ABSTRACT
A 51-year-old male was unexpectedly diagnosed with unroofed coronary sinus atrial septal defect (CSASD) by coronary computed tomography angiography for a complaint of epigastric pain. As there was no persistent left superior vena cava (LSVC), we planned to undertake a totally endoscopic MICS approach. A 4-cm skin incision was made on the right lateral chest wall under general anesthesia. The 4th intercostal space was used to enter the chest and the right femoral vessels were cannulated for cardiopulmonary bypass. After cross-clamping of the aorta, a right-sided atriotomy incision was made on the left atrium. The CSASD was located at the ventral and caudal regions of the mitral valve and the defect was closed using a bovine pericardial patch. No major postoperative complications were observed. The patient was discharged 7 days after the operation as postoperative transthoracic echocardiography revealed no residual shunt. We thus observed that totally endoscopic MICS patch closure via left atriotomy using a right-side approach for CSASD without LSVC was beneficial to the patient.
ABSTRACT
To improve the long-term clinical results of coronary artery bypass grafting, we evaluated our graft selections and the designs that were used, in relation to the quality of the anastomoses and patient backgrounds. We retrospectively reviewed the records of 505 patients who underwent isolated coronary artery bypass grafting involving more than 3 vessel reconstructions between May 1999 and March 2007. Neither the selection of a saphenous vein graft nor that of an internal thoracic artery graft was a statistically significant cardiac event factor. The cardiac event-free rates (at 1 and 5 years) according to anastomotic site were as follows : a) 92.9% and 76.6% for a radial artery graft and 93.2% and 83.9% for a saphenous vein graft at the right coronary artery ; b) 93.0% and 70.3% for a radial artery graft and 95.1% and 80.4% for a saphenous vein graft at the distal right coronary artery ; c) 94.5% and 77.8% for a left internal thoracic artery graft and 93.0% and available for a right internal thoracic artery graft at the left anterior descending artery ; d) 96.5% and 79.8% for a radial artery graft, 93.0% and 78.0% for a saphenous vein graft, and 91.3% and 75.6% for an internal thoracic artery graft at the left circumflex artery. Significant cardiac event factors were dialysis (risk ratio, 5.28 ; <i>p</i><0.001), the use of a right gastroepiploic artery graft as the inflow blood vessel of a radial artery graft (risk ratio, 5.75 ; <i>p</i>=0.02), and off-pump coronary artery bypass grafting (risk ratio, 1.62 ; <i>p</i>=0.03). As a tendency toward more frequent early-stage cardiac events among patients with radial artery grafts was confirmed, careful follow-up is important for this group of patients. Right gastroepiploic artery grafts should be chosen carefully with full consideration of the anastomotic site quality and the flow demand, as the blood supply capability of such grafts is limited. For dialysis patients, although the mid-term clinical results are still being evaluated, a saphenous vein grafts have bwer early-stage of cardiac events. In younger patients, off-pump bypass is not the only treatment method available, and revascularization with extracorporeal circulation can reliably achieve good long-term results. To improve the long-term clinical results for coronary artery bypass grafts, graft selection and design should be carefully considered on a case-by-case basis. The quality of the anastomotic site and the patient background are important factors, especially with regard to the selection of a saphenous vein graft or a right gastroepiploic artery graft. A radial artery graft should be selected for use in relatively young patients because of its superior patency. Off-pump bypass may not necessarily be the treatment of choice in some cases because revascularization using extracorporeal circulation can reliably achieve better long-term results.
ABSTRACT
A 67-year-old man, who had suffered from right cerebral infarction that resulted in left hemiparesis, underwent right superficial temporal artery-middle cerebral artery anastomosis in 1991. From March 2000, dizziness occurred during use of his right hand. His arteriogram revealed late filling of the occluded right subclavian artery by reversed flow from the right vertebral artery and 50% stenosis of the left internal carotid artery. We performed subcutaneous axillo-axillary bypass grafting with mild hypothermia on June 1st, 2000. An 8mm ePTFE tube with a ring was anastomosed to both axillary arteries in end-to-side fashion with continuous sutures. Thereafter, symptoms disappeared. One month after the procedure, his arteriogram showed that the bypass filled the right vertebral artery in an antegrade fashion as well as the right axillary artery. Axillo-axillary bypass grafting with mild hypothermia seemed to be safe and effective for high-risk subclavian steal syndrome.