Rupture of an infected vein graft in the course of mediastinitis following coronary artery bypass grafting: report of a case

A 51-year-old man developed a Staphylococcal mediastinitis and septicemia 23 days after coronary artery bypass grafting. He was initially treated with surgical debridement and closed irrigation with 0.5% povidone iodine solution. However, since the infection could not be eradicated by this method, an open packing method was subsequently required. Nineteen days after the diagnosis of mediastinitis, massive bleeding occurred due to rupture of an infected vein graft to the LAD. Although he went into profound hemorrhagic shock, suture ligation of the vein graft was successfully performed. The sternum was reapproximated 34 days after the initial debridement. Postoperative coronary angiograms revealed the patent vein grafts to the RCA and LCX, and PTCA was performed to the native stenosis of the LAD. The patient was discharged 5 months after the bypass operation and is now doing well 3 years postoperatively. Rupture of the heart or vessels in the course of postoperative mediastinitis is a very rare but highly lethal complication. We think that it is important to eradicate the infection as soon as possible to prevent the bleeding complication and that the decision as to which method, closed or open, should be employed, is crucial.     

Treatment of carotid-cavernous sinus fistula by the balloon technique combined with a by-pass procedure using a vein graft-technical note note

A case with spontaneous carotid-cavernous fistula treated by balloon catheter technique combined with a extra-intracranial by-pass using a saphenous vein graft between the common carotid artery and the middle cerebral artery is reported. A 72-year-old female was admitted with complaints of recurrent symptoms of carotid-cavernous fistula 4 months after spontaneous remission. Angiograms showed the presence left internal carotid-cavernous sinus fistula. Poor cross-filling from the right internal carotid artery to the territory of the left internal carotid artery via the hypoplastic right A1 and left posterior communicating artery was also observed. Symptoms such as chemosis, exophthalmos and visual disturbance gradually progressed during the hospitalization. A common carotid-middle cerebral artery anastomosis was performed with a saphenous vein graft and the carotid cavernous fistula was occluded directly with a balloon catheter. The blood flow via the graft, cortical blood flow, cortical tissue O2 and CO2 were continuously measured during the operation. After the internal carotid artery occlusion, sufficient blood flow via the graft and no significant changes of the cortical blood flow, cortical tissue O2 and CO2 were observed. The postoperative angiogram showed that the by-pass was patent and all branches of the left internal carotid artery were filled via the by-pass. The postoperative course was uneventful and the progressive symptoms improved except for visual disturbance on the left. She is in good condition one year after the operation. The usefulness of this surgical procedure with monitoring of cerebral blood flow and metabolism during operation is also discussed.     

Minimally invasive direct coronary artery bypass grafting using the saphenous vein in redo CABG.

We describe a patient who underwent minimally invasive direct coronary artery bypass (MIDCAB), who had previously undergone coronary artery bypass grafting (CABG) through a median sternotomy with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and a right gastroepiploic artery (GEA) graft to the posterior descending artery. MIDCAB was less invasive and was an effective alternative procedure for the second operation. Because the patient had no LIMA or GEA available for a graft because of prior use, we used a saphenous vein graft (SVG) for bypassing from the left subclavian