Off-pump coronary artery bypass in patients with Takayasu's disease

We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease in which severe angina was successfully relieved by off-pump coronary artery bypass grafting. In one case, visceral arteries such as the right gastroepiploic artery, the superior mesenteric artery, and the splenic artery were used as proximal blood sources of saphenous vein grafts. In another case, an aortic connector system was employed for proximal anastomoses of saphenous vein grafts. The use of off-pump coronary artery bypass grafting techniques should be considered in surgical coronary revascularization in patients with Takayasu's disease, thus leading to wide-spreading indication for the surgery.     

Modification of port-access coronary artery bypass in high-risk patients.

BACKGROUND: Minimally invasive port-access coronary artery bypass surgery has many potential advantages over routine median sternotomy coronary revascularization in patients with serious co-morbid conditions. The common femoral artery and vein have been the standard peripheral cannulation and balloon deployment sites. However, these sites present some risk, especially from proximal arteriosclerotic or aneurysmal disease. METHODS: We utilized Heartport endovenous and endoaortic cannulas (Heartport Inc, Redwood City, CA) for axilloaxillary or femoral-descending aortic cardiopulmonary bypass in 9 patients in an attempt to avoid potential cerebral and systemic embolization. All patients were successfully cannulated and the endoaortic clamp was deployed to perform a total of eleven grafts (five right coronary arteries and six circumflex coronary arteries). The patients ranged from 66 to 80 years of age. Five patients had abdominal aortic aneurysmal disease and 4 had severe peripheral vascular disease. RESULTS: All patients achieved full cardiopulmonary bypass with flows in excess of 3 L/min. without difficulty. There were no complications referable to the arm and its neurovascular structures. All axillary arteriotomies were closed primarily, without the need for thrombectomy or reconstruction. There were no neurological complications and 30-day survival was 100%. Three patients underwent successful abdominal aortic aneurysm resection prior to discharge. CONCLUSIONS: Axilloaxillary and femoral-descending aortic cannulation utilizing standard Heartport cannulas (Heartport, Inc) offer alternative sites for cardiopulmonary bypass in patients with severe peripheral vascular disease.     

Effect of coronary artery bypass grafting on native coronary artery stenosis. Comparison of internal thoracic artery and saphenous vein grafts

BACKGROUND: The purpose of this study was to investigate the influence of coronary artery bypass grafting on the degree of stenosis of the native coronary artery. METHODS: Experimental design: retrospective data analysis. Setting: University hospital. Patients: consecutive patients undergoing coronary artery bypass grafting (n=52). Bypasses using internal thoracic artery grafts (n=26) and saphenous vein grafts (n=37) to incompletely occluded coronary arteries were studied. Interventions: coronary artery bypass grafting using internal thoracic artery or saphenous vein grafts. Measures: stenosis of the native coronary artery on angiography. RESULTS: Three recipient coronary arteries bypassed with internal thoracic artery grafts (12%) and 14 recipient coronary arteries bypassed with saphenous vein grafts (38%) showed progression of narrowing (p=0.024). Two recipient coronary arteries bypassed with internal thoracic artery grafts (8%) and 13 recipient coronary arteries bypassed with saphenous vein grafts (35%) showed total occlusion (p=0.016). Hypertension, hyperlipidemia, diabetes mellitus, and smoking history did not correlate with progression of stenosis of the native coronary arteries. Graft flow measured during surgery in the saphenous vein grafts was not significantly different between the group that exhibited progression of the native stenosis and the group that did not. CONCLUSIONS: Coronary artery bypass grafting with saphenous vein grafts may result in progression of stenosis of the recipient coronary artery. This is less likely after coronary artery bypass grafting with internal thoracic artery grafts. This difference may be due to the ability of the pedicled internal thoracic artery graft to regulate flow. Thus competitive flow in the native coronary artery is minimized. This has significant clinical implications.     

