- Case report
- Open Access
- Open Peer Review
Axillary artery to left anterior descending coronary artery bypass with an externally stented graft: a technical report
© Athanasiou et al; licensee BioMed Central Ltd. 2008
- Received: 17 December 2007
- Accepted: 12 February 2008
- Published: 12 February 2008
With the proliferation of minimally invasive cardiac surgery a number of alternative inflow sites for coronary artery bypass grafting have been utilized, especially in higher risk patients. The use of axillary-coronary artery bypass is a safe and effective alternative especially in the case of patients requiring redo coronary revascularization. However, the length and convoluted course of the axillary-coronary vein graft makes is susceptible to twisting, trauma and neointimal hyperplasia. We therefore report a case of an axillary-coronary artery bypass in a high risk patient in which a Dacron conduit was used to externally support and protect the vein graft to the left anterior descending artery. Surgical technique and considerations are presented and discussed.
- Leave Anterior Descend
- Vein Graft
- Saphenous Vein Graft
- Axillary Artery
- Neointimal Hyperplasia
The renewed interest in minimally invasive coronary artery bypass graft surgery without the use of cardiopulmonary bypass (MIDCAB) has produced various techniques utilizing alternative inflow sources for myocardial revascularization. These techniques are particularly applicable to high risk patients with a severely calcified thoracic aorta or in patients who require repeat coronary artery revascularization but in which the left internal mammary artery to anterior descending artery graft is occluded while other grafts are still patent. In these patients the potential risk to underlying vital structures during repeat sternotomy or mini sternotomy is higher and a minimally invasive anterior thoracotomy approach is preferable.
The use of the axillary artery as a site for the proximal graft anastomosis has been previously described in several single case reports [1, 2] and small case series [3–9]. However, utilizing the axillary artery as an inflow vessel is technically challenging as the extrathoracic section of the graft makes it more susceptible to kinking and occlusion. We report a case of axillary artery to left anterior descending (LAD) graft surgery in which the graft was externally stented with a Dacron tube conduit and present the surgical technique utilized.
A 64 year old patient was referred to our cardiothoracic surgery service with persistent symptoms of angina (NYHA Class: III). His previous medical history included type II diabetes mellitus managed with oral antiglycemic medication, hypertension and hypercholesterolemia. He had undergone a previous coronary artery bypass graft (CABG) surgery seven years ago with a left internal thoracic artery (LITA) anastomosed to the proximal LAD coronary artery, and two saphenous vein (SV) grafts to the proximal posterior descending artery (PDA) and an obtuse marginal (OM) branch. Despite a number of uneventful years his symptoms gradually returned. Repeat angiographic studies demonstrated a complete occlusion of the LITA, the SV to the OM graft was patent while the SV graft to the PDA graft had a 50% stenosis. Myocardial perfusion imaging demonstrated reduced perfusion and ischaemic myocardium primarily in the LAD perfusion area. Therefore given the risks of re-sternotomy a limited revascularization of the LAD territory through a minimally invasive surgical approach was decided upon.
Patient follow up
The patient's postoperative course was uneventful and was discharged home after five days. At six week and three month follow up the patient was well and had returned to normal activity. The patient refused follow up angiography at three months, but it is planed to be performed after a year. Dobutamine stress echo demonstrated good function at the LAD territory.
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