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26 Use of the Subscapular-Thoracodorsal Artery for Coronary Artery Bypass Grafting G.-W

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26 Use of the Subscapular-Thoracodorsal Artery for Coronary Artery Bypass Grafting G.-W Chapter 26 26 Use of the Subscapular-Thoracodorsal Artery for Coronary Artery Bypass Grafting G.-W. He, N.L. Mills The subscapular-thoracodorsal artery is not usually used as a primary arterial graft because of the availabil- ityofmorefrequentlyusedarterialgrafts,leftandright internal mammary artery (IMA), radial arteries, the gastroepiploic artery, and inferior epigastric arteries plus saphenous veins, which already meet the needs of primary and most reoperative coronary artery bypass grafts (CABGs). These arteries are also easier or more convenient to be taken during surgery. However, in some reoperative CABG patients, when other conduits are exhausted, the subscapular-thoracodorsal artery canbeused.ThishasbeendemonstratedbyMills[1], who reported the successful use of the subscapular- thoracodorsal artery in five reoperative CABG patients. 26.1 Anatomical Notes The largest branch of the axillary artery is the subscap- ularartery.Itarisesfromthelastthirdofthatarteryto course downward and in a medial direction along the anterior border of the subscapularis muscle. It tracks the edge of the latissimus dorsi. The circumflex scapu- lar artery is the first branch of the subscapular artery Fig. 26.1. Anatomy of the subscapular artery and is usually a sizeable vessel. The subscapular artery becomes the thoracodorsal (dorsal thoracic) artery af- ter the circumflex scapular artery origin (Fig. 26.1). It 128 mm and the proximal-distal diameter ratio is about offers numerous branches supplying thoracic muscles 3.44±1.49 [4, 5]. We therefore describe the subscapular as it courses inferiorly. Its harvest as a free graft does artery and thoracodorsal artery together as a coronary not harm the latissimus dorsi muscle because of gener- bypass conduit. ous collateral from intercostal branches. The vena co- mitantes drain the area and unite with the circumflex scapular vein to enter as a single vessel into the axillary 26.2 vein. The subscapular artery in its upper third ranges Historic Notes from 3.25 to 4.5 mm in internal diameter. The lengths ofthesearteriesasfreegraftsrangefrom12to14cm. Disappointing long-term results with the saphenous The graft should be used only if the distal internal di- veinforcoronaryarterybypassgraftinghaveresulted ameter at the point of the planned anastomosis is 2 mm inanintensivesearchforotherarterialgraftsforcoro- or larger. nary artery bypass conduits. The results of new arterial The thoracodorsal artery is, in fact, the continuation grafts, as well as old resurrected (i.e., radial artery) of the subscapular artery (75%), but it could also be a grafts, must be compared to the internal mammary ar- direct branch from the axillary artery in 25% of pa- tery, which is the gold standard of all arterial CABGs. tients [2, 3]. The mean length is reported to be about Saphenousveingraftstobypassacircumflexcoronary 26 Use of the Subscapular-Thoracodorsal Artery for Coronary Artery Bypass Grafting 219 artery system by way of a left thoracotomy have been 26.3 used since the 1980s [6]. Although the indications for Harvest of the Subscapular Artery use of the left thoracotomy for a coronary artery bypass are only in the range of 2%, such an approach can be As described before, there are two ways to harvest the very advantageous in reoperative coronary artery sur- subscapular-thoracodorsal artery. gery [7]. That technique has certain advantages. It al- lows the surgeon to avoid time consuming and poten- 26.3.1 tially dangerous dissection of adhesions that coexist Through Left Thoracotomy with reoperative median sternotomy. Such dangers in- clude embolization of old vein grafts and damage to If the CABG is going to be performed through the left critically functioning saphenous vein grafts. Even more thoracotomy, as described by Mills, a standard left lat- importantly, injury to an internal mammary artery eral thoracotomy is carried out. Prior to entering the graft imbedded in scar tissue may be prevented. Medi- left thoracic cavity, the latissimus dorsi muscle is iden- an sternotomy operations may be avoided when the pa- tified. Initially, a vertical incision up into the axilla in tient has had previous mediastinitis. Through this ap- line with the leading border of the latissimus dorsi proach concomitant pulmonary lesions in the left he- muscle was made. However, with experience it was mithorax may be easily addressed. found that the graft could be harvested without a verti- Plastic surgeons have used transplanted latissimus cal incision extension using appropriate retraction of dorsi muscle grafts for reconstructive operations for the muscles in that area. Arterial branches and the vena many