Delayed presentation and successful surgical management of inadvertent internal mammary artery to coronary vein fistula: A case report

Latrogenic aortocoronary vein fistula following coronary artery bypass surgery is a rare complication. After cardioplegia in an arrested heart during coronary artery bypass surgery, a sclerotic cardiac vein in an area of epicardial fat or adjacent to an intramyocardial portion of the Left Anterior Descending Coronary Artery (LAD) can easily be confused for the target vessel. We present a case report of inadvertant internal mammary to cardiac vein fistula with delayed presentation at Ten years following Coronary artery bypass surgery for triple vessel disease. The Left internal mammary artery was inadvertently anastamosed to anterior cardiac vein. The other two vein grafts were totally occluded. The clinical characteristics and consequences as well as the angiographic characteristics of this Fistula are described. Precautions that may be taken to prevent this complication are also addressed.     

Robotically enhanced coronary artery bypass surgery

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28–76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min⁻¹. Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.     

Minimally invasive coronary artery bypass surgery

From 19.06.97 to 06.01.2000 36 patients with coronary heart disease underwent direct myocardium revascularization surgery by minimally invasive method (through minithoracotomy, off-pump and on the beating heart), anastomosis between left internal mammaria artery and anterior descending artery (ADA). The majority of the patients (55.6%) had one-vessel damage of ADA coronary bed, in the patients with damage of two and more vessels full revascularization of coronary bed was achieved by two coronary arteries bypass at once or by combination of minimally invasive coronary bypass (MICB) with PTCA. MICB is performed in specially selected patients according to stuct indications. Technique of operation, early postoperative course, possibilities of combination of MICB with other methods of treatment is described. Potential of MICB is discussed.     

Minimally invasive direct coronary artery bypass grafting for third-time coronary artery revascularization.

We performed a minimally invasive direct coronary artery bypass (MIDCAB) on two patients for third-time revascularization. The first patient was a 66-year-old woman who had patent bilateral internal thoracic artery (ITA) grafts and an occluded radial artery (RA) graft anastomosed to the posterolateral (PL) branch. She underwent her third revascularization for left circumflex coronary artery reconstruction with the MIDCAB technique using the right gastroepiploic artery. The second patient was a 65-year-old man who had occluded saphenous vein grafts (SVGs) on the anterior aspect of the heart, a stenotic left ITA graft to the left anterior descending artery, and a stenotic SVG to the PL branch. He underwent his third revascularization by MIDCAB using a bilateral RA-Y graft. Postoperative angiography of the two cases showed that the new grafts were widely patent.     

Clinical evaluation of surgical treatment of children with Kawasaki disease

Clinical problems in the surgical treatment for the vascular lesion after Kawasaki disease were evaluated in five patients who underwent myocardial revascularization. Each patient had significant stenosis or complete occlusion with aneurysmal formation. Four patients received single aortocoronary bypass and one patient received double bypass. Three saphenous veins and three internal mammary arteries were used for bypass grafting. There were no operative or late deaths. Three saphenous vein grafts and two internal mammary artery grafts were patent both in the early postoperative and in the late postoperative studies. Progression of the obstructive lesions at other coronary arteries which were not bypassed at the operation were found in two patients. One patient revealed bilateral common iliac aneurysms associated with progressive obstruction of urinary tract followed by renal dysfunction. It appears that even the patient who had satisfactory surgical results in late studies are required to be followed up with utmost care to other coronary lesions or other vascular lesions in addition to the lesions bypassed.     

The surgical treatment of unstable angina pectoris.

Since the advent of saphenous vein bypass grafting as successful means of myocardial revascularization, a variety of coronary artery disease syndrome have come under surgical attack. The proper role of surgery in many of these coronary syndromes remains ill-defined. However, clear indications for surgical revascularization exist in patients with unstable angina pectoris, i.e., progressive angina and onset of rest pain and noctural angina in spite of adequate medical therapy. An analysis has been made of 100 consecutive patients with unstable angina pectoris who underwent myocardial revascularization over the past 2 years at the Woodruff Medical Center of Emory University. Included in this group are the following subgroups: 1) Emergency cases with pre-infarction angina (including Printzmetal angina); 2) Cases of combined valvular heart disease and coronary artery disease; and 3) Advanced coronary artery disease with certain complications of previous myocardial infarction. A discussion of the relative merits of saphenous vein grafts and internal mammary artery anastomoses is presented and indicates that the technique selected should be determined by the quality of the distal native coronary circulation. Surgical mortality and morbidity figures, patency rates of saphenous vein grafts and internal mammary artery anastomoses visualized postoperatively, and the number of patients wiht dramatic relief of angina pectoris in this series support current enthusiasms for available surgical techniques for myocardial revascularization.     

