Axillary-bifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.

OBJECTIVE: It has been suggested that more bypass outflow targets for bypass grafts improve patency and outcomes. Our objective was to examine this in a multicenter contemporary series of axillary to femoral artery grafts. METHODS: The Vascular Quality Initiative database was queried for all axillary-unifemoral (AxUF) and axillary-bifemoral (AxBF) bypass grafts performed between 2010 and 2017 for claudication, rest pain, and tissue loss. Patients with acute limb ischemia were excluded. Patients' demographics and comorbidities as well as operative details and outcomes were recorded. Univariable, multivariable, and Kaplan-Meier analyses were used to assess long-term outcomes. RESULTS: There were 412 (32.9%) AxUF grafts and 839 (67.1%) AxBF grafts identified. Overall, the mean age of the patients was 68.3 years, 51.1% were male, and 84.7% were white. Compared with AxBF grafts, AxUF grafts were more often performed for urgent cases; in patients who were younger, male, nonambulatory, and diabetic; and in those with preoperative anticoagulation, critical limb ischemia, prior bypass, aneurysm repair, peripheral vascular intervention, and major amputation (P < .05 for all). There were no significant differences between AxUF and AxBF grafts in perioperative wound complications (4.2% vs 2.9%; P = .23), cardiac complications (7.3% vs 10.4%; P = .08), pulmonary complications (4.1% vs 6%, P = .18), early stenosis/occlusion (0.2% vs 0.8%; P = .22), perioperative mortality (2.9% vs 3.2%; P = .77), and length of stay (6.4 ± 5.6 days vs 6.7 ± 8 days; P = .29). The mean estimated blood loss (268.1 mL vs 348.6 mL; P < .001) and mean operative time (201 minutes vs 224.1 minutes; P < .001) were significantly lower for AxUF grafts. Kaplan-Meier analysis showed that AxUF and AxBF grafts had similar freedom from graft occlusion (62.6% vs 71.8%; P = .074), major adverse limb event-free survival (57.1% vs 66.6%; P = .052), and survival (86% vs 86%; P = .897) at 1 year. Major amputation-free survival was lower for AxUF grafts (63.7% vs 73%; P = .028). Multivariable analysis also showed that the type of graft configuration did not independently predict occlusion/death (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.77-1.46; P = .72), amputation/death (HR, 1.12; 95% CI, 0.83-1.51; P = .45), major adverse limb event/death (HR, 0.97; 95% CI, 0.73-1.3; P = .85), or mortality (HR, 0.91; 95% CI, 0.65-1.26; P = .55). Three-year survival after placement of AxUF and AxBF grafts was similar (75.1% vs 78.2%; P = .414). CONCLUSIONS: AxUF and AxBF grafts have similar perioperative and 1-year outcomes. Graft patency was not significantly different between an AxBF graft and an AxUF graft at 1 year. Overall, patients treated with these reconstructions have many comorbidities and low long-term survival.

Shoulder-related donor site morbidity after delayed breast reconstruction with pedicled flaps from the back: An open label randomized controlled clinical trial.

BACKGROUND: This randomized controlled trial (RCT) investigates differences in shoulder-related morbidity after delayed breast reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforater (TAP) flap. MATERIAL AND METHODS: In accordance with the CONSORT guidelines, we included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either of the two flaps. Shoulder-function was assessed at baseline and at 3, 6 and 12 months after surgery. The primary endpoint was patient-reported shoulder-related pain. A further objective assessment by the Constant Shoulder Score (CSS) was included as secondary endpoints. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction, with 25 patients in each group. Patient-reported shoulder-related pain was significantly lower in the TAP group at 12 months after surgery when adjusting for pain at baseline: OR = 0.05 95%CI(0.005-0.51), p-value = 0.011. The estimated effect on the total CSS at 12 months, when applying the TAP flap instead of the LD flap and adjusting for the baseline score, was 6.2 points with 95%CI(0.5-12.0), p-value 0.033. The TAP flap seems to have a statistically significant positive effect on pain and activity in daily life (ADL), while there were no significant effect on range of motion and strength after one year. CONCLUSION: Patient reconstructed by the TAP flap are less likely to experience shoulder-related pain and have a better shoulder-function one year after the reconstruction. Harvest of the LD flap carries a higher risk of shoulder-function impairment, chronic pain and reduced ADL.

Direct puncture of the prosthetic bypass graft in the treatment of critical limb ischemia patient undergoing prior axillo-femoral bypass.

