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.     

Mistaken grafting to diagonal branch in minimally invasive direct coronary artery bypass: a case required reoperation

The patient was a 75 year-old male who was admitted with recurrent chest pain during hemodialysis one year after PTCA to the right coronary artery and left circumflex branch (LCX). He had the history of cerebral infarction and chronic renal insufficiency. Coronary angiography showed severe stenosis from the left main trunk to left anterior descending artery (LAD) and restenosis at the PTCA site of LCX. The LCX lesion was dilated with PTCA. Minimally invasive coronary artery bypass (MIDCAB) with left internal thoracic artery (LITA) to LAD was carried out uneventfully. However, chest pain appeared on 1 POD. LITA angiography revealed that LITA was anastomosed to the diagonal branch that had occluded completely in the preoperative angiography. Off-pump CAB to LAD using inferior epigastric artery was carried out through median sternotmy on the same day. He recovered smoothly, and LITA angiography before discharge demonstrated that both grafts to LAD and diagonal branch are patent.     

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.     

Kinking of skeletonized internal thoracic artery graft

A 66-year-old woman underwent coronary artery bypass grafting (CABG). Postoperative angiography on postoperative day (POD) 11 revealed that right internal thoracic artery (RITA) anastomosed to left anterior descending artery (LAD) had a kinking. The angiography performed 30 months after operation revealed no specific changes in the kinking of RITA and in the left ventricular function. Another case was a 74-year-old man with chronic renal failure under hemodialysis. He underwent CABG with left internal thoracic artery (LITA) to LAD. Post-operatively he had chest pain during hemodialysis. On POD 10, angiography revealed that LITA had a kinking with moderate stenosis and normal left ventricular function. The angiography performed 10 months after operation revealed no specific changes in the kinking of LITA. However, left ventriculography revealed akinesis in the antero-apical region. It suggested that the viability was lost due to the graft kinking of LITA and steal phenomenon on hemodialysis.     

Growth potential of left internal thoracic artery grafts: analysis of angiographic findings

BACKGROUND: The growth potential of the internal thoracic artery (ITA) is still undetermined, and little is known about the long-term effects of anastomosing it to the coronary artery. METHODS: Fifty-three patients whose left ITA (LITA) had been anastomosed to the left anterior descending (LAD) coronary artery underwent coronary angiography within 1 month of operation and in late follow-up (mean interval: 4.5 +/- 1.5 years). The diameter ratios of LITA to LAD were designated as the matching ratio. RESULTS: In follow-up, the diameter of the LITA increased from 1.83 +/- 0.40 to 2.46 +/- 0.53 mm in the 29 patients with progressive proximal native coronary stenosis. However, late results indicate that the matching ratio did not vary according to the location of the LITA anastomosis on the LAD (proximal portion: 1.13 +/- 0.16, distal portion 1.19 +/- 0.13), and reached an upper limit of about 1.4. CONCLUSIONS: Growth potential of the LITA is limited by the diameter of the coronary artery onto which it is anastomosed. The most effective procedure for enhancing the growth potential of the LITA is to anastomose as proximally as possible onto the LAD.     

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.     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。     

Spontaneous recanalization of postoperative severe graft stenosis. What is the cause and prognosis of the "string sign" in the internal thoracic artery?

A 68-year-old female with unstable angina was treated surgically. She was referred to the surgical ward by cardiologists because of a diagnosis of unstable angina with three vessel disease. On a coronary angiogram (CAG), 90% stenoses were found in the left anterior descending coronary artery (LAD), circumflex (CX), and right coronary artery (RCA). She received elective coronary artery bypass grafting (CABG), in which the left internal thoracic artery (LITA) was anastomosed to the LAD and reversed saphenous vein grafts (SVG) were made to segment 12 of the CX, and segment 4PD of the RCA, respectively. The postoperative course was uneventful, but postoperative early graftgraphy revealed distal narrowing of the LITA graft as the so-called "string sign". However, one year post surgery, the LITA string sign was not found and its patency had markedly improved on the second graftgram. It is reported that the LITA "string sign" might cause late graft occlusion. However, this LITA graft evidently enlarged the size and increased the flow of the artery in proportion to myocardial blood demand. To our knowledge, it has not been reported that an in situ LITA string sign on postoperative early graftgram has disappeared in the late phase. We hypothesize that the LITA string sign might be caused by several different factors such as flow competition, spasm, and/or technical problems. In any event, the LITA string sign does not cause graft occlusion in the late postoperative period in every case.     

Left atrial myxoma combined with coronary artery bypass grafting

We experienced 2 cases of surgical treatment for left atrial myxoma combined with coronary artery bypass grafting (CABG) using only in situ arterial grafts. A 58-year-old man who had undergone CABG [left internal thoracic artery (LITA)-right coronary artery (RCA) and saphenous vein graft (SVG)-left anterior descending artery (LAD)] 14 years before was admitted to our hospital, complaining of anterior chest pain. Coronary arteriography demonstrated total occlusion of the LAD and RCA, as well as the stenosis of high lateral branch (HL) and SVG. Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then the right internal thoracic artery (RITA) was anastomosed to the LAD. The postoperative course was uneventful. A 69-year-old woman was admitted to another hospital, complaining of chest pain and dyspnea. Coronary arteriography revealed stenosis of LAD, left circumflex artery (LCx) and HL, as well as left main trunk (LMT). Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then CABG [LITA-HL, gastroepiploic artery (GEA)-RCA and RITA-LAD] was carried out. The postoperative course was uneventful. The priority between CABG and the surgical treatment for cardiac myxoma remains controversial from the point of view of myocardial protection and prevention of systemic embolism of myxomal fragment.     