Off-pump awake coronary revascularization using bilateral internal thoracic arteries

Background

A new technique has been developed that permits complete arterial revascularization of the lateral and/or inferior wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, without cardiopulmonary bypass and mechanical ventilation, creates the least invasive revascularization method for the lateral and/or posterior wall of the heart yet described.

Methods

In 7 patients double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started one hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique by standard median sternotomy. Circumflex, or the right coronary artery, were anastomosed with bilateral internal thoracic arteries using a heart positioner. Six patients received double bypass grafting and one patient received triple bypass grafts (bilateral internal thoracic arteries and one radial artery).

Results

All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in three patients, but it was repaired in two. Only one patient completed the procedure with unilateral pneumothorax. There were no hemodynamic and pulmonary problems during lateral or posterior wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses.

Conclusions

Complete arterial revascularization by median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach gives a chance for awake revascularization of the right and/or circumflex coronary artery.     

Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery

OBJECTIVE: Minimally invasive direct coronary artery bypass is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique can be used in both primary and reoperative cases by employing the internal thoracic artery to perform arterial revascularization of the anterior surface of the heart. METHODS: Patients were selected who had significant coronary artery disease limited to 1 or 2 coronary distributions on the anterior surface of the heart. Coronary target vessels were grafted with the internal thoracic artery through a small anterior thoracotomy. After partial heparinization the anastomosis was facilitated by local coronary occlusion and handheld stabilization. RESULTS: Between August 1994 and July 1997, 162 patients underwent minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. The left and right internal thoracic arteries were used for grafting of the left anterior descending artery in 142 patients (88%), the proximal right coronary artery in 7 patients (4%), existing saphenous vein grafts in 5 patients (3%), and diagonal branches in 2 patients (1%). Sequential grafting with the left internal thoracic artery was performed in 2 patients (1%) and bilateral internal thoracic artery grafting was performed in 4 patients (3%). Eight patients (4.9%) died within 30 days after the operation, 3 of cardiac causes. Seven additional patients died during the follow-up period. Nine patients (5.6%) required reintervention for graft stenosis or occlusion during follow-up. Of 141 patients seen 2 or more weeks after the operation, 135 (96%) had resolution of their anginal symptoms at a mean follow-up of 12 months (range 0-31 months). CONCLUSIONS: Anterior minimally invasive direct coronary artery bypass grafting with the internal thoracic artery avoids the risks of repeated sternotomy, aortic manipulation, and cardiopulmonary bypass. There was a low rate of reintervention, and patients had excellent resolution of anginal symptoms. Postoperative length of stay was comparatively short, and continued follow-up will be essential to evaluate long-term graft patency and patient survival.     

Current problems in coronary artery surgery: new methods of myocardial revascularization and vascular anastomosis

Recently, aortocoronary bypass for the patients with ischemic heart disease has been widely performed and excellent operative results have been obtained in Japan. But, there are some problems in coronary artery surgery for the patients with small coronary artery or multiple stenoses of the coronary arteries. For the purpose to resolve of these problems, operative transluminal angioplasty and onlay patch grafting have been routinely done for severely ill cases, and good patency rate of bypass grafts has been confirmed by postoperative angiography in our clinic. Another problem is alternative surgical treatment for these patients whom A-C bypass could not be done, because of diffuse stenosis of the coronary arteries. As a new method of myocardial revascularization for such cases, arterialization of the coronary venous system (Ao-CS bypass, or Ao-LADV bypass) was experimentally performed. Subsequently, improvements of hemodynamics and blood gas analysis during the bypass were obviously recognized in the latter group. Besides, transmyocardial punctures were created by CO2 Laser (output: 60-90 W, irradiation time: 0.15-0.25 sec) in the ischemic myocardium. Newly created myocardial channels were microscopically studied from the stand points of tissue reaction and patency rate. Subsequently, tinned layers of carbonization and coagulation necrosis were observed in the channels and they disappeared gradually, and long-term patency of the channels could be apparently expected from these findings. On the other hand, vascular anastomosis (side-to-side, end-to-end, and end-to-side) by low energy CO2 Laser was experimentally done in which good healing at the site of anastomosis could be microscopically observed.(ABSTRACT TRUNCATED AT 250 WORDS)     

The fate of the radial artery conduit in coronary artery bypass grafting surgery.

Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Impressive long-term disease-free patency rate of the left internal thoracic artery-left anterior descending coronary artery (LITA-LAD) graft, coupled with proven long-term survival benefits, has led to its becoming a 'golden standard' of CABG. Previous long-term studies have also shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularization, compared with internal thoracic artery grafts. Thus, the use of arterial conduits has expanded beyond the internal thoracic arteries (ITAs) to include the right gastroepiploic artery, the inferior epigastric artery, and the radial artery. The assumption is that although the performance of one or two arterial ITA graft is superb, more arterial grafts should perform better in the long-term follow-up. Several studies concerning the use of the radial artery bypass grafts have documented excellent clinical results and satisfactory short-term as well as mid-term patency rates at restudy angiography, supporting its continued use as a bypass conduit. However, a note of caution concerning radial artery conduit patency rate have appeared in few recent reports. Thus, in this paper, we summarize the current evidence about the radial artery as a conduit in CABG surgery, with special emphasis on the clinical results.     

The surgical treatment of congenital coronary to pulmonary artery fistula.

Six patients with coronary to pulmonary artery fistula underwent surgical treatment between January 1973 and August 1975. All fistula terminated in the main pulmonary artery just distal to the pulmonary valve. Two patients had severe coronary artery disease associated with the fistula. In all patients, the fistula was over-sewn from within the pulmonary artery in addition to ligation to the fistulous vessel on the surface of the pulmonary artery or heart, cardiopulmonary bypass being employed. Two patients underwent concomitant aortocoronary artery saphenous vein bypass for occlusive coronary artery disease. Follow-up data revealed that three patients were free of symptoms and two were improved, while one was lost to follow-up.     

Should axillary artery to coronary artery bypass be part of the cardiac surgeon's armamentarium?

BACKGROUND: The axillary artery has been used as an alternate inflow source for revascularization of the lower extremities for four decades. Since 1997, there have been several reports of axillary artery to coronary artery bypass. METHODS: All cases of axillary artery to coronary artery bypass at our institution from 1997 through 2003 were reviewed. PubMed was queried for publications on this subject and all pertinent reports were reviewed. RESULTS: Thirty-eight patients underwent axillary artery to coronary artery bypass at our hospital. Most (34) of the operations were performed without cardiopulmonary bypass. Saphenous vein (37) or radial artery (1) grafts were placed to one or more coronary arteries from either the left (36) or right (2) axillary artery. Twenty patients underwent sternotomy, and 18 had either a left (16) or right (2) minimally invasive direct coronary artery bypass (MIDCAB) procedure performed. Most of the sternotomies were for primary myocardial revascularization and most of the MIDCABs were reoperations. There were three deaths-all from non-cardiac causes, one myocardial infarction, and one transient brachial plexus injury. Doppler ultrasound, angiographic, and clinical follow-up were limited, but graft patency has been demonstrated up to 9 years. CONCLUSION: Axillary artery to coronary artery bypass should be part of the armamentarium of surgeons who perform myocardial revascularization operations.     

Current role of saphenous vein graft in coronary artery bypass grafting

Saphenous vein was the conduit used in the first series of coronary artery bypass grafting (CABG), and, with the exception of surgical revascularization of the left anterior descending artery, it remains the most commonly used bypass conduit. However, its durability and longevity are not ideal. Arterial grafts have better patency than saphenous vein grafts and therefore should be preferred over them. However, in certain situations, like grafting right coronary arteries with lesser degree of proximal stenosis and higher competitive flow, or in certain patient populations, like those at very high risk of wound infections and octogenarians, arterial grafting may not be the best option and saphenous vein grafting should be considered instead.     

Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure

Background. Coronary artery bypass grafting without cardiopulmonary bypass (off-pump-CAB; OPCAB) as a minimally invasive procedure has been used increasingly to treat coronary artery disease. The procedure makes multivessel revascularization possible, with new instruments and techniques, and hybrid therapy (combination of angioplasty and OPCAB) can be a new method of treating coronary disease. We present our experience using OPCAB and our strategy for coronary revascularization.

