The subclavian and axillary arteries as inflow vessels for coronary artery bypass grafts--combined experience from three cardiac surgery centers.

BACKGROUND: The subclavian and axillary arteries represent reliable inflow vessels in peripheral vascular surgery. During recent years they have also been used for special situations in coronary artery bypass grafting. We report on a preliminary, triple center experience with subclavian/axillary artery to coronary artery bypass grafting. METHODS: Twenty-one patients (11 male, 10 female, median age 70 years) received subclavian artery/axillary artery to coronary artery bypass grafts. Indications for application of this bypass variation were internal mammary artery problems during minimally invasive coronary artery bypass grafting (n = 10), untouchable ascending aorta (n = 6), high risk reoperations (n = 3), severe chronic obstructive pulmonary disease (COPD) (n = 1) and right ventricular ischemia after ascending aortic replacement for acute aortic dissection type A (n = 1). Fourteen procedures were carried out via minithoracotomy, and seven via sternotomy. Inflow vessels were the left subclavian/axillary artery in 12 cases, the right subclavian/axillary artery in eight cases and bilateral subclavian/axillary artery in one case. Bypass conduits were the saphenous vein (n = 20 for revascularization of the left anterior descending artery, the right coronary artery and obtuse marginal branches) and the radial artery (n = 2 for revascularization of diagonal branches). RESULTS: The procedure was without major technical problems in all patients. Hospital mortality was 1/21. Neither brachial plexus injury nor arm ischemia occurred. Mean pre- and postoperative angina classification was 3.0 +/- 0.8 and 1.2 +/- 0.4 respectively (p < 0.001). After a mean follow-up period of seven months, one out of 14 axillocoronary vein grafts studied by ultrasonic duplex scan or angiography was found occluded. Graft patency could be demonstrated for an observation period of up to two years. CONCLUSION: Subclavian/axillary artery to coronary artery bypass is feasible and can be applied for complications in minimally invasive coronary artery bypass grafting, for redo operations and for management of the severely atherosclerotic ascending aorta. To reach the left anterior descending artery-system, the saphenous vein as well as the radial artery can be used. Complications concerning the infraclavicular incision seem to be no problem. Short-term patency rates are acceptable.

Minimally invasive reoperation through a lateral thoracotomy for circumflex coronary artery bypass.

We report 4 cases of redo coronary artery bypass grafting in which the circumflex coronary artery was successfully revascularized using a minimally invasive approach. In reoperative cases, it is easier to approach the circumflex coronary artery from the left side than from the front. Minimally invasive direct coronary artery bypass technology has made it possible to avoid using cardiopulmonary bypass. In our 4 cases, the revascularization procedure was performed via a small left thoracotomy, and without cardiopulmonary bypass. The patients made a good recovery and are free of angina 22 months after operation. We conclude that the thoracotomy approach provides the opportunity to avoid several hazards: a redo sternotomy, dissection of a hostile mediastinum, and manipulation of the heart.

The "T-MIDCAB" procedure. Use of extension grafts from the undisturbed internal mammary artery in high-risk patients.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCAB) is an attractive new alternative for revascularizing patients with high perioperative risk for standard coronary surgery. However, limited surgical exposure through a small thoracotomy makes harvesting the full length of the internal mammary artery (IMA) very difficult and time consuming. We are now employing a new alternative with a "T" shaped bridge graft constructed from the undisturbed IMA using a 4 centimeter interposition segment of donor vessel. We prefer this approach in high risk cases in order to reduce the trauma of the thoracotomy, minimize pain and narcotic use, promote early extubation, and achieve immediate post-operative mobilization and recovery in patients who would otherwise be at risk for a poor outcome with conventional grafting techniques. METHODS: From September 10, 1997 to December 19, 1997 eight high-risk patients underwent at least one "T-MIDCAB" graft from the undisturbed IMA to the coronary artery using a short segment of either radial artery or saphenous vein. All cases were performed using a limited access anterior thoracotomy through the bed of the resected costal cartilage and without intercostal retraction. Five males and three females ranging from 58 to 83 years (average 73 years) were operated using this new concept. Pre-operative ejection fractions ranged from 25% to 80% (mean 43%). Parsonnet scores ranged from 21 to 43 (average 34) with predicted mortalities ranging from 30 to 40%. RESULTS: Eleven "T" grafts were placed (1.38 distals/patient). All 8 patients survived. Postoperative complications were minimal. The average length of stay was only 8 days (range 3 to 9 days). Intensive care unit stay averaged 3 days (range 1 to 4 days). One patient underwent postoperative angiography which demonstrated full patency of the conduit and all anastomoses. CONCLUSIONS: "T-MIDCAB" using a bridge graft of free radial artery or saphenous vein appears to be successful in high risk patients. The authors noted shorter operative times, reduced chest wall trauma and better pain control than with standard MIDCAB and full IMA harvesting. Cautious use of this procedure as an alternative to more morbid types of surgical revascularization is advised.