- Email: [email protected]
Bypass grafts in Takayasu’s disease
316
CORRESPONDENCE
Ann Thorac Surg 2000;69:311–20
palpation. Dr Del Campo alludes to his experience, noting that “the blunt end [of the needle] does not penetrate the glove or finger.” The advantage of using the long, narrow “tonsil” clamp is that the ligature can be placed far enough into the chest to be seen quite easily. The ligature can then be grasped by a second such clamp placed simultaneously by the surgeon or assistant through the interspace above (or below) the first or through the thoracotomy incision. This maneuver saves steps and time. No matter what technique is used, holes in the interspaces are inevitable. The relatively larger aperture resulting from use of the tonsil clamp has not been observed to have more ill effect than other techniques. G. R. Mason, MD Department of Thoracic and Cardiovascular Surgery Loyola University Medical Center 2160 S First Ave Maywood, IL 60153
Bypass Grafts in Takayasu’s Disease To the Editor:
Fig 1. Suture placement technique with needle in the reverse position. The needle is always inserted away from the neurovascular bundle. This technique does not require any extra steps and is easy to teach. I have used it for more than 15 years without problems. Carlos Del Campo, MD Department of Cardiovascular Surgery St. Jude Medical Center 301 Bastanchury, Suite 195 Fullerton, CA 92835
Reference 1. Mason GR. Lateral thoracotomy closure technique. Ann Thorac Surg 1999;67:1509.
Reply To the Editor: Prior to the introduction of the swedged-on suture, an instrument called a ligature carrier was used in the same fashion as is described by Dr Del Campo. The shape and the length of the handle and the curvature of the carrier portion are very similar to a needle holder carrying the TP-1 needle that Dr Del Campo favors. Although the ligature carrier is not as commonly used as it once was, the St. Jude Hospital may still have such instruments. If Dr Del Campo were to use this technique, he would save hospital costs of $4.28 per ligature (prices from Ethicon: J650G: 12 packs in a box, four strands and needles per pack at $241.63 [list price], J617H Vicryl ties—36 per box, one per pack in 54-inch length at $87.57 [list price]), perhaps the cost of swedging. The disadvantage of the needle technique is that the curvature of the needle or carrier does not always conform to the patient’s anatomy, and this leads one to search for the needle by finger © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
The two cases reported by Lall and associates [1], which included one child with Takayasu’s aortitis, raise the problem of using the internal mammary artery for bypass grafting in this disease. The mainstay of management should indeed be treatment of the ostial stenosis, as peripheral coronary lesions are very rare in Takayasu’s [2]. However, it should be remembered that major branches of the aortic arch are particularly affected in this disease. A study of 321 cases in Japan showed that the disease affected, in order of frequency, the left subclavian and carotid artery, next the right subclavian, followed by the abdominal and thoracic aorta [3]; not for nothing is it known as pulseless disease. Thus, the long-term outlook for any pedicled arterial graft, especially the mammary, is uncertain. This consideration, and the fact that the right coronary angioplasty is technically far easier, led us to carry out right coronary pericardial patch angioplasty, which was then used as a base for a saphenous vein graft to the only graftable part of the left coronary system [4, 5]. In retrospect, a free mammary graft would have been more appropriate. Philip R. Belcher, MD University Department of Cardiac Surgery The Royal Infirmary 10 Alexandra Parade Glasgow G31 2ER, Scotland e-mail: [email protected].