A 76-year-old man presented with a non-healing ischemic ulceration of the left foot. He had undergone left axillo-femoral bypass surgery 4 years previously. Diagnostic angiography showed total occlusion from the left common iliac to the common femoral artery and the anterior and posterior tibial artery as well as severe stenosis of the superficial femoral and peroneal artery. Because there were no other access sites except for the axillo-femoral bypass graft, we performed endovascular therapy (EVT) by direct puncture of this bypass graft. Here, we have described the utility of direct puncture of axillo-femoral prosthetic bypass graft for EVT of the infrainguinal arteries.

Totally endoscopic quadruple coronary artery bypass grafting is feasible using robotic technology.

Multivessel robotic totally endoscopic coronary artery bypass grafting is currently under development. Quadruple totally endoscopic coronary artery bypass has so far not been reported. A 75-year-old patient with multivessel coronary artery disease underwent daVinci Si-assisted completely endoscopic placement of a left internal mammary artery bypass to the left anterior descending artery and construction of a right internal mammary artery Y-graft off the left internal mammary artery to the posterior descending artery. The left internal mammary artery was also connected to a diagonal branch as a sequential graft. The obtuse marginal branch was revascularized using an endoscopically harvested vein graft originating from the left axillary artery.

Acceso axilar en el implante percutáneo de la válvula aórtica: optimización del tratamiento endovascular de la estenosis aórtica severa / Axillary approach for transcatheter aortic valve implantation: optimization of the endovascular treatment for the aortic valve stenosis

Introducción y objetivos. Validar el acceso axilar como una opción eficaz y segura para el implante percutáneo de válvula aórtica percutánea CoreValve®, en pacientes con contraindicación para el acceso femoral, en tres hospitales españoles. Métodos. Incluimos a pacientes con estenosis aórtica severa sintomática y alto riesgo quirúrgico o contraindicación para cirugía, seleccionados por un equipo multidisciplinario para implante percutáneo de válvula aórtica; además, los pacientes tenían contraindicación para el abordaje arterial femoral. Resultados. Incluimos a 19 de los 186 pacientes (10,2%) a los que se implantó una válvula percutánea entre noviembre de 2008 y marzo de 2010. La media de edad era 78,3±8,65 años y el 73,7% eran varones. El EuroSCORE logístico medio de la muestra fue del 28,7%±16,3%. La tasa de éxito de implante fue del 100%. Tras el implante, el gradiente transvalvular máximo pasó de 81,7±21,5 a 15,8±5,5 mmHg, y ningún paciente presentó insuficiencia aórtica residual > 2. La mortalidad total, con un seguimiento medio de 9,2±3,2 meses, fue del 10,5%, con nula mortalidad intraoperatoria y a los 30 días. La incidencia total de complicaciones mayores atribuibles al procedimiento fue del 15,7%. Se implantó marcapasos definitivo por bloqueo auriculoventricular en 8 pacientes (44,4%). Conclusiones. El uso del acceso axilar en pacientes seleccionados para implante percutáneo de válvula aórtica CoreValve® con contraindicación para el acceso femoral es seguro y eficaz y proporciona excelentes resultados en términos de éxito del implante y mortalidad, tanto intrahospitalaria como a los 30 días (AU)

Introduction and objectives: To validate the axillary approach as a safe and efficient option for the transcatheter aortic valve implantation in patients who have contraindication for femoral approach at three Spanish hospitals. Methods: We included patients with severe symptomatic aortic stenosis at very high or prohibitive surgical risk, selected by a multidisciplinary team, for transcatheter aortic valve implantation, and had contraindication to the femoral approach. Results: We included 19 of 186 (10.5%) patients, who were implanted a percutaneous aortic valve, between November 2008 and March 2010. Themean age was 78.3 (standard deviation [SD] +/- 8.65) years and 73.7% were males. The mean logistic EuroSCORE was 28.7% (SD +/- 16.3%). The procedural success rate was 100%. After the procedure the maximum transvalve gradient decreased from 81.7 mmHg (SD +/- 21.5) to 15.8 mmHg (SD +/- 5.5), and no patient presented residual aortic regurgitation >2. The all-cause mortality, with a mean follow-up time of 9.2 (SD +/- 3.2) months was 10.5%, and the in-hospital and 30-day mortality rates were 0%. The global incidence of major complications due to the procedure was 15.7%. Definitive pacemaker implantation was carried out for atrioventricular block in 8 patients (44.4%). Conclusions: The axillary approach for transcatheter aortic valve implantation using the CoreValveW and contraindication to the femoral approach is safe and efficient for selected patients, with excellent results in terms of success implantation and in hospital and 30-day mortality (AU)

Perfusion pressure does not affect neurologic outcome in axillary artery side graft cannulation in type a aortic dissection.