years. Both the subscapular artery and vein are comitantes supplying the latissimus dorsi muscle are anastomosed in these operations to provide a viable identified and traced retrograde to identify the thora- implant. The latissimus dorsi muscle based on the tho- codorsal artery as it lies under the cover of the latissi- racodorsal neurovascular bundle has been used for dy- mus dorsi muscle. The narrow Deaver retractors work namic cardiomyoplasty since 1985. These experiences well to obtain exposure for harvest of this graft. The indicated that the subscapular artery was an appropri- branches of the thoracodorsal artery are ligated along atesizeandlengthforuseinCABG.Thusitbegantobe with the venous branches with 4-0 silk and divided. used clinically as a free graft for coronary artery bypass The dissection is carried out superiorly and the cir- surgeries when a left thoracotomy was indicated for cumflex scapular artery is identified. That artery is li- other reasons in patients requiring reoperation [8]. gated and the subscapular artery is traced to its origin More recently, another strategy has been used to from the axillary artery and doubly ligated near that take the subscapular-thoracodorsal artery. Simic and point. After ligating and dividing the subscapular ar- associates [9] described an approach for preparation tery proximally and distally, it is dilated gently with an and use of thoracodorsal artery as a free graft for coro- intraluminal solution of body temperature papaverine nary artery bypass grafting. The preparation and re- hydrochloride in normal saline (60 mg in 40 ml of nor- moval of thoracodorsal artery were performed through mal saline). A 1-mm olive tip needle tied into the distal the right axilla when the patient was placed in the later- vessel is used to introduce the solution into the sub- al decubitus position. The thoracodorsal artery, as a scapular artery. At that time, it is important to check for free graft, had 14 cm of length with an internal diame- and ligate any missed branches that might bleed after terofabout2.5mm,andthearterywallhadabetter reinstituting blood flow through the graft. A fenestrat- consistency than the mammary artery. The right axilla ed suction drain apparatus (Hemovac) is placed along incision was closed and the patient was positioned in the bed of the harvested graft to prevent a hematoma the supine position for harvesting of the radial artery and is brought out through a separate stab wound. It is and then CBG was performed through median sterno- removed on the first postoperative day unless there is tomy. significant persistent drainage. The muscles are rou- Amorerecentreport[10]describestheuseofsub- tinely closed anatomically and the subscapularis mus- scapular-thoracodorsal artery in the primary minimal- cle is not divided. ly invasive direct coronary artery bypass (MIDCAB) for multiple vessel disease. Watanabe and associates 26.3.2 used a small left thoracotomy to harvest the subscapu- Through Small Left Thoracotomy lar-thoracodorsal artery and the left IMA as well as to perform CABG. They anastomosed the left IMA to LAD If MIDCAB is used, as Watanabe and associates [10] de- and used a free radial artery to create a subscapular- scribed, the patient is placed in the right lateral posi- thoracodorsal artery-radial artery composite graft and tion. An incision of approximately 3 cm is made over anastomosed this composite graft to the obtuse mar- thefourthintercostalspacealongtheanteriormargin ginal branch. of the left latissimus dorsi muscle. The subscapular- thoracodorsal artery courses between the latissimus 220 X Rarely or Possibly Used Arterial Grafting dorsimuscleandtheserratusanteriormuscleandis pass with mild hypothermia is used, the heart is fibril- easily visualized when the latissimus dorsi muscle is re- lated and the anastomosis performed using decreased tracted laterally. The right radial artery (RA) is also bypass flow if necessary. The technique is inexpensive, harvested. The left subscapular-thoracodorsal artery is affords excellent venous drainage, and has been used by divided distally after heparinization and anastomosed one of the authors (Mills) successfully over 200 times. to the free RA. The subscapular-thoracodorsal artery- Thelengthofthechesttubeisappropriate,asthetipof RA composite graft is introduced through the fourth thetubeisinvariablyjustabovetheoriginoftheinferi- intercostal space via the major fissure of the left lung. orvenacava.Asterileguidewireisroutinelyusedto Stay sutures are applied to the pericardium and pulled pass this catheter above the pelvic brim after its intro- upward, thus providing adequate exposure of the coro- duction into the femoral vein. Pulmonary artery moni- nary arteries. toring is used to insure that left heart decompression is not necessary. The exposure is adequate for the opera- tion to be performed with a warm beating
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