References 1. Lall KS, Dombrowicz E, Pillay TM, Pollock JCS. Coronary ostial patch angioplasty in children. Ann Thorac Surg 1999;67: 1478– 80. 2. Takayasu M. Case of queer changes in central blood vessels of retina. Acta Soc Ophthalmol Jap 1908;12:554– 62. 3. Ueda H, Ito I, Saito Y. Studies on arteritis, with special reference to pulseless disease and its diagnosis. Naika 1965; 15:239–56. 4. Morgan JM, Honey M, Gray HH, Belcher P, Paneth M. Angina pectoris in a case of Takayasu’s disease: revascularization by coronary ostioplasty and bypass grafting. Eur Heart J 1987;8: 1354– 8. 5. Belcher PR, Morgan JM. Aorta-coronary bypass grafting for Takayasu’s aortitis [Letter]. J Thorac Cardiovasc Surg 1992; 103:389. 0003-4975/00/$20.00
CORRESPONDENCE
Ann Thorac Surg 2000;69:311–20
palpation. Dr Del Campo alludes to his experience, noting that “the blunt end [of the needle] does not penetrate the glove or finger.” The advantage of using the long, narrow “tonsil” clamp is that the ligature can be placed far enough into the chest to be seen quite easily. The ligature can then be grasped by a second such clamp placed simultaneously by the surgeon or assistant through the interspace above (or below) the first or through the thoracotomy incision. This maneuver saves steps and time. No matter what technique is used, holes in the interspaces are inevitable. The relatively larger aperture resulting from use of the tonsil clamp has not been observed to have more ill effect than other techniques. G. R. Mason, MD Department of Thoracic and Cardiovascular Surgery Loyola University Medical Center 2160 S First Ave Maywood, IL 60153
Bypass Grafts in Takayasu’s Disease To the Editor:
Fig 1. Suture placement technique with needle in the reverse position. The needle is always inserted away from the neurovascular bundle. This technique does not require any extra steps and is easy to teach. I have used it for more than 15 years without problems. Carlos Del Campo, MD Department of Cardiovascular Surgery St. Jude Medical Center 301 Bastanchury, Suite 195 Fullerton, CA 92835
Reference 1. Mason GR. Lateral thoracotomy closure technique. Ann Thorac Surg 1999;67:1509.
Reply To the Editor: Prior to the introduction of the swedged-on suture, an instrument called a ligature carrier was used in the same fashion as is described by Dr Del Campo. The shape and the length of the handle and the curvature of the carrier portion are very similar to a needle holder carrying the TP-1 needle that Dr Del Campo favors. Although the ligature carrier is not as commonly used as it once was, the St. Jude Hospital may still have such instruments. If Dr Del Campo were to use this technique, he would save hospital costs of $4.28 per ligature (prices from Ethicon: J650G: 12 packs in a box, four strands and needles per pack at $241.63 [list price], J617H Vicryl ties—36 per box, one per pack in 54-inch length at $87.57 [list price]), perhaps the cost of swedging. The disadvantage of the needle technique is that the curvature of the needle or carrier does not always conform to the patient’s anatomy, and this leads one to search for the needle by finger © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
The two cases reported by Lall and associates [1], which included one child with Takayasu’s aortitis, raise the problem of using the internal mammary artery for bypass grafting in this disease. The mainstay of management should indeed be treatment of the ostial stenosis, as peripheral coronary lesions are very rare in Takayasu’s [2]. However, it should be remembered that major branches of the aortic arch are particularly affected in this disease. A study of 321 cases in Japan showed that the disease affected, in order of frequency, the left subclavian and carotid artery, next the right subclavian, followed by the abdominal and thoracic aorta [3]; not for nothing is it known as pulseless disease. Thus, the long-term outlook for any pedicled arterial graft, especially the mammary, is uncertain. This consideration, and the fact that the right coronary angioplasty is technically far easier, led us to carry out right coronary pericardial patch angioplasty, which was then used as a base for a saphenous vein graft to the only graftable part of the left coronary system [4, 5]. In retrospect, a free mammary graft would have been more appropriate. Philip R. Belcher, MD University Department of Cardiac Surgery The Royal Infirmary 10 Alexandra Parade Glasgow G31 2ER, Scotland e-mail: [email protected].
References 1. Lall KS, Dombrowicz E, Pillay TM, Pollock JCS. Coronary ostial patch angioplasty in children. Ann Thorac Surg 1999;67: 1478– 80. 2. Takayasu M. Case of queer changes in central blood vessels of retina. Acta Soc Ophthalmol Jap 1908;12:554– 62. 3. Ueda H, Ito I, Saito Y. Studies on arteritis, with special reference to pulseless disease and its diagnosis. Naika 1965; 15:239–56. 4. Morgan JM, Honey M, Gray HH, Belcher P, Paneth M. Angina pectoris in a case of Takayasu’s disease: revascularization by coronary ostioplasty and bypass grafting. Eur Heart J 1987;8: 1354– 8. 5. Belcher PR, Morgan JM. Aorta-coronary bypass grafting for Takayasu’s aortitis [Letter]. J Thorac Cardiovasc Surg 1992; 103:389. 0003-4975/00/$20.00