Methods. Of 216 patients treated with OPCAB, the lesion was single in 100 and multivessel in 116. Preoperative risks that could increase the mortality and morbidity rates were present in 127 patients, excluding 55 who were 75 years old or older.

Results. There were four hospital deaths, three of which were noncardiac, and five operative morbidities: transient cerebral ischemia in 3, perioperative myocardial infarction in 1, and congestive heart failure in 1. A postoperative angiogram was done in 157 patients (220 grafts), and with heart stabilization the patency rate without stenosis improved to 93.6%. For 116 patients with multivessel disease, technically complete revascularization was done in 84%, either with multivessel revascularization in 61 patients or the hybrid procedure in 37 patients. Among 20 patients with left main trunk lesion, five had the hybrid procedure. Angina recurred in 3, including 1 who died suddenly of infarction. The angiogram at recurrence showed restenosis of left main lesion and occlusion of the graft to the left anterior descending artery. Postoperative follow-up for 2 years showed 12 patients with recurrent angina and five late deaths from noncardiac-related events.

Conclusions. The heart stabilizer and new techniques for coronary revascularization with a beating heart have improved the anastomotic quality of grafts. The hybrid procedures were effective in selected patients but were considered contraindicated in patients with left main trunk lesion. OPCAB was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.     

Surgical versus medical treatment of coronary artery disease. Nine year follow-up of 9,061 patients.

To ascertain whether surgical therapy increases the life expectancy of patients with coronary artery occlusive disease, 9,061 consecutive patients undergoing aortocoronary bypass from July 1968 through June 1977 were reviewed and followed for up to nine years.Among all patients undergoing aortocoronary bypass without concomitant procedures, early mortality was 3.5 per cent (9.1 per cent in 1970 and 1.7 per cent during 1977). Late mortality was significantly lower in those patients receiving four grafts or more (0.7 per cent) and triple grafts (2.2 per cent) compared with patients undergoing either double grafts (4.4 per cent) or single grafts (3.5 per cent). This emphasizes the importance of complete revascularization. Nine year follow-up determined that 91.0 per cent of surviving patients were asymptomatic or significantly improved.Actuarial (Cutler) curves including early and late mortality demonstrated that 92 per cent of patients were alive at three years and 80 per cent at nine years after aortocoronary bypass. These results compare favorably with those of the recently published randomized Veterans' Administration Cooperative Study, which reported that at three years 87 per cent of medically treated patients were alive. Their follow-up extended only three years, but if their actuarial curves are projected to nine years, only 61 per cent of medically treated patients will be anticipated to be alive, compared to 80 per cent of patients treated surgically in the present series. These data suggest that surgical treatment of patients with coronary artery occlusive disease significantly improves long-term survival.     

Dor operation combined with redo coronary artery bypass grafting; report of two successful cases

Case 1. A 69-year-old male, who had undergone coronary artery bypass grafting with saphenous vein graft for acute myocardial infarction 16 years previously, was admitted into our hospital for heart failure and recurrent angina. Coronary angiography showed occlusion of the graft and 75% stenosis in the proximal circumflex artery. Left ventriculography showed end-diastolic volume of 216 ml and ejection fraction of 24%. Dor operation combined with redo coronary artery bypass grafting was performed. Postoperatively, the ejection fraction improved to 53% and the cardiac index improved from 1.8 to 2.2 l/min/m2. Case 2. A 67-year-old male, who had undergone double coronary artery bypass grafting using saphenous vein grafts for acute myocardial infarction 8 years previously, was admitted into our hospital for heart failure and recurrent angina. Coronary angiography showed occlusion of the 2 grafts and 99% stenosis of the proximal left anterior descending artery. Although the left ventricle was slightly dilated, echocardiography demonstrated a thrombus in the left ventricle. Dor operation was performed concomitantly with removing of the thrombus and redo coronary artery bypass grafting. Postoperatively, the ejection fraction improved to 68% and the cardiac index improved from 1.6 to 2.3 l/min/m2. When the patients underwent coronary artery bypass surgery with saphenous vein grafts for acute myocardial infarction, they could be susceptible to left ventricular asynergy and graft failure on the long run. Therefore, the patients who need redo coronary revascularization may be potential candidates for Dor operation, and they require close examination regarding the myocardial viability, volume and shape of the left ventricle.     

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impeding renal failure

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.