Patency of saphenous vein coronary artery bypass grafts from the vascular prosthesis of the ascending aorta.

BACKGROUND: Patients who have Stanford type A aortic dissection with impaired coronary arteries or who have aneurysms from the ascending aorta to the aortic arch with coronary artery disease need coronary artery bypass grafting (CABG) with tube graft replacement of the ascending aorta simultaneously. When vein grafts are used for CABG in these patients, the proximal anastomoses of vein grafts are attached to the prosthetic tube graft of the ascending aorta. However, the validity of proximal anastomoses of vein grafts to the prosthetic tube graft of the ascending aorta has not been confirmed. PATIENTS AND METHODS: We retrospectively analyzed patients who underwent venous coronary bypass grafting with prosthetic graft replacement of the ascending aorta. Between January 1984 and October 2002, 35 patients underwent CABG using saphenous vein grafts at the time of tube graft replacement of the ascending aorta, and the proximal anastomoses of the vein grafts were attached to the tube graft of the ascending aorta. Thirty-three venous bypass grafts were analyzed in 24 survivors. RESULTS: The postoperative catheterization showed only one early vein graft occlusion of 16 vein grafts anastomosed distally to the left anterior descending artery (LAD). All 14 venous grafts anastomosed to the right coronary artery (RCA) and 3 to the left circumflex artery (LCX) were patent. Therefore, the postoperative patency rate at discharge was 97.0% (32/33). Spiral computed tomography performed for long term follow-up revealed occlusion of two vein grafts (3.5 years and 9.7 years) anastomosed to the LAD. CONCLUSIONS: The patency rate of vein grafts anastomosed from prosthetic grafts of the ascending aorta to the native coronary arteries was similar to that of conventional CABG using saphenous vein grafts.     

Coronary artery bypass grafting for ischemic heart disease combined with aortitis

Coronary artery bypass grafting (CABG) was performed in a 67-year-old woman with aortitis. She had a past history of right radical mastectomy. Preoperative coronary angiogram showed diffuse stenotic lesions in both right and left coronary arteries. The pressure gradient between ascending aorta and peripheral radial artery was 90 mmHg and the cause of coronary stenosis seemed to be hypertension due to stenotic distal aorta. The aortogram showed occluded bilateral internal thoracic arteries (ITA) and stenotic abdominal aorta. The cephalic artery was supplied by a large meandering artery via dilated gastroepiploic artery (GEA). And thus the GEA was not useful for CABG. Quadruple CABG was performed with mild varicose saphenous vein (saphenous vein grafts to left anterior descending artery and third branch, and sequential saphenous vein graft to right posterior descending and atrioventricular branches). It seemed to be important to demonstrate the arterial lesion of ITA and GEA before CABG in patients with aortitis.     

Reoperative off-pump coronary revascularization via left thoracotomy using the PAS-Port system to the descending thoracic aorta: report of a case

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.     

Off-pump coronary artery bypass grafting via a left thoracotomy in a patient with left main trunk disease

We report a case of multiple coronary artery bypass grafting (CABG) via a left thoracotomy without cardiopulmonary bypass. A 54-year-old female with unstable angina pectoris associated with left main trunk disease underwent emergency CABG. Because the patient had a history of total arch and aortic root replacement due to type A aortic dissection, a left thoracotomy approach was selected. The proximal end of the Y-shaped saphenous vein graft was anastomosed to the left subclavian artery, rather than to the descending aorta, owing to the remaining aortic dissection. The distal end of the Y-shaped saphenous vein graft was anastomosed to the left anterior descending artery and the posterolateral branch without cardiopulmonary bypass. The postoperative course was uneventful. The results of this surgery seem to indicate that off-pump CABG via a left thoracotomy is a viable technique, especially for patients undergoing repeat CABG.     

A case report of coronary subclavian steal syndrome in a young woman

A 41-year-old woman presented with complaints of increasing angina pectoris and coldness of her left arm for 1 month. Six months ago, she had undergone triple coronary artery bypass grafting (CABG) including left internal mammary artery (LIMA) to left anterior descending artery (LAD) and two saphenous vein grafts to the diagonal branch of LAD and obtuse marginal branch of the circumflex artery. Coronary angiography revealed that contrast media injected into the saphenous vein graft coursing down the diagonal branch flowed up to LAD and drained into the LIMA opacifying the left subclavian artery. Arch angiography documented a total occlusion of the left subclavian artery. A polytetrafluoroethylene graft was anastomosed between the left common carotid and axillary artery. After operation, the symptoms disappeared and blood pressure in her left arm recovered. This complication could be prevented by identification of subclavian artery stenosis during coronary angiogram or CABG. This study may suggest that subclavian artery angiography should be performed in patients who will undergo CABG even for a young woman such as our case.     