Off-pump coronary artery bypass grafting for single coronary artery; report of a case

A 55-year-old male with single coronary artery complicated by angina pectoris was referred to our department for coronary artery bypass grafting (CABG) . Coronary arteriography could not identify the left coronary orifice. Right coronary arteriography showed that the circumflex branch (Cx) followed the course of the normal right coronary artery (RCA) , and the left anterior descending branch (LAD) followed the Cx. Other findings included 90% stenosis in #4 posterior descending (PD) of RCA. Off-pump CABG was successfully performed to D1 with the left internal thoracic artery graft and to #4PD with the radial artery graft.     

The analysis for surgical procedures of coronary-artery bypass grafting: selection of graft materials]

We analyzed 222 patients undergoing coronary artery bypass grafting (CABG) in our institute. Our selection of graft materials consists of only one arterial conduit and one or more saphenous vein grafts (SVG). An arterial conduits (left internal thoracic artery (LITA) was mainly used for the left anterior descending coronary artery (LAD), while a SVG was used for coronary arterial branch. Our approach was evaluated by the mid-term prognosis as well as cardiac events. Seventy-one percent of patients with CABG could be followed. The graft patency rate was better for ITA grafts than for SVG (97.8% vs 88%). The incidence of late cardiac events was lower in patients with the LITA, to the LAD. Furthermore, these patients had a better survival rate at 4 years comparing with patients who had vein bypass grafts alone. We suggest that this selection of graft materials may be accepted in CABG for the good quality, avoiding the cardiac events.     

One stage operation for aneurysm of the diverticulum of the ductus arteriosus and coronary artery bypass grafting

Aneurysm of the diverticulum of the ductus arteriosus in the adult is rare. One stage operation for aneurysm of the diverticulum of the ductus arteriosis and coronary artery bypass grafting (CABG) is reported. A 61-year-old man was admitted for diagnosis of thoracic aneurysm on chest X-ray and CT. Chest CT scan showed an aneurysm above the left main pulmonary artery. An aortography showed the left vertebral artery originated directly from the aortic arch and a saccular aneurysm arising from the aortic isthmus and lesser curvature of the aortic arch. Coronary arteriography showed 75% stenosis at the right coronary artery (seg. #1) and 75% stenosis at the left anterior descending artery. Operation was performed through a median sternotomy. The aneurysm of 6 to 3 cm was located between the aortic isthmus and left pulmonary artery. Ascending aorta and right atrium were used to institute cardiopulmonary bypass (CPB). CABG (LITA to #7, SVG to #4 PD) was performed. Arterial cannulation was then switched to the left femoral artery. The proximal aorta was cross-clamped between the left vertebral artery and the left subclavian artery under the partial CPB, and the distal aorta was occluded with a occulusive balloon catheter via the right femoral artery. The selective left axillar artery cannulation was performed to perfuse LITA. The aneurysm was resected and closed with a patch. His post-operative course was uneventful.     

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     

A case of coronary artery bypass grafting in a patient who has a rosary-like coronary lesion with Buerger's disease]

We report a case of coronary artery bypass grafting using left intra thoracic artery (LITA) in a 63-year-old male with Buerger's disease. His coronary angiography showed a long lesion seemed rosary in the left anterior descending (LAD). At operation, the surface of the coronary artery was dark red with white speckles. The LAD was opened distal end of disease, the intima of the coronary artery made much soft thin fold. The disease was never atheromatous. His coronary angiography showed a very rarely finding that seemed rosary.     

Myocardial revascularization with the left internal thoracic artery Y graft configuration.

BACKGROUND: The proved long-term patency of the left internal thoracic artery (LITA) has made it the conduit of choice for myocardial revascularization. Maximal utilizable LITA length can be achieved by using a semiskeletonizing harvest technique. Expanded LITA use with sequential and Y graft techniques allows for a wider territory of myocardial revascularization. METHODS: A retrospective analysis of 30 patients undergoing coronary artery bypass surgery with a LITA-Y graft between December 1994 and November 1996 was performed. In selected patients the LITA was cut to length and anastomosed to the left anterior descending artery (LAD), with the redundant length of LITA used as a free graft to the lateral circumflex and diagonal systems. The proximal end of the free LITA was anastomosed to the in situ LITA to form the Y graft. Selection criteria included: a) minimal distal disease in the LAD and circumflex systems; and b) graftable circumflex branches proximal to the mid free wall of the left ventricle, allowing total revascularization of the left coronary system with the Y graft. RESULTS: Thirty patients (22 male, 8 female) underwent the LITA-Y graft procedure. There were no deaths or episodes of myocardial infarction. One patient required inotropic and intraaortic balloon pump support. Two patients with isolated coronary ostial stenosis developed recurrence of angina due to occlusion of the free limb of the LITA. CONCLUSIONS: In patients with suitable coronary artery anatomy, the LITA-Y graft can be successfully performed with good short-term outcome, but may be contraindicated in the management of isolated coronary ostial stenosis.     

