title: Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting.
abstract: OBJECTIVE
  Cannulation and clamping of a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) can lead to cerebral embolization of atheromatous debris and should therefore be avoided whenever possible. A variety of surgical techniques including performance of extraanatomical coronary bypass conduits has been described to solve this problem. We report on a preliminary series of four patients in whom the axillary artery was used as an inflow vessel for venous coronary artery bypass grafts which were performed on the beating heart in order to achieve an aortic no touch concept.
  
  
  METHODS
  The axillary artery was exposed between the pectoralis major muscle and the deltoid muscle via an infraclavicular incision. A saphenous vein graft of at least 40 cm in length was sutured to the axillary artery and then brought into the pericardial cavity following an intercostal and transpleural route. The graft was anastomosed to the target vessel using local coronary occlusion. The procedure was carried out via sternotomy in three patients who also received additional internal mammary artery in situ grafts for adequate coronary revascularization. In one high risk patient an isolated axillocoronary bypass was performed in a minimally invasive fashion via anterolateral minithoracotomy.
  
  
  RESULTS
  The procedure was completed without major technical difficulties in all four patients. The mean graft length required was 33.2 +/- 1.6 cm, postoperative ultrasonic duplex scans of the axillocoronary grafts revealed a mean flow of 62.5 +/- 23.6 ml/min. No stroke or brachial plexus injury occurred. Three patients are in angina class I (Canadian Cardiovascular Society Classification), one patient is in class II postoperatively. After a mean follow-up of 11.5 +/- 6.6 months postoperatively all grafts remain patent.
  
  
  CONCLUSIONS
  Axillocoronary bypass grafting can be easily performed for management of the untouchable ascending aorta. Straightforward surgical technique and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass grafts.
authors.affiliation: Innsbruck University Hospital, University Clinic of Surgery/Cardiac Surgery, Austria. johannes.o.bonatti@uibk.ac.at
authors.forename: J
authors.initials: J
authors.lastname: Bonatti
authors.forename: H
authors.initials: H
authors.lastname: Hangler
authors.forename: D
authors.initials: D
authors.lastname: Oturanlar
authors.forename: L
authors.initials: L
authors.lastname: Posch
authors.forename: L C
authors.initials: LC
authors.lastname: Müller
authors.forename: W
authors.initials: W
authors.lastname: Voelckel
authors.forename: B
authors.initials: B
authors.lastname: Schwarz
authors.forename: G
authors.initials: G
authors.lastname: Bodner
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic; D001018:Aortic Diseases / Q000150:complications; D001161:Arteriosclerosis / Q000150:complications; D001366:Axillary Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D001783:Blood Flow Velocity; D003250:Constriction; D001026:Coronary Artery Bypass / Q000379:methods*; D003326:Coronary Circulation; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D018619:Echocardiography, Doppler, Pulsed; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology / Q000517:prevention & control; D008297:Male; D009200:Myocardial Contraction; D016896:Treatment Outcome