Reoperative minimally invasive axillocoronary artery bypass to the obtuse marginal branch

A 73-year-old man was admitted with unstable angina, having severe coronary artery disease involving 3 vessels. He had undergone coronary artery bypass grafting to the left anterior descending artery and the obtuse marginal branch using saphenous vein grafts in 1979. Computed tomography showed severe calcium deposition and atherosclerosis in the ascending and descending aorta. We conducted axillocoronary artery bypass to the obtuse marginal branch and left internal thoracic artery as an in situ graft to the left anterior descending artery without cardiopulmonary bypass. Grafts were satisfactory and clinical results good.     

Reoperative Coronary Artery Bypass Grafting Via a Left Thoracotomy and a Small Laparotomy Without Cardiopulmonary Bypass: Report of a Case

A 66-year-old woman with aortic stenosis underwent an aortic root replacement with a composite graft and coronary artery reconstruction 2 years before presentation. On coronary angiography performed 2 years after operation, saphenous vein graft (SVG) to right coronary artery and SVG to first diagonal branch had both become totally occluded. SVG to left anterior descending artery showed 75% stenosis on the heel side of the distal anastomosis. The patient underwent a second coronary artery bypass via a left thoracotomy (the left internal thoracic artery was anastomosed to the first diagonal branch by interposing it with the left radial artery) and a small laparotomy (the right gastroepiploic artery was anastomosed to the right coronary artery) without a cardiopulmonary bypass. This approach is preferable to avoiding both a resternotomy and cardiopulmonary bypass in patients requiring repeat surgery. Received: September 29, 2000 / Accepted: May 15, 2001     

Aortic root remodeling and coronary artery bypass grafting for acute type A aortic dissection involving the left main coronary artery; report of a case

A 56-year-old male was admitted for sudden chest pain followed by loss of consciousness and paraplegia. The electrocardiogram (ECG) revealed ST-elevation in leads II, III, and aVF and ST-depression in leads V3 to V6. The ultrasonic cardiography (UCG) demonstrated an intimal flap in the ascending aorta, grade III aortic regurgitation (AR), and akinesis of the posterior wall of the left ventricle. Transesophageal echocardiography directly showed dissection of the left main coronary artery. Emergency coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD), obtuse marginal artery (OM) and posterolateral artery (PL) was performed using the saphenous vein. In addition, valve-sparing aortic root remodeling was performed in conjunction with replacement of the ascending aorta. The left coronary orifice was repaired and reattached to the prosthetic graft. The patient was weaned from cardiopulmonary bypass without catecholamine support. He was discharged from the hospital on foot after rehabilitation of the paraplegia. AR remains mild by UCG 3 years after surgery.     

Re-do coronary artery bypass grafting with the descending branch of the lateral femoral circumflex artery in a patient with chronic hemodialysis

A 52-year-old man with hemodialysis had undergone coronary artery bypass grafting (CABG); left internal thoracic artery (LITA) to left anterior descending artery (LAD), right gastroepiploic artery (RGEA) to posterolateral branch (PL), saphenous vein graft (SVG) to diagonal artery (Dx) 5 years previously. After 3 years, angiography was performed due to recurrence of angina pectoris and revealed RGEA and SVG was totally occluded. Since repeated intervention was unsuccessful, reoperation was necessary. Therefore, we performed re-do CABG without cardiopulmonary bypass using lateral femoral circumflex artery (LFCA) as an arterial conduit for myocardial revascularization via the 6th left intercostal posterolateral thoracotomy. Postoperative angiography showed that the LFCA bypass graft was patent and supplied sufficient blood to anastomosed vessel. The patient has had no angina pectoris subsequently. We believe this procedure is useful for re-do myocardial revascularization, and LFCA deserves to be taken into account as an alternative graft in a patient with chronic hemodialysis.     

