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Significance of Right Internal Thoracic Artery as Proximal Anastomotic Site

First Department of Surgery Osaka University Medical School Osaka, Japan

For reprint information contact: Nobuaki Hirata, MD Tel: 81 797 87 1161 Fax: 81 797 87 5624 Division of Cardiovascular Surgery, Takarazuka Municipal Hospital, 4-5-1 Kohama, Takarazuka, Hyogo 665-0827, Japan.

	Abstract

TOP Abstract Introduction Patients and Methods Results Discussion References

 
The efficacy of the right internal thoracic artery as the proximal anastomosis site in patients with a severely atherosclerotic ascending aorta was evaluated. Coronary artery bypass grafting was performed in 5 patients in whom the right internal thoracic artery was selected as the proximal anastomotic site. The graft flow in the right internal thoracic artery plus saphenous vein or radial artery graft was 52 ± 34 mL•min^–1 (range, 30 to 111 mL•min^–1). The right internal thoracic artery was found to supply adequate graft flow even to the sequential graft, in each patient. The right internal thoracic artery should be kept in mind when it is difficult to determine the best site for a proximal anastomosis in patients with severe atherosclerosis of the ascending aorta.

	Introduction

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Recently, there has been an increase in the number of high-risk patients undergoing coronary artery bypass grafting, such as those with a severely atherosclerotic ascending aorta.^1,2 In such patients, determination of the best site for the proximal anastomosis is important. Usually, the subclavian artery or brachiocephalic artery is used as the proximal anastomotic site.^3,4 However, most patients with a severely atherosclerotic ascending aorta also have atherosclerotic changes in the subclavian or brachiocephalic arteries. Moreover, anastomosis to the subclavian artery is difficult because of its position in relation to a median sternotomy. Herein, the efficacy of the right internal thoracic artery (ITA) as the proximal anastomosis site in patients with a severely atherosclerotic ascending aorta was evaluated.

	Patients and Methods

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Among 130 consecutive patients undergoing coronary artery bypass grafting, 28 had an atherosclerotic ascending aorta. The aortic no-touch technique was used in 6 patients and in 5 of these, the right ITA was used as the proximal anastomosis site. The right ITA could not be used as an in situ graft. There were 4 men and 1 woman with a mean age of 70 ± 3 years (range, 67 to 73 years). Because of the severity of aortic disease (Figure 1), no clamping, cannulating, or proximal hooking of the grafts was per-formed. Coronary artery bypass grafting was undertaken under ventricular fibrillation with cardiopulmonary bypass (CPB) in 1 patient, on the beating heart with CPB in 3 patients, and on the beating heart without CPB in 1. An arterial cannula was inserted into the femoral artery and a venous cannula was inserted into the femoral vein and/or right atrium. The graft sites in each patient are noted in Table 1. Saphenous vein or radial artery was used for the composite graft. The right ITA was fully mobilized for convenience of handling and the anastomosis was performed with temporary placement of small bulldog clamps both above and below the anastomotic sites. The anastomosis was carried out as proximal to the right ITA as possible within the length of the composite graft. The length of the arteriotomy was approximately 5 to 7 mm and it was made as a side-to-end Y-shaped anastomosis using 8/0 polypropylene. The right ITA was occluded just to the distal side of the end-to-side anastomosis to force all of the right ITA blood into the coronary graft.

View larger version (76K): [in this window] [in a new window]   Figure 1. Severely calcified ascending aorta (porcelain aorta).

	Results

TOP Abstract Introduction Patients and Methods Results Discussion References

 
The mean graft flow of the right ITA plus saphenous vein or radial artery graft was 52 ± 34 mL•min^–1 (range, 30 to 111 mL•min^–1). Figure 2 shows a sequential graft with saphenous vein to the obtuse marginal and diagonal branches. The graft flow was 70 mL•min^–1 to the obtuse marginal branch and 41 mL•min^–1 to the diagonal branch. Total flow through the right ITA was 111 mL•min^–1. There were no neurological complications in any of these patients.

View larger version (137K): [in this window] [in a new window]   Figure 2. The Y-graft with a saphenous vein graft to the obtuse marginal branch and the diagonal branch. The proximal anastomosis site was the right internal thoracic artery with a side-to-end anastomosis.

	Discussion

TOP Abstract Introduction Patients and Methods Results Discussion References

It should be noted that there are other in-situ arterial grafts such as the gastroepiploic artery and a free right ITA graft can be anastomosed to the left ITA as a Y-graft. If these methodological considerations cannot be utilized, the right ITA may be selected as a site for the proximal anastomosis in patients with a severely atherosclerotic ascending aorta. In this experience of 5 such patients, the right ITA had sufficient graft flow capacity, even to the sequential graft, to perform the operation successfully in each case. The right ITA should be kept in mind if it is difficult to determine the best site for a proximal anastomosis in patients with a severely atherosclerotic ascending aorta.

	References

TOP Abstract Introduction Patients and Methods Results Discussion References

 

1. Estafanous FG, Loop FD, Higgins TL, Tekyi-Mensah S, Lytle BW, Cosgrove DM III, et al. Increased risk and decreased morbidity of coronary artery bypass grafting between 1986 and 1994. Ann Thorac Surg 1998;65:383–9.[Abstract/Free Full Text]

2. Ivanor J, Weisel RD, David TE, Naylor CD. Fifteen-year trends in risk severity and operative mortality in elderly patients undergoing coronary artery bypass graft surgery. Circulation 1998;97:673–80.[Abstract/Free Full Text]

3. Bar-El Y, Goor DA. Clamping of the atherosclerotic ascending aorta during coronary artery bypass operations. Its cost in strokes. J Thorac Cardiovasc Surg 1992;104:469–74.[Abstract]

4. Weinstein G, Killen DA. Innominate artery-coronary artery bypass graft in a patient with calcific aortitis. J Thorac Cardiovasc Surg 1980;79:312–3.[Abstract]

5. Tatoulis J, Buxton BF, Fuller JA. Results of 1,454 free right internal thoracic artery-to-coronary artery grafts. Ann Thorac Surg 1997;64:1263–9.[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shigeaki Ohtake Yoshiki Sawa Toshiki Takahashi Hikaru Matsuda Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hirata, N. Articles by Matsuda, H. Search for Related Content PubMed Articles by Hirata, N. Articles by Matsuda, H.