end of the RGEA was too small, and concerns regarding the future flow to a very large coronary bed precluded its use as an in situ graft.
Results: All patients underwent the operative procedures without any neurological or cardiovascular adverse effects, and all are midterm, symptom-free survivors. Postoperative graft patency was confirmed intraoperatively with flow measurements and postoperatively with control angiography or coronary imaging computed tomography.
Conclusions: The RITA and proximal RGEA can serve safely as sites for proximal anastomosis in patients with atherosclerotic calcified aorta undergoing OPCAB.
Beldi G, Bosshard A, Hess OM, et al. 2000. Transit time flow measurement: experimental validation and comparison of three different systems. Ann Thorac Surg 70:212-7.nCheng W, Denton TA, Fontana GP, et al. 2002. Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg 124:313-20.nKatariya K, Yassin S, Tehrani HY, et al. 2004. Initial experience with sutureless proximal anastomoses performed with a mechanical connector leading to clampless off-pump coronary artery bypass surgery. Ann Thorac Surg 77:563-8.nLytle BW, Loop FD. 2001. Superiority of bilateral internal thoracic artery grafting; it's been a long time comin'. Circulation 104:2152-4.nOchi M, Hatori N, Fuji M, et al. 2001. Limited flow capacity of the right gastroepiploic artery graft: postoperative echocardiographic and angiographic evaluation. Ann Thorac Surg 71:1210-4.nRoach GW, Kanchuger M, Mangano CM, et al. 1996. Adverse cerebral< outcomes after coronary bypass surgery. Multicenter study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 335:1857-63.nSabik JD, Gillinov AM, Blackstone EH, et al. 2002. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg 124:698-707.nSharony R, Grossi EA, Saunders PC, et al. 2004. Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease. J Thorac Cardiovasc Surg 127:406-13.nStamou SC, Jablonski KA, Pfister AJ, et al. 2002. Stroke after conventional versus minimally invasive coronary artery bypass. Ann Thorac Surg 74:394-9.nSuma H, Isomura T, Horii T, Sato T. 2000. Late angiographic result of using the right gastroepiploic artery as a graft J Thorac Cardiovasc Surg 120:496-8.n
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