Off-pump coronary artery bypass via left thoracotomy in patient with infective pancreatic fistula after surgery for bile duct carcinoma; report of a case

A 62-year-old man with infective pancreatic fistula after surgery for bile duct carcinoma underwent off-pump coronary artery bypass (OPCAB) through left thoracotomy to avoid the use of cardiopulmonary bypass and the postoperative mediastinitis, since this patient has infective pancreatic fistula close to the xiphoid process. The coronary arterial revascularizations were performed: left internal thoracic artery to left anterior descending branch and saphenous vein graft to descending thoracic aorta. The aortic mechanical anastomosis device, aortic connector, was utilized the proximal anastomosis of saphenous vein graft so as to avoid aortic clamp, while the distal anastomoses were completed with stabilizer and apical retraction device. Postoperative angiogram showed both grafts were patent. No signs of infection or recurrence of malignant neoplasm was observed. OPCAB via left thoracotomy is one of useful options for patients in whom median sternotomy is not suitable approach for myocardial revascularizations.     

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

Surgical repair of a pseudoaneurysm derived from a nine-year-old saphenous vein graft after coronary artery bypass

A 57-year-old male presented intermittent pain between the left shoulder and neck. He had undergone coronary artery bypass twice and all grafts had been confirmed to be angiographically intact at three and a half years prior. Coronary angiography revealed that a pseudoaneurysm derived from around the proximal ascending aortic anastomosis of the saphenous vein graft that connected to the left anterior descending branch and #4-atrioventricular branch sequentially. The pseudoaneurysm compressed the saphenous vein graft itself. He underwent repair of the pseudoaneurysm through median sternotomy after left subclavian artery-saphenous vein graft bypass utilizing a free left radial artery without cardiopulmonary bypass through left anterolateral thoracotomy. A 7 mm length longitudinal tear in the saphenous vein graft near the proximal anastomosis had caused the pseudoaneurysm. This tear had likely been caused by perforation by a catheter during coronary arteriography three and a half years ago.     

非体外循环冠状动脉搭桥术的技术改进──先吻合桥血管近端的“顺行序贯式”吻合术

目的探讨先吻合桥血管近端的“顺行序贳式”吻合技术住非体外循环心脏不停跳冠状动脉旁路移植术（off-pump coronary artery bypass grafting,OPCABG）中应用的临床意义和价值。方法56例患者行OPCABG术中采用先吻合桥血管近端的“顺行序贯式”吻合术：先行带蒂左乳内动脉与左前降支吻合;若使用游离桥血管则先与升主动脉吻合,再与左前降支吻合。然后用大隐静脉或桡动脉进行“序贯式”吻合搭桥。结果与左前降支吻合的桥血管：带蒂左乳内动脉49支,游离左乳内动脉1支,桡动脉4支,大隐静脉2支。采用大隐静脉进行“序贯式”吻合：4个吻合口（包括近端吻合口）32例,3个吻合口15例。桡动脉进行“序贯式”吻合：4个吻合口2例,3个吻合口7冽。大隐静脉-右冠状动脉单桥5支。总搭桥207支,平均3．7支／例。术后心绞痛症状全部缓解,无围术期急性心肌梗塞。54例随访2～70个月,无新发心绞痛,无死亡病例。结论应用先吻合桥血管近端的“顺行序贯式”吻合技术,可使OPCABG更简便、安全、有效,更有益于多支病变患者,尤其是急危重症的冠心病患者。     

Reoperative coronary artery bypass via left thoracotomy.

The patient was a 49-year-old woman. When she was 39 years old, she underwent coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery, saphenous vein graft to first diagonal branch). At the age 48, she had effort angina. On coronary angiography, triple-vessel disease was found, and she was treated conservatively. Progression of the disease was confirmed with detection of the left circumflex artery associated with jeopardized collateral to the right coronary artery showing total occlusion. The patient underwent reoperation. Since the left internal thoracic artery was patent despite occlusion of the saphenous vein graft, the approach of left thoracotomy was employed. Under cardiopulmonary bypass with ventricular fibrillation and left vent through left atrial appendage, the right radial artery was anastomosed to the left circumflex artery from the descending thoracic aorta, and the right gastroepiploic artery was anastomosed to the right coronary artery (4AV branch). Patency of the bypass was confirmed postoperatively. We consider this operative technique was especially useful for reoperation in cases of a patent internal thoracic artery in which left thoracotomy can be conducted safely.     

Endarterectomy and graft replacement of severely calcified (porcelain) ascending aorta with coronary ostial involvement in a patient requiring aortic valve replacement.

