Asian Cardiovasc Thorac Ann 2005;13:229-232
© 2005 Asia Publishing EXchange Ltd
Concomitant Aortoaxillary Bypass and Coronary Artery Bypass Grafting
Takehiro Inoue, MD,
Toshihiko Saga, MD
Department of Cardiovascular Surgery, Kinki University School of Medicine, Osaka, Japan
For reprint information contact: Takehiro Inoue, MD, Tel: 81 72 366 0221, Fax: 81 72 367 8657, Email: rtc-ryo{at}med.kindai.ac.jp, Department of Cardiovascular Surgery, Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.
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ABSTRACT
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The optimal revascularization strategy for patients with subclavian and coronary artery disease has not been established. This study assessed the mid-term clinical outcome of concomitant aortoaxillary bypass and coronary artery bypass grafting in 5 patients. A ring-reinforced polytetrafluoroethylene graft was attached to the ascending aorta and led to the proximal segment of the axillary artery via the pleural cavity. Patients were followed up for 2–10 years (mean, 5.4 ± 3.4 years). Postoperative aortography and angiography demonstrated patent aortoaxillary and coronary bypass grafts in the short-term follow-up of all patients. Two patients with Takayasu aortitis needed re-operations for recurrent angina and annuloaortic dilatation. Another patient required removal of the aortoaxillary bypass graft because of infection, and subsequently underwent a left femoroaxillary bypass one year after the original procedure. Subclavian steal phenomenon did not occur. Aortoaxillary bypass with coronary artery bypass may be an effective option for patients with co-existing subclavian and coronary artery disease.
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INTRODUCTION
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Co-existing occlusive disease in the coronary and peripheral arteries occurs frequently, and the treatment of choice is concomitant revascularization.1 Subclavian artery occlusive disease has become clinically significant since the internal mammary artery (IMA) has been used for coronary artery bypass grafting (CABG), because collateral inflow from the other subclavian branches is predictable. Coronary-subclavian steal is uncommon but sufficiently important to consider before or after CABG.2–4 Therefore, the optimal management of patients with both subclavian and coronary artery disease has not been established. To investigate the efficacy of coronary artery revascularization with subclavian artery reconstruction, we evaluated the mid-term outcomes of 5 patients who underwent concomitant aortoaxillary bypass and CABG.
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PATIENTS AND METHODS
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From September 1985 to September 2003, 990 patients underwent CABG with the use of cardiopulmonary bypass (CPB) at our institution. Among them, 5 patients (0.5%) with both coronary artery and subclavian artery occlusive disease had concomitant aortoaxillary bypass and CABG; their characteristics are summarized in Table 1
. Both female patients had a history of aortitis, and 4 patients had a history of myocardial infarction. All patients exhibited an upper arm pressure difference of more than 40 mm Hg. Vertebrobasilar insufficiency was observed in 2 patients, but all 5 experienced symptoms of upper extremity ischemia. The upper extremity of the affected subclavian side was extremely stressed with numbness by manual work. All patients underwent cineangiography of the coronary vessels and aortography with runoff views of the carotid, subclavian, and vertebral circulation. The internal mammary artery (IMA) was utilized as a bypass graft in 2 patients, and the saphenous vein was used in 3. In one patient, the ipsilateral free left IMA (LIMA) on the affected side of the subclavian artery was anastomosed to the left anterior descending artery during CABG, while the contralateral right IMA was used as an in situ bypass graft.
After a median sternotomy, a transverse incision was made below the clavicle to expose the proximal axillary artery. CABG was performed under standard CPB with mild hypothermia. After completion of the proximal anastomoses of the vein grafts during a single period of aortic cross clamping, another incision was made on the anterior aortic wall superior to the vein graft attachment. An 8 mm ring-reinforced polytetrafluoroethylene graft was anastomosed to the ascending aorta. After aortic declamping, the prosthetic graft was led to the proximal segment of the axillary artery through the first or second intercostal space via the pleural cavity, and anastomosed to the axillary artery. All patients underwent angiography 1–3 months postoperatively, and clinical symptoms (e.g., angina pectoris, vertebrobasilar insufficiency, and upper extremity ischemia) were recorded at outpatient evaluation.
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RESULTS
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The patients were followed up for 2–10 years (mean, 5.4 ± 3.4 years), and no deaths occurred. Normalization of upper arm pressure and relief of clinical symptoms (vertebrobasilar insufficiency, upper extremity ischemia) were achieved in all cases. Postoperative coronary angiography and aortography demonstrated patency of all grafts in the short-term follow-up period (Table 2). Postoperative aortography showed that the LIMA had good opacification after aortoaxillary bypass (Figure 1). Given this postoperative angiography, the affected IMA was considered to be adequate for CABG.
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Figure 1. Angiogram of a 68-year-old patient at 3 months postoperatively. The left subclavian artery was reconstructed using an aortoaxillary bypass graft. The left internal mammary artery demonstrated good opacification.