Beating-heart totally endoscopic coronary artery bypass grafting: Report of a case

This case report presents beating-heart totally endoscopic coronary artery bypass grafting (TECAB) for single-vessel coronary artery disease. A 72-year-old man with isolated left anterior descending (LAD) coronary artery disease was considered eligible for TECAB. Left internal thoracic artery (LITA) mobilization and subsequent off-pump revascularization applying the LITA to the LAD in a closed chest environment was performed using the da Vinci surgical system (Intuitive Surgical, Mountain View, CA, USA). The LITA was first harvested completely in a totally skeletonized fashion through three incisions 1–2 cm long in the left thoracic wall. The LAD was immobilized with the aid of a heart stabilizer. The LITA was then anastomosed to the LAD with 10 interrupted sutures of a Nitinol self-closing S15 U-clip device (Medtronic, Minneapolis, MN, USA) on the beating heart without the use of cardiopulmonary bypass. The time acquired to perform anastomosis was 20 min, and the total operative time was 5 h 34 min. The postoperative course was uneventful and the patient was discharged 5 days after the operation. Beating-heart TECAB was successfully performed for this patient with single-vessel LAD disease. This approach may be an evolutionary step toward beating-heart multivessel TECAB.     

Total aortic arch replacement for a patient with poor left ventricular function and patent coronary artery bypass grafts: how to establish effective myocardial protection

A 66-year-old man who had previously undergone coronary artery bypass grafting (CABG) was admitted to our institution for surgical treatment of a ruptured aortic arch aneurysm. He had three patent bypassed grafts including the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), complicated by left ventricular dysfunction. Coronary angiography performed 1 year after the initial surgery revealed total occlusion of the LAD. In addition, the aneurysm was located next to the LITA; therefore, there was a significant risk of injury to the LITA during intraoperative dissection. For such a complicated and challenging case, we successfully performed a total aortic arch replacement using a Y-shaped composite saphenous vein graft (SVG) for the administration of cardioplegic solution to establish effective myocardial protection. This procedure, by which effective myocardial protection can be achieved, is a useful treatment option for aortic arch surgery after CABG with a patent LITA graft.     

Minimally invasive coronary artery bypass (MIDCAB) for double vessel using Y arterial graft which consists of left internal thoracic artery and right inferior epigastric artery

MIDCAB is a rapidly evolving technique to revascularize the left anterior descending coronary artery (LAD) with the left internal thoracic artery (LITA). Our case is a 60-year-old female with unstable angina due to restenosis of the proximal LAD following PTCA and proximal stenosis of the large first diagonal branch (D1). She underwent double vessel MIDCAB (LITA-LAD and LITA-RIEA-D1) using Y composite arterial conduit with LITA and right epigastric artery (RIEA), because of chronic renal failure on maintenance hemodialysis. Postoperative course was uneventful and postoperative angiography revealed a patent Y graft. Y graft using IEA appears to be an interesting operative method in double vessel MIDCAB.     

Revascularization of Left Anterior Descending (LAD) Artery with In Situ Left Internal Thoracic Artery (LITA) and Coronary‐Coronary Free LITA Grafts: 12‐Year Patency

Abstract Background: We aim to present a patient with coronary‐coronary bypass grafting (CCBG), left anterior descending‐left anterior descending (LAD‐LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12‐year follow‐up angiogram to confirm the longest reported patency. Methods and Results: A 57‐year‐old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. Conclusions: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long‐term patency.     

Two cases of coronary artery bypass grafting associated with antiphospholipid syndrome in systemic lupus erythematosus]

We report two cases of coronary artery bypass grafting (CABG) associated with antiphospholipid syndrome (APS) in systemic lupus erythematosus (SLE). Patient 1, 65-year-old female, who had been treated for SLE with prednisolone for 11 years was transferred to our hospital due to unstable angina caused by stenosis of the left main trunk (LMT) and the left anterior descending artery (LAD). She underwent emergency CABG of the LAD using left internal thoracic artery (LITA). Post operative doppler study demonstrated patent LITA to the LAD. Patient 2, 67-year-old female who had been treated for SLE with prednisolone for 8 years was transferred to our hospital due to acute myocardial infarction caused by stenosis of the LMT and the left circumflex artery (LCX). She underwent emergency CABG of the LAD and the LCX using saphenous vein grafts (SVGs). Post operative angiography confirmed a patent SVG to the LAD and an occuluded SVG to the LCX. In cases of SLE, the frequency of occurrences of ischemic heart diseases is high. Until now, however, there are few instances reported on performing CABG for patients with SLE. We are reporting here our particular cases of APS with SLE, discussing the involvement of APS as causative factor of ischemic heart diseases and related issue of surgical and post surgical antithrombotic treatments.