OBJECTIVE: Antegrade selective cerebral perfusion (ASCP) through the right axillary is a safe and effective method for cerebral protection in aortic surgery. In the present study, we evaluated whether or not pressure control in ASCP affected the neurologic outcome. METHOD: Sixty-two patients (17 female, 45 male) with a mean age of 53.9 +/- 9.4 years (range, 23-74 years) with a diagnosis of Type A aortic dissection were operated on by using the right axillary artery side graft cannulation technique. ASCP with pressure control was used in the first 37 (59.6%) patients (group 1), whereas ASCP with flow control was used in the consecutive 25 patients (39.4%) (group 2). The groups were compared according to postoperative neurologic outcomes. RESULTS: The hospital mortality rate was 9.7% with 6 patients. The mean ASCP flows of group 1 was 663 +/- 76 mL/min and 692 +/- 51 mL/min in group 2. This difference was not statistically significant (P = .120). The neurological dysfunction rates were 2.7% in group 1 with 1 patient and 8% in group 2 with 2 patients (P = .560). CONCLUSION: In this study, we could not find a statistically significant difference in patients treated with ASCP through the right axillary applicated with pressure control versus flow control.

Complete regression of an intramural hematoma of the aorta after distal reperfusion.

A 58-year-old man with hypertension, severe abdominal pain, and pulseless extremities was diagnosed with an isolated abdominal intramural hematoma (IMH). The IMH extended from the distal descending thoracic aorta to just proximal to the renal arteries. beta-Blockade treatment resolved the abdominal pain but induced progressive oliguria; decreasing beta-blockade treatment increased urine output but caused return of abdominal pain. An axillobifemoral bypass allowed distal perfusion and retrograde visceral artery perfusion while maintaining normal blood pressure. The abdominal pain resolved, urine output increased, and the patient was discharged on day 7. Six months later the patient required an emergent thrombectomy of the axillobifemoral graft and normal antegrade aortic flow was found. A computed tomography scan showed resolution of the IMH.

Anatomical bases of the bypass-flap: study of the thoracodorsal axis.

Cutaneous tissue loss in patients with lesions on the arterial axes remains difficult to treat. Currently, combined surgery associating distal bypass and free flap seems to be the technique that yields the best results. The hemodynamic advantages of this technique, recently demonstrated, are the distal resistance and the increase in bypass flow. Nevertheless, it is complex and its indications limited. Two major drawbacks can be noted: The increasing risk of thrombosis due to the multiplication of anastomoses on the same arterial axis and the deterioration in venous autograft. To overcome these inconveniences we propose a new technique that we call bypass-flap (BF): the graft of an anatomical entity comprised of one artery and one flap. This graft secures the cover of tissue loss and the revascularization of the limb. Apart from its combined nature this technique presents three major advantages. The arterial autograft is superior to the venous graft, the gradually decreasing diameter of the artery secures the congruence of the anastaomoses, and the arterial flow of the graft is higher than a simple bypass due to the joint vascularization of the flap. The arterial graft includes the subscapular and the thoracodorsal arteries. The free flap is composed of serratus anterior muscle supplied by branches of the graft. This investigation studied the feasibility of the bypass flap and determined the length and diameter of the arterial graft and its muscular branch. Forty anatomical preparations were performed on 20 cadavers. The dissections were performed after injection of Rhodorsil. The anatomical feasibility of the bypass flap was confirmed in 37 cases. The total length of the arterial graft that preserved an external diameter above 2 mm was measured at 13 cm (8.5-15.5). This includes the subscapular artery and the thoracodorsal artery with its intramuscular part (if external diameter of that part always above 2 mm). The length of the pedicle of the serratus anterior flap was measured at 7.5 cm (3.0-12.5 cm).

A successful management of concomitant renovascular hypertension and symptomatic subclavian steal syndrome due to Takayasu's arteritis using balloon angioplasty and axillo-axillary bypass grafting.

We present a case of Takayasu's arteritis with severe renovascular hypertension and symptomatic subclavian steal syndrome. A 60-year-old woman underwent successful percutaneous balloon renal angioplasty and axillo-axillary bypass grafting. The role of hybrid therapy, angioplasty and extra-anatomical bypass grafting for revascularization of symptomatic ischemia in this disease is reviewed. (Ann Thorac Cardiovasc Surg 2003: 9; 334-6)

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion.

OBJECTIVE: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.

Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: technical note.

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.

The axillocoronary bypass. Blood flow and short-term graft histology in a porcine model.