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One patient with Takayasu aortitis developed recurrence of angina and required repeat CABG 6 years postoperatively. Details of the repeat CABG are not available because the operation was performed at another facility. Another patient developed infection of the aortoaxillary bypass graft with Pseudomonas aeruginosa 1 year postoperatively, and required removal of the graft with subsequent subclavian reconstruction by extrathoracic left femoroaxillary bypass. Another patient underwent surgical repair by the Bentall technique for annuloaortic ectasia secondary to Takayasu aortitis. Subclavian steal phenomenon did not occur.
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DISCUSSION
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The co-existence of subclavian artery occlusive disease in patients with coronary artery disease requires the surgeon to decide whether to use the IMA as a bypass graft.5 Proximal subclavian artery occlusion may result in reversal of IMA flow and produce myocardial ischemia, so-called "coronary-subclavian steal".2 The use of alternative conduits, such as a free IMA graft, radial artery, or a vein, avoids coronary-subclavian steal, but it is unclear whether these conduits can match the long-term patency of an in situ IMA graft.6 Due to the superiority of the IMA graft in myocardial revascularization, CABG using the affected IMA could potentially give a favorable prognosis for patients with subclavian and coronary artery disease. The affected IMA was not used in this study because the long-term patency of the aortoaxillary bypass graft is not known. Recently, Ochi and colleagues7 reported adequate function of LIMA supplying blood to a coronary artery through an aortoaxillary bypass graft. Given that enlargement of the IMA after aortoaxillary bypass was seen in postoperative angiography, aortoaxillary bypass could offer the potential of using the affected LIMA as an in situ conduit. However, we recommend that surgeons should consider the risk of using the affected IMA for coronary artery revascularization.
Several surgical techniques can be employed for subclavian artery reconstruction.8,9 Extrathoracic approaches, such as carotid-subclavian bypass and subclavian-carotid transposition, offer long-term graft patency and the advantage of avoiding a thoracotomy in fragile elderly patients.9 Patients with subclavian artery occlusive disease frequently have several risk factors associated with atherosclerosis, including hypertension, diabetes, hyperlipidemia, and cigarette smoking. The transthoracic approach is employed in those with atherosclerotic involvement of multiple vessels or with concomitant open heart procedures.8 Although the transthoracic approach was associated with relatively high morbidity and mortality rates, these have dropped significantly in recent reports.10,11 When a symptomatic subclavian occlusive lesion co-exists with severe coronary artery disease, carotid-subclavian bypass or aortoaxillary bypass may be preferable as a concomitant procedure with CABG. Aortoaxillary bypass carries some advantages in the context of open heart procedures. When the carotid artery has atherosclerotic involvement and is not acceptable as a donor artery for subclavian artery revascularization, aortoaxillary bypass is a convenient choice of anastomosis. Furthermore, dissection of the area around the proximal subclavian artery, including the phrenic nerve, the brachial plexus, and cervical sympathetic chain, is not required. The aortoaxillary bypass graft is easily led to the axillary artery without kinking, and the site of distal anastomosis is technically attractive.11
Percutaneous transluminal angioplasty and stenting are sometimes indicated for subclavian artery occlusive disease, and directional atherectomy has recently been described.12–14 Although angioplasty with stenting is favored over a repeat median sternotomy, differences exist in the operative risk and outcome of each procedure.5 While angioplasty with stenting remains inferior to surgical bypass, it is useful for patients in whom surgery is contraindicated. Recent studies on transthoracic subclavian revascularization (aorta to subclavian artery or axillary artery bypass) have reported excellent operative and long-term patency.11,15 These procedures have the advantage of ensuring sufficient inflow from the aorta rather than the brachiocephalic vessels. Although the aortoaxillary bypass graft tends to be longer than the graft used in other procedures, our data indicate that the grafts remained patent over a mean follow-up of 5 years, showing smooth flow in the aortoaxillary bypass on postoperative angiography (Figure 1
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The technique of CABG on the beating heart, without CPB, is now accepted, particularly for patients with renal failure, respiratory problems, advanced age, or cerebrovascular abnormalities.16,17 As those with subclavian artery occlusive disease frequently have atherosclerotic involvement of multiple arch vessels, CABG without CPB may decrease cerebral complications attributed to plaque emboli, low perfusion pressure, or microemboli. In this situation, in situ IMA is the key graft for achieving CABG on the beating heart without CPB. Therefore, when a patient with subclavian artery occlusive disease has to undergo CABG without CPB due to several risk factors, the affected IMA may be considered for use after subclavian artery reconstruction, if feasible. To assess the availability of the affected IMA after subclavian artery reconstruction, a longer follow-up period would be necessary to establish the long-term patency and efficacy of aortoaxillary bypass grafts.
It is recommended that the presence of subclavian artery occlusive disease should be investigated before electing CABG. In such cases, subclavian artery reconstruction with CABG can be safely and effectively performed via aortoaxillary bypass. The possibility that the IMA may serve as a coronary bypass conduit following subclavian revascularization with aortoaxillary bypass should be investigated, and longer follow-up of patients with aortoaxillary bypass grafts may be of further benefit.
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REFERENCES
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ABSTRACT
INTRODUCTION
