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.     

Pseudoaneurysm developed after aortic root homograft implantation

A 55-year-old man with severe infective endocarditis underwent aortic root replacement using a homograft concomitant with saphenous vein grafting to the left anterior descending artery. The patient developed angina due to stenosis of the proximal anastomosis of the vein graft accompanied by a 2-cm pseudoaneurysm. This complex lesion was successfully managed with urgent coronary artery bypass surgery through a left thoracotomy, followed by a redo replacement of the old aortic homograft The mechanism and the basis of the treatment strategy adopted for this case are described.     

Redo-OPCAB via left thoracotomy using symmetry aortic connector system: a report of two cases

Left thoracotomy is an established approach for redo coronary artery bypass grafting (CABG). This approach has also been successfully used in off-pump coronary artery bypass (OPCAB). Traditionally, the grafts have been anastomosed proximally to the descending thoracic aorta or the left subclavian artery. Recently, proximal connectors have been introduced by various manufacturers for use on ascending aorta during primary CABG and OPCAB. One such device is the Symmetry aortic connector system (St. Jude Medical, Minneapolis, MN). These devices have obviated the need for partial occluding clamps for the construction of the proximal anastomoses and hence are extremely useful when the aorta is heavily calcified. We used this device successfully in two patients undergoing redo-OPCAB, where the proximal anastomosis was constructed on the descending aorta. In so doing, we also used the shortest possible length of vein graft since the descending aorta at that level was much closer than the left subclavian artery. This can be an additional factor in redo-operations where the availability of vein can be an issue.     

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     

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.     

Reoperative off-pump coronary artery bypass via left thoracotomy with porcelain aorta; left axillary artery to circumflex artery bypass; report of a case

A 62-year-old man who underwent coronary artery bypass grafting (CABG) [left internal thoracic artery (LITA)-left anterior descending (LAD), saphenous vein graft (SVG) right coronary artery (RCA)] 13 years previously developed angina pectoris and congestive heart failure because of occlusion of SVG and native vessels. Coronary angiography (CAG) revealed that inflow to the coronary artery remained only from LITA. Repeat off-pump CABG (OPCAB) with SVG to the circumflex artery via left thoracotomy was performed. The proximal end of SVG was anastomosed to the left axillary artery because of the porcelain aorta and the patent LITA graft. The patient developed no complications and was discharged from hospital on postoperative day 21. OPCAB for circumflex artery by left thoracotomy is an effective and safe approach in redo CABG, particularly in instances of patent LITA.     

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.     

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.     

Left thoracotomy for reoperative coronary artery bypass procedures

This paper describes our experience in performing saphenous vein bypass grafts to the circumflex coronary artery system with a left thoracotomy in 9 patients. Illustrative case reports demonstrate the spectrum of patients for whom this approach has been useful. The advantage of this technique is that it allows the surgeon to avoid the adhesions that make a redo sternotomy time-consuming and potentially dangerous when previously patent saphenous vein or internal mammary grafts are present. It is particularly useful for patients requiring grafting to the circumflex coronary artery system, especially if the patient is in relatively unstable condition and would benefit from rapid institution of cardiopulmonary bypass. The technique generally employs cannulation of the descending thoracic aorta for arterial inflow and of the main pulmonary artery for venous return. Usually the proximal end of the graft is easily placed to the left subclavian artery. Coronary anastomosis is performed on the cold (15 degrees C), fibrillating heart, and aortic cross-clamping and cardioplegic arrest have not been necessary. Venting is possible through the left atrial appendage should any rise in filling pressures occur. Saphenous vein or internal mammary artery may be used. All patients undergoing this technique have had expeditious discharge from the hospital and excellent relief of symptoms. The technique is an alternative to median sternotomy for properly selected patients.     