BACKGROUND: Bypass grafts arising from the axillary artery may be indicated for complications during minimally invasive direct coronary artery bypass grafting, for redo operations and for management of a severely atherosclerotic ascending aorta. As basic data research on this technique is scanty, we investigated intraoperative function and postoperative morphology of axillocoronary bypass grafts in a porcine model. METHODS: Thirteen German domestic pigs received an axillocoronary vein graft (Group I, n=7) or an aortocoronary vein graft (Group II, n=6) to the left anterior descending artery. In Group I the proximal anastomosis was performed to the left axillary artery, and after partial rib resection the graft was brought transpleurally to the target vessel. In both groups the coronary anastomosis was carried out on the beating heart without cardiopulmonary bypass. Graft flow was measured using transit time ultrasonic flow probes. RESULTS: Intraoperatively all grafts showed a typical diastolic flow profile. Stable graft flow was lower in axillocoronary bypass grafts: 47 (30-60 mL/min) in Group I and 65 (35-126 mL/min) in Group II (p=0.005). Flow given as percentage of cardiac output, however, did not differ between the two grafts: 0.9 (0.6-1.2%) in Group I and 1.2 (0.8-2.4%) in Group II (p=NS). At day 4 after surgery there was no clear histologic predilection site for microtrauma and early degenerative changes in the axillocoronary graft. CONCLUSIONS: Axillocoronary bypass flow compares well with flow in the aortocoronary graft. Microtrauma after implantation and early degenerative changes in the axillocoronary vein bypass are not particularly impacted by the thoracic entry site.

Minimally invasive subclavian/axillary artery to coronary artery bypass (SAXCAB): review and classification.

BACKGROUND AND PURPOSE: Subclavian/axillary artery to coronary artery bypass (SAXCAB) surgery is defined as a minimally (or less) invasive coronary revascularization procedure where one or more grafts are anastomosed to the second or third parts of the subclavian artery or any of the three parts of the axillary artery (inflow source) and attached to one or more coronary arteries, and where there are two separate minimally invasive incisions to expose the target coronary artery and the inflow sources, respectively. The indications and contraindications for SAXCAB surgery are discussed, and the relevant chest wall anatomy and that of the subclavian and axillary arteries are reviewed. The effect of respiration and anatomic variability as they impact the SAXCAB graft are discussed. Three components of the anatomy that are important in SAXCAB surgery are discussed: The relation of the first rib to the clavicle insofar as it affects access to the third part of the subclavian artery, the anatomy of the subclavian and axillary arteries and their branches, and the anatomy of the chest wall and its movement. In addition, the different SAXCAB variations that have been applied clinically are reviewed and classified, and future aspects of SAXCAB research are discussed. SAXCAB surgery is unique among the different types of minimally invasive direct coronary artery bypass (MIDCAB) surgery because of the enormous diversity of the techniques that have been described. Based on these descriptions, a new classification of SAXCAB grafting is proposed depending on whether the graft is inside or outside the rib cage and whether or not the coronary artery is exposed by rib resection or through an intercostal space. The third part of the classification takes into consideration the mode of entry into the chest, whether it is by rib resection or through an intercostal space. METHODS: Inquiries were made by telephone and by mail in the year 2000 to a number of surgeons who had published details of their SAXCAB techniques, and informal information was obtained by a series of personal communications as to the estimated number of operations they had performed and the outcomes. Published data was also used to formulate a rough guide as to the international status of the procedure at this time. RESULTS: The total estimated international experience is about 100 cases and the patency is between 70 and 100 percent in the time frame of about one to two years. CONCLUSIONS: The MIDCAB technique in general has been successful in providing an alternative way to revascularize the coronary arteries, and the SAXCAB has proved to be one of the most interesting classes of MIDCAB surgery. SAXCAB grafts seem to be unique among coronary revascularization procedures and, indeed, probably almost all vascular procedures, in that there is enormous diversity in the route for the graft from the inflow source to the target coronary artery. Being knowledgeable about the different varieties of SAXCAB surgeries will help the surgeon during a rescue operation as the surgery can be tailored to suit a particular patient. The SAXCAB seems to be a very safe operation, and it is striking that so far no one has reported any major complications.

Bypass graft to the midpopliteal artery with a combined anterior and posterior approach.

