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To the Editor:
We read with great interest the paper by Rathore and colleagues,1 who have underscored a problem that indeed occurs from time to time. Emphysematous lung that occupies the entire dome of the left pleural cavity and expands well over the midline can occasionally present a substantial challenge in the surgeon's positioning of the left internal thoracic artery (ITA) conduit. The particular problem is the traction of the most proximal part of the left ITA (LITA) graft, due to pressure on the graft from the apical segment of the emphysematous lung. It cannot be avoided, even with the use of classic pericardial incision-slit or flap techniques,2 or a crisscross incision on the fascia over the LITA. Skeletonization of the ITA has recently been advocated as a method by which to increase available graft length. However, skeletonized ITA loses its “milieu,” which theoretically may reduce its long-term resistance to atherosclerosis (due to accumulation of metabolic waste deposits over a period of years)—and subsequently attenuate the superior longevity of the conduit.3
The technique that Rathore and associates presented (in which the LITA graft was placed in the “fissure” of the upper left lobe for protection) was reported earlier by Rao and colleagues,4 and good results in 35 patients were confirmed later by Bernet and co-authors.5 Although it is a very tidy technique, disadvantages include the cost of a single-use device (U.S. $250)5 and possible pitfalls during the creation of a slit in the apical segment.
We have hesitated to further traumatize emphysematous lung by performing a surgical incision in the apical segment. Since 2000, we have used a new, simple, combined technique (pericardial incision plus pericardial strip)2 in more than 30 patients. With this technique, we suture a strip of autologous pericardium (5–8 cm in length and 2–3 cm in width) to the upper edge of the previously formed deep slit in the pericardium. The upper part of the pericardial strip is then sutured to the periosteum of the rib, just lateral to the origin of the LITA, thus forming the barrier toward the lung. This prevents herniation of the lung, avoiding the pressure on the LITA. The emphysematous lung is still allowed to expand fully, but only around the LITA conduit, and without exerting any pressure on it. Our technique enables adequate protection of the LITA graft, yet allows the lung to expand freely, which avoids unwanted traction and ventilation problems in the upper portion of the left lung. We believe that this modification of the surgical technique is as effective as—but less traumatic than—the slitting of the left upper lobe that has been promoted by Rao and Bernet, and now by Rathore and colleagues.