Aortic valve replacement in a patient with a patent internal thoracic artery graft

Myocardial protection in patients requiring a second open-heart surgical procedure after coronary artery bypass grafting, especially when there is a patent left internal thoracic artery graft to the left anterior descending coronary artery, remains controversial. We present the case of a patient in whom aortic valve replacement was undertaken 18 months after coronary artery revascularization. Unusual features included beating-heart aortic valve replacement with continuous retrograde coronary sinus perfusion and avoidance of dissection of the patent grafts, including the left internal thoracic artery and a saphenous vein graft.     

Type A dissection caused by aortic cannulation during coronary artery bypass grafting; report of a case

A 71-year-old woman who had severe stenosis in the origin of the left anterior descending coronary artery with large diagonal branch was scheduled for coronary artery bypass grafting (CABG). After harvesting of bypass conduits, aortic cannulation was performed into the ascending aorta. Immediately after insertion of the cannula, however, the ascending aorta changed to a bluish color. Epiaortic ultrasonography revealed aortic dissection. Replacement of the ascending aorta was carried out using circulatory arrest under deep hypothermia. The intimal tear was located at the cannulation site. After this procedure, scheduled CABG the left internal thoracic artery to the left anterior descending coronary artery and the saphenous vein graft to the diagonal branch was performed. The proximal site of the saphenous vein graft was anastomosed to the replaced graft. The postoperative course was uneventful. Rapid identification and appropriate surgical management are necessary to minimize patient morbidity and mortality.     

Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk

We report the case of a 52-year-old man who was admitted for atypical thoracic pain 18 years after a saphenous vein bypass graft of the left anterior descending coronary artery. Investigations demonstrated an aneurysm of the middle portion of the vein graft with a fistulous communication to the pulmonary artery trunk. The aneurysm was excised surgically, and the fistula was closed with an autogenous pericardial patch.     

Left thoracotomy approach in reoperative off-pump coronary revascularization

Objective: Reoperative coronary bypass grafting is at high risk. Particularly in redo cases where the patent graft is running near the midline of the sternum, the graft may be exposed to injury by a median sternotomy and subsequent dissection. Whereas, off-pump bypass grafting from the left axillary artery or descending thoracic artery by a left thoracotomy approach is safe for preventing graft damage.Methods: From March 1998 to February 2002, we performed off-pump coronary artery bypass grafting by a left thoracotomy approach in 9 patients. The left axillary artery was used as the inflow vessel in 4 cases, and the descending thoracic, aorta in 5.Results: The radial artery was anastomosed proximally to the axillary artery in 4 cases and the descending thoracic aorta in one case. The saphenous vein graft was anastomosed, proximally to the descending thoracic aorta in 4 cases. Transdiaphragmatic minimally invasive bypass grafting for the right coronary artery was simultaneously performed in 3 cases. Postoperative cardiac events were ventricular arrhythmia in 6 cases and supraventricular arrhythmia in 3 cases. There was no damage to the patent grafts. Postoperative coronary angiography performed, in 8 cases revealed all the grafts to be patent without stenosis. Cardiac symptoms were not found after the operation in any of the cases.Conclusions: These procedures can prevent the injury to patent grafts caused by a median sternotomy, and will be one of the useful strategies for reoperative off-pump coronary artery bypass grafting.     

Aortic dissection induced by symmetry aortic connector system

A 74-year-old male with severe triple vessel disease underwent off-pump coronary artery bypass grafting (OPCAB). Preoperative computed tomography (CT) showed severely calcified ascending aorta. We revasculize the left coronary arteries with in situ internal thoracic artery (ITA) graft and the right coronary artery with a saphenous vein graft, which was attached to the disease-free portion of the aortic root, using Symmetry aortic connector system (ACS). Although the operation was uncomplicated, and postoperative course was uneventful until the 5th postoperative day when acute type A aortic dissection occurred. The patient died of aortic rupture on the 7th postoperative day. Necropsy disclosed that the entry located just on the proximal anastomotic site of the vein graft. It is possible placement of ACS device would trigger the dissecting process. With regard to the use of these one-shot devices for diseased aorta, its safety needs further investigation, even though it might be placed on an apparently intact portion.     