PURPOSE: The medial supragenicular and infragenicular approaches to the popliteal artery were introduced almost 50 years ago and replaced the posterior approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use of a combined anterior and posterior approach to evaluate its potential clinical benefits. TECHNIQUE: After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graft is passed into that incision, and all but the popliteal incision is closed. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally. METHODS: Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypass was not feasible, were assessed in terms of indications for surgery, conduit type, complications, length of postoperative hospitalization, and graft patency. RESULTS: Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. The procedure was performed in five patients with a popliteal trifurcation anomaly, nine patients with a blind popliteal segment, 20 patients with limited length of autologous vein, and five patients with an above-knee graft infection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Three other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for the last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two composite sequential grafts remained patent at 1 year. CONCLUSIONS: Bypass grafting to the midpopliteal artery with a combined anterior and posterior approach offers a safe and effective option to below-knee bypass grafting when an above-knee bypass grafting is not feasible. Compared with the medial infragenicular incision, the posterior incision results in reduced morbidity rates, rapid mobilization, and early hospital discharge.

Treatment for aortic graft infection.

Nine patients with an aortic graft infection presented after undergoing aortic grafting. Seven of 9 patients underwent an initial aortic reconstruction in our hospital. The incidence of aortic graft infection was 1.5% (7/456). There were 6 cases of paraprosthetic infection and 3 cases of aortointestinal fistulas. The treatments consisted of a complete graft excision and an axillofemoral bypass in 6 patients, a complete graft excision alone, a partial graft excision and a femorofemoral bypass, and the preservation of the graft with omental wrapping and irrigation in 1 each. Broad-spectrum antibiotics were intravenously administered to all patients and were then replaced by selective antibiotics for the responsible organisms. All surviving patients received antibiotics orally for 3-6 months. The early postoperative mortality rate was 11.1%. Aortoduodenal fistula occurred in 1 patient with graft excision alone. Graft thrombosis occurred in 2 patients with an axillofemoral bypass. No late graft infection or stump blowout occurred in any patient. We believe that a complete excision of the infected graft as well as the maintenance of distal tissue perfusion is necessary. However, based on the condition of the patient, the appearance of the operating field, and the difficulty of a repeat operation, we would like to stress the importance of selecting the best and safest treatment plan for each case.

Extra-anatomic redo of MIDCAB and OPCAB: an early experience.

BACKGROUND: Eighteen patients with unstable angina underwent repeat myocardial revascularization without cardiopulmonary bypass using saphenous vein grafts from either the left (13) or right (2) axillary arteries or the descending thoracic aorta (3). Patients' ages ranged from 53 to 85 years. Left ventricular ejection fractions ranged from 15% to 60%. METHODS: In 14 patients, the heart was exposed through an anterior thoracotomy, a minimally invasive direct coronary artery bypass (MIDCAB) technique. In 3 patients a left posterolateral thoractomy (lateral MIDCAB) was performed. One patient underwent repeat sternotomy (off-pump coronary artery bypass: OPCAB). In MIDCAB and lateral MIDCAB patients, the "target" vessel was a coronary artery in 8 patients and a previously placed vein graft in the remaining 9 patients. One patient underwent repeat sternotomy, and 3 coronary arteries were bypassed with a complex vein graft attached to the left axillary artery. Two patients died of mesenteric ischemia on the 2nd and 7th postoperative day. The remainder of patients were discharged from the hospital free of angina. Early graft patency was demonstrated by noninvasive vascular laboratory testing and/or angiography in the 13 survivors in whom the axillary artery had been the site of the proximal anastomosis. RESULTS: Follow-up ranged from 1 to 25 months. No other patients have died, and none have undergone additional surgical or catheter-based procedures. Three patients have developed recurrent angina, and in 4 patients the extra-anatomic bypass grafts have apparently become occluded. CONCLUSION: Extra-anatomic, off-pump bypass from the axillary artery or descending thoracic aorta to one or more coronary arteries can be performed safely in seriously ill patients requiring a repeat bypass procedure. The early results, regarding relief of angina, are encouraging.

Minimally invasive axillary-coronary artery bypass.

BACKGROUND: Some patients with proximal obstructive lesions of the left anterior descending coronary artery who are suitable for minimally invasive coronary bypass surgery do not have an available left internal mammary artery because it has already been used for a graft, is diseased or has been damaged. The ascending aorta is not accessible for proximal graft anastomosis from a small anterolateral thoracotomy used to expose the coronary artery. The aim of this report is to show that the axillary artery is suitable for the proximal anastomosis in minimally invasive coronary bypass operations. METHODS: Ten patients had minimally invasive axillary-coronary artery bypass to the anterior descending coronary artery. Cardiopulmonary bypass was not used. The saphenous vein was used in nine and the radial artery in one. RESULTS: Satisfactory grafts were achieved in all patients without mortality or major complications. CONCLUSION: Grafts from the axillary artery can be used successfully for minimally invasive bypass to the anterior descending coronary artery.