We report a successful aortic valve replacement within an extensively calcified (porcelain) aorta, involving the left coronary artery ostium. Clamping such an aorta can result in embolization, dissection, and mural laceration. A 72-year-old female presented with a severely calcified and stenotic aortic valve with a peak pressure gradient of 101 mmHg. Computed tomography demonstrated extensive calcification of the ascending aorta. Coronary angiogram showed a 50% ostial left coronary artery stenosis. Under deep hypothermic circulatory arrest, the aorta was transected at the proximal arch and distal graft anastomosis was performed. This was followed by endarterectomy of the porcelain ascending aorta and the left coronary ostium. Aortic valve replacement, proximal aortic graft anastomosis, and a coronary artery bypass grafting (CABG) with the left internal thoracic artery (LITA) anastomosed to the left anterior descending artery (LAD) were then performed in a sequential manner.     

Combined aortic valve replacement and coronary artery bypass grafting for a calcified ascending aorta

Although a severely calcified ascending aorta is encountered infrequently, it presents formidable problems during cardiac surgery. We describe a case of severe aortic valve stenosis and coronary artery disease combined with a severely calcified ascending aorta. The patient was an 80-year-old man with a calcified ascending aorta. He successfully underwent an aortic valve replacement and a single coronary artery bypass graft (CABG) using a saphenous vein graft with the proximal end connected on a Dacron patch, which was used for aortoplasty of the calcified plate along the aortotomy. These procedures were performed under moderate hypothermia with aortic clamping. This patch aortoplasty can be a useful alternative in cases that require aortotomy and proximal anastomoses of a CABG on a calcified ascending aorta.     

From Vineberg to bypass: a "second-hand" internal mammary artery.

A patient operated upon 20 years ago for myocardial revascularization with two Vineberg procedures and one coronary artery bypass graft (CABG) on the right coronary artery had a recurrence of unstable angina due to the thrombosis of the left internal mammary artery (IMA) and the right CABG. The right IMA was patent but stenosed distally. Reoperation was performed with a direct end to side anastomosis of the patent right IMA onto the left anterior descending artery and a saphenous vein graft as a CABG on the marginal branch. We comment on the choice of this "second hand" IMA graft and the pathological appearances of the patent IMA.     

Aneurysm of the left sinus of Valsalva producing obstruction of the left main coronary artery and aortic regurgitation

A 50-year-old male was admitted with dyspnea on exertion and palpitation. On physical examination, a grade 2/6 aortic regurgitant murmur was heard at the left sternal border. A chest roentogenogram showed an oval shadow on the left cardiac border. Digital subtraction angiogram, aortogram and coronary arteriogram revealed an unruptured-large aneurysm of the left sinus of Valsalva, which compressed the left main coronary artery and produced aortic regurgitation. Surgical correction consisted of obliteration of the orifice of the aneursym with woven Dacron graft patch, aortic valve replacement using SJM23A, and a saphenous vein bypass from the ascending aorta to the left anterior descending coronary artery. Postoperative studies showed complete obliteration of the orifice of the aneurysm, a patent aorto-coronary bypass graft and no perivalvular leakage. This aneurysm was considered congenital in origin, because of no inflammatory and infectious evidence, negative serologic test for syphilis and no aneurysmal dilatation of the ascending aorta.     

Utilizing a patent proximal vein graft stump in a case of coronary artery reoperation

A patient was referred for coronary artery bypass reoperation. The right internal mammary artery (RIMA) was anastomosed to the left anterior descending artery (LAD) and a left radial artery graft (RA) was sequentially anastomosed to the posterior descending artery (PDA) and left ventricular branches (LVB) of the right coronary artery (RCA). The patent proximal stump of an occluded saphenous vein graft was used as an interposition segment to lengthen the RA graft, thereby avoiding the need for a further anastomosis on the ascending aorta.     

Redo off-pump coronary artery bypass grafting for high risk hemodialysis patients

BACKGROUND: The number of reoperative (redo) coronary artery bypass grafting (CABG) for patients with long-term hemodialysis has been increasing. Off-pump CABG (OPCAB) may decrease risks associated with redo CABG. METHODS: Two patients on chronic hemodialysis with calcification of the ascending aorta underwent redo double coronary OPCAB for the left anterior descending artery (LAD) and the posterior descending artery (PDA) via median sternotomy. The LAD was bypassed with the left internal thoracic artery (LITA). The PDA was exposed with minimum dissection and bypassed with a composite graft of the right internal thoracic artery (RITA) and the saphenous vein (SV). RESULTS: Both patients made a quick recovery with no complications and one had postoperative angiography that showed the patent grafts. Both patients were free from angina pectoris at follow-up of 6 months and 3 months, respectively. CONCLUSION: Redo OPCAB of the LAD and PDA can be performed with minimal dissection via median sternotomy using the LITA and a composite graft of the RITA and SV.