Axillocoronary bypass in a patient with a severely atherosclerotic aorta.

We report an axillocoronary bypass in a 70-year-old man with a severely atherosclerotic, calcified aorta. The patient had insulin-dependent diabetes mellitus and had 2-vessel coronary artery disease with a lesion in the left main coronary artery. He underwent an axillary artery-circumflex artery bypass with a saphenous vein graft combined with a bypass of the left internal thoracic artery to the left anterior descending artery without aortic cross-clamping. An easy, safe procedure, axillocoronary bypass is a viable option in coronary artery bypass grafting for patients with severely atherosclerotic, calcified aortas.     

Reoperative off-pump subclavian-coronary artery bypass grafting in an elderly patient with left internal thoracic artery stenosis]

A 80-year-old Japanese female was diagnosed to have angina pectoris and admitted to our hospital. She had been operated on with mitral valve replacement and coronary artery bypass grafting to right and circumflex coronary artery 4 years before. The coronary angiogram showed significant stenosis with severe calcification in the left anterior descending coronary artery, and it was unsuitable for catheter intervention. The patient also had stenotic left internal thoracic artery and multiple cerebral infarction, but successful off-pump subclavian-coronary artery bypass grafting using saphenous vein graft through small thoracotomy was performed without new neurological deficit. This procedure is useful for patients with left internal thoracic artery unsuitable for MIDCABG, due to quality, size, or injury during preparation.     

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.     

Off-pump coronary artery bypass grafting via partial sternotomy. An alternative to left anterior small thoracotomy.

Four patients, who were considered to be inappropriate candidates for left anterior small thoracotomy, underwent off-pump coronary artery bypass grafting via partial sternotomy. Under a median skin incision over the lower half of the sternum, the sternum below the second rib was cut in an "inverted L" (or "C") shape. Without cardiopulmonary bypass, the left internal thoracic artery was anastomosed to the left anterior descending artery in all patients, and a saphenous vein graft was anastomosed to the right coronary artery in one of them. Partial sternotomy has some advantages as an alternative to left anterior small thoracotomy, in that it enables multiple-bypass grafting without cardiopulmonary bypass and conversion to cardiopulmonary bypass, should it be come necessary, would be relatively uncomplicated.     

Off-pump coronary artery bypass using bilateral in situ internal thoracic artery grafts for left coronary artery system: a case report

A 63-year-old man with triple vessel disease in the coronary artery and multiple arterial stenoses in intra-cranial vessels underwent off-pump coronary artery bypass (OPCAB). We were able to perform three coronary artery bypass grafting (in situ left internal thoracic artery (left ITA)--left anterior descending artery, in situ right ITA--circumflex artery through the transverse sinus, and saphenous vein graft--right coronary artery) using octopus 2 and "Lima" suture technique without cardio-pulmonary bypass. Operation time was 355 minutes and established blood loss was 440 ml. Postoperative course was uneventful. Postoperative angiogram revealed well patent three grafts. Using bilateral in situ ITAs OPCAB could achieve high quality.     

Off-pump redo coronary artery bypass grafting from descending aorta to the posterolateral area through a left thoracotomy in patients with a patent internal thoracic artery graft

The patients were a 73-year-old man (Case 1) and 56-year-old man (Case 2) who developed angina pectoris and heart failure. Case 2 showed chronic renal failure on hemodialysis. These patients whowed posterolateral myocardial ischemia with a patent internal thoracic artery graft to the left anterior descending artery. Left ventricle ejection fraction was 29% and 33%, respectively. Catheter intervention was unsuccessful, so we performed revascularization from the descending aorta to coronary arteries with saphenous vein grafts via a left thrracotomy using an off-pump technique. In case 2, proximal anastomosis was constructed with the Symmetric aortic connector. This procedure appeared to be a very safe and useful method as an option for redo coronary artery bypass grafting in the posterolateral area in patients with patent old grafts and poor left ventricular function.