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.

Measurement of aortic root size by biplane angiography before cardiac valve replacement.

Aortic valve replacement (AVR) in the patient with a small aortic root demands special consideration because the hemodynamic function of artificial valves with a small external diameter is often poor. In this study, the internal diameter of the aortic root was measured from biplane ventriculography. This measured root diameter was then used to predict the external diameter of the artificial valve. Twelve patients underwent biplane ventriculography followed by AVR with Carpentier-Edwards bioprostheses. The artificial valve diameter was predicted with a correlation coefficient of 0.93, a standard error of estimate of 0.89 mm, and an average absolute difference between preoperative measurement and valve diameter of 0.69 mm. Therefore, the aortic root diameter can be accurately measured from the ventriculogram, thus detecting the patient with a small aortic root before surgery.

Large mediastinal hematomas not associated with aortic rupture. Case presentations and surgical approach.

Mediastinal hematomas not associated with aortic disruption are thought to be common entities, and it is generally believed that most will spontaneously resolve. However, large mediastinal hematomas can cause fluctuations in cardiorespiratory physiology and can even cause death. Three cases of mediastinal hematomas are presented, as well as their surgical approach. Mediastinal hematomas should be evacuated because of their potential morbidity and mortality.