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Internal Mammary — Coronary Artery Anastomosis
Internal MammaryCoronary Artery Anastomosis “No-Touch”Technique Chalit Cheanvechai, M.D., Jorge M. Garcia, M.D., and Donald B. Effler, M.D. ABSTRACT A simple technique for internal mammary-coronary artery anastomosis that can be applied to all branches of the coronary circulation is described. The anastomosis can be constructed in 10 to 15 minutes. This technique eliminates pinching of the internal mammary artery by forceps.
T
he internal mammary-coronary artery anastomosis has gained popularity in recent years [l-41. One of the objections to this type of graft is the delicate nature of the internal mammary artery, a small and friable vessel. Minimal trauma during construction of the anastomosis can lead to tearing of the intima, which can result in a technically unsatisfactory anastomosis that may precipitate leaks, prolong the operative time, and predispose the graft to anastomotic constriction or occlusion. We have developed a “no-touch”technique of internal mammary-coronary artery anastomosisto avoid this complication and to facilitate handling the internal mammary artery without damaging the vessel.
Technique Through a median sternotomy incision, the internal mammary artery is dissected from the chest wall by electrocautery. All intercostal branches are ligated by silk or hemoclips; caution must be taken not to injure the phrenic nerve near the origin of the internal mammary artery. After the dissection is completed, the artery is sprayed with 1 % papaverine solution and wrapped with a sponge soaked in papaverine. The artery pedicle is transected at the level of the fifth or sixth intercostal space, and the surrounding tissue at the distal end, about 2.5 cm in length, is removed. The artery is then cut obliquely, and 7-0 silk holding sutures are placed on each side of the artery tip (Fig. 1 B). A ventral slit approximately 3 to 4 mm in length is made. At this point the patient is placed on cardiopulmonary bypass, and an appropriate arteriotomy is made in the anterior descending coronary artery. Bleeding is controlled by aortic cross-clamping. Sutures of 7-0 silk are placed at the midportion of each side of the arteriotomy. Three 7-0 silk sutures are then placed at each tip of the arteriotomy (Fig. 1C). According to the length of the incision, one or two From the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio. Accepted for publication February 19, 1975. Address reprint requests to Dr. Effler, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44106.
VOL. 20, NO. 6, DECEMBER, 1975
709
CHEANVECHAI, GARCIA, AND EFFLER
FIG. 1 . (A) Arteriotoml sate. (B),The internal mammary artery with two holding sutures (arrows). (C) The arteriotomy wit ezght snatml sutures. (0) The steps of the anastomosis. (E) The last three sutures (nos. 10-12).
710
THE ANNALS OF THORACIC SURGERY
HOW T O DO I T :
Internal Mammay-Coronay Anastomosis
FIG. 2. A similar technique is used for anastomosis of the circumflex artery. The pedicle is anchored to the myocardium or e zcardial at (arrow) before perj!;ming t d anastomosis.
sutures will be required between these sutures on the side of the arteriotomy; a total of twelve to fourteen stitches are needed for each anastomosis. T h e anastomosis is then begun at the proximal tip of the arteriotomy, with each suture being tied after it is passed through the internal mammary artery (Fig. 1D). T h e surgeon ties the suture on his side while the assistant gently pulls on the holding sutures for good approximation. After the fifth suture is tied, suturing is begun on the assistant’s side at suture no. 6 with the assistant tying all the sutures on his side as the surgeon gently pulls on the holding sutures. After completion of suture no. 9,nos. 10 and 11 are placed and the holding sutures are removed. Gentle traction is applied on nos. 10 and 11, and suture no. 12 is then placed (Fig. 1E). After completion, the pedicle is anchored to epicardial fat to avoid kinking and tension on the anastomosis. This technique is also used for anastomoses to the right, diagonal, and circumflex coronary arteries. Before performing an anastomosis to the circumflex coronary artery, the pedicle must be anchored to the myocardium using 5-0 o r 6-0 silk sutures to prevent the pedicle from dropping into the pericardial sac (Fig. 2). In the past three years, this technique has been used in 675 patients. T h e operations performed are shown in the Table.
Comment We have employed this technique for all internal mammary-coronary artery anastomoses either as a graft in situ or as a free graft from the ascending aorta. T h e results have been good. T h e technique is helpful particularly for a circumflex graft. T h e two holding sutures completely eliminate handling of the internal mammary artery by forceps, and the anoxia time is between 10 and 15 minutes.
VOL. 20, NO. 6, DECEMBER, 1975
711
CHEANVECHAI, GARCIA, AND EFFLER OPERATIONS PERFORMED IN 675 PATIENTS USING “NO-TOUCH’’TECHNIQUE OF ANASTOMOSIS
Procedure LIMA to LAD LIMA to Cx LIMA to diagonal branch RIMA to LAD RIMA to RCA Free IMA graft to LAD Free IMA graft to diagonal branch Free IMA to Cx Free IMA to RCA
No. of Patients 480 84 36 9 3 53 4 3 3
LIMA = left internal mammary artery; LAD = left anterior descending coronary artery; Cx = circumflex artery; RIMA = right internal mammary artery; RCA = right coronary artery; IMA = internal mammary artery.
This technique is also useful in teaching residents; at our institution the anastomosis is constructed by residents under direct supervision of the staff. We hope this communication will be helpful to others who are interested in this type of operation.
References 1. Green, G. E.
Internal mammary artery-to-coronary artery anastomosis: Three-year experience with 165 patients. Ann Thorac Surg 14:260, 1972. 2. Kay, E. B., Naraghipour, H., Beg, R. A., DeManey, M., Tambe, A., and Zimmerman, H. A. Internal mammary artery bypass graft -long-term patency rate and follow-up. Ann Thorac Surg 18:269, 1974. 3. Loop, F. D., Spampinato, N., Siegel, W., and Effler, D. B. Internal mammary artery grafts without optical assistance: Clinical and angiographic analysis of 175 consecutive cases. Circulation 47 (Suppl 3):162, 1973. 4. Mills, N. L., and Ochsner, J. L. Technique of internal mammary-to-coronary artery bypass. Ann Thorac Surg 17:237, 1974.
712
T H E ANNALS OF THORACIC SURGERY
T
he internal mammary-coronary artery anastomosis has gained popularity in recent years [l-41. One of the objections to this type of graft is the delicate nature of the internal mammary artery, a small and friable vessel. Minimal trauma during construction of the anastomosis can lead to tearing of the intima, which can result in a technically unsatisfactory anastomosis that may precipitate leaks, prolong the operative time, and predispose the graft to anastomotic constriction or occlusion. We have developed a “no-touch”technique of internal mammary-coronary artery anastomosisto avoid this complication and to facilitate handling the internal mammary artery without damaging the vessel.
Technique Through a median sternotomy incision, the internal mammary artery is dissected from the chest wall by electrocautery. All intercostal branches are ligated by silk or hemoclips; caution must be taken not to injure the phrenic nerve near the origin of the internal mammary artery. After the dissection is completed, the artery is sprayed with 1 % papaverine solution and wrapped with a sponge soaked in papaverine. The artery pedicle is transected at the level of the fifth or sixth intercostal space, and the surrounding tissue at the distal end, about 2.5 cm in length, is removed. The artery is then cut obliquely, and 7-0 silk holding sutures are placed on each side of the artery tip (Fig. 1 B). A ventral slit approximately 3 to 4 mm in length is made. At this point the patient is placed on cardiopulmonary bypass, and an appropriate arteriotomy is made in the anterior descending coronary artery. Bleeding is controlled by aortic cross-clamping. Sutures of 7-0 silk are placed at the midportion of each side of the arteriotomy. Three 7-0 silk sutures are then placed at each tip of the arteriotomy (Fig. 1C). According to the length of the incision, one or two From the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio. Accepted for publication February 19, 1975. Address reprint requests to Dr. Effler, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44106.
VOL. 20, NO. 6, DECEMBER, 1975
709
CHEANVECHAI, GARCIA, AND EFFLER
FIG. 1 . (A) Arteriotoml sate. (B),The internal mammary artery with two holding sutures (arrows). (C) The arteriotomy wit ezght snatml sutures. (0) The steps of the anastomosis. (E) The last three sutures (nos. 10-12).
710
THE ANNALS OF THORACIC SURGERY
HOW T O DO I T :
Internal Mammay-Coronay Anastomosis
FIG. 2. A similar technique is used for anastomosis of the circumflex artery. The pedicle is anchored to the myocardium or e zcardial at (arrow) before perj!;ming t d anastomosis.
sutures will be required between these sutures on the side of the arteriotomy; a total of twelve to fourteen stitches are needed for each anastomosis. T h e anastomosis is then begun at the proximal tip of the arteriotomy, with each suture being tied after it is passed through the internal mammary artery (Fig. 1D). T h e surgeon ties the suture on his side while the assistant gently pulls on the holding sutures for good approximation. After the fifth suture is tied, suturing is begun on the assistant’s side at suture no. 6 with the assistant tying all the sutures on his side as the surgeon gently pulls on the holding sutures. After completion of suture no. 9,nos. 10 and 11 are placed and the holding sutures are removed. Gentle traction is applied on nos. 10 and 11, and suture no. 12 is then placed (Fig. 1E). After completion, the pedicle is anchored to epicardial fat to avoid kinking and tension on the anastomosis. This technique is also used for anastomoses to the right, diagonal, and circumflex coronary arteries. Before performing an anastomosis to the circumflex coronary artery, the pedicle must be anchored to the myocardium using 5-0 o r 6-0 silk sutures to prevent the pedicle from dropping into the pericardial sac (Fig. 2). In the past three years, this technique has been used in 675 patients. T h e operations performed are shown in the Table.
Comment We have employed this technique for all internal mammary-coronary artery anastomoses either as a graft in situ or as a free graft from the ascending aorta. T h e results have been good. T h e technique is helpful particularly for a circumflex graft. T h e two holding sutures completely eliminate handling of the internal mammary artery by forceps, and the anoxia time is between 10 and 15 minutes.
VOL. 20, NO. 6, DECEMBER, 1975
711
CHEANVECHAI, GARCIA, AND EFFLER OPERATIONS PERFORMED IN 675 PATIENTS USING “NO-TOUCH’’TECHNIQUE OF ANASTOMOSIS
Procedure LIMA to LAD LIMA to Cx LIMA to diagonal branch RIMA to LAD RIMA to RCA Free IMA graft to LAD Free IMA graft to diagonal branch Free IMA to Cx Free IMA to RCA
No. of Patients 480 84 36 9 3 53 4 3 3
LIMA = left internal mammary artery; LAD = left anterior descending coronary artery; Cx = circumflex artery; RIMA = right internal mammary artery; RCA = right coronary artery; IMA = internal mammary artery.
This technique is also useful in teaching residents; at our institution the anastomosis is constructed by residents under direct supervision of the staff. We hope this communication will be helpful to others who are interested in this type of operation.
References 1. Green, G. E.
Internal mammary artery-to-coronary artery anastomosis: Three-year experience with 165 patients. Ann Thorac Surg 14:260, 1972. 2. Kay, E. B., Naraghipour, H., Beg, R. A., DeManey, M., Tambe, A., and Zimmerman, H. A. Internal mammary artery bypass graft -long-term patency rate and follow-up. Ann Thorac Surg 18:269, 1974. 3. Loop, F. D., Spampinato, N., Siegel, W., and Effler, D. B. Internal mammary artery grafts without optical assistance: Clinical and angiographic analysis of 175 consecutive cases. Circulation 47 (Suppl 3):162, 1973. 4. Mills, N. L., and Ochsner, J. L. Technique of internal mammary-to-coronary artery bypass. Ann Thorac Surg 17:237, 1974.
712
T H E ANNALS OF THORACIC SURGERY