Axillary artery to left anterior descending coronary artery bypass with an externally stented graft: a technical report

The renewed interest in minimally invasive coronary artery bypass graft surgery without the use of cardiopulmonary bypass (MIDCAB) has produced various techniques utilizing alternative inflow sources for myocardial revascularization. These techniques are particularly applicable to high risk patients with a severely calcified thoracic aorta or in patients who require repeat coronary artery revascularization but in which the left internal mammary artery to anterior descending artery graft is occluded while other grafts are still patent. In these patients the potential risk to underlying vital structures during repeat sternotomy or mini sternotomy is higher and a minimally invasive anterior thoracotomy approach is preferable.The use of the axillary artery as a site for the proximal graft anastomosis has been previously described in several single case reports [1,2] and small case series [3-9]. However, utilizing the axillary artery as an inflow vessel is technically challenging as the extrathoracic section of the graft makes it more susceptible to kinking and occlusion. We report a case of axillary artery to left anterior descending (LAD) graft surgery in which the graft was externally stented with a Dacron tube conduit and present the surgical technique utilized.A 64 year old patient was referred to our cardiothoracic surgery service with persistent symptoms of angina (NYHA Class: III). His previous medical history included type II diabetes mellitus managed with oral antiglycemic medication, hypertension and hypercholesterolemia. He had undergone a previous coronary artery bypass graft (CABG) surgery seven years ago with a left internal thoracic artery (LITA) anastomosed to the proximal LAD coronary artery, and two saphenous vein (SV) grafts to the proximal posterior descending artery (PDA) and an obtuse marginal (OM) branch. Despite a number of uneventful years his symptoms gradually returned. Repeat angiographic studies demonstrated a complete occlusion of the LITA,