The Subclavian and Axillary Arteries as Inflow Vessels for Coronary Artery Bypass Grafts – Combined Experience from Three Cardiac Surgery Centers

(#2000-74718 ... July 12, 2000)

Johannes Bonatti, MD,¹ Alan. S. Coulson, MD, ² Shahroukh A. Bakhshay, MD, ² Lydia Posch, MD,¹ Timothy J. Sloan, MD ³

¹Innsbruck University Hospital, Department of Cardiac Surgery, Innsbruck, Austria
²Dameron Hospital Heart Center, Stockton, California
³St. Joseph's Hospital, Stockton, California

ABSTRACT

Background: The subclavian and axillary arteries represent reliable inflow vessels in peripheral vascular surgery. During recent years they have also been used for special situations in coronary artery bypass grafting. We report on a preliminary, triple center experience with subclavian/axillary artery to coronary artery bypass grafting.

Methods: Twenty-one patients (11 male, 10 female, median age 70 years) received subclavian artery/axillary artery to coronary artery bypass grafts. Indications for application of this bypass variation were internal mammary artery problems during minimally invasive coronary artery bypass grafting (n = 10), untouchable ascending aorta (n = 6), high risk reoperations (n = 3), severe chronic obstructive pulmonary disease (COPD) (n = 1) and right ventricular ischemia after ascending aortic replacement for acute aortic dissection type A (n = 1).

Fourteen procedures were carried out via minithoracotomy, and seven via sternotomy. Inflow vessels were the left subclavian/axillary artery in 12 cases, the right subclavian/axillary artery in eight cases and bilateral subclavian/axillary artery in one case. Bypass conduits were the saphenous vein (n = 20 for revascularization of the left anterior descending artery, the right coronary artery and obtuse marginal branches) and the radial artery (n = 2 for revascularization of diagonal branches).

Results: The procedure was without major technical problems in all patients. Hospital mortality was 1/21. Neither brachial plexus injury nor arm ischemia occurred. Mean pre- and postoperative angina classification was 3.0 ± 0.8 and 1.2 ± 0.4 respectively (p < 0.001). After a mean follow-up period of seven months, one out of 14 axillocoronary vein grafts studied by ultrasonic duplex scan or angiography was found occluded. Graft patency could be demonstrated for an observation period of up to two years.

Conclusion: Subclavian/axillary artery to coronary artery bypass is feasible and can be applied for complications in minimally invasive coronary artery bypass grafting, for redo operations and for management of the severely atherosclerotic ascending aorta. To reach the left anterior descending artery-system, the saphenous vein as well as the radial artery can be used. Complications concerning the infraclavicular incision seem to be no problem. Short-term patency rates are acceptable.

AUTHOR/ARTICLE INFORMATION

Presented at the 18th International Cardiovascular Surgical Symposium, Zürs, Austria.

Submitted July 11, 2000; accepted July 12, 2000.

Address correspondence and reprint requests to: Johannes Bonatti, MD, Innsbruck University Hospital, Division of Cardiac Surgery, Anichstrasse 35, Innsbruck, Austria, Phone: ++43 512 504 3806, Fax: ++43 512 504 5953, Email: johannes.o.bonatti@uibk.ac.at

Keywords: Axillary artery, subclavian artery, coronary artery bypass, minimally invasive, extraanatomic, MIDCAB, SAXCAB, redo-operation, untouchable ascending aorta, revascularization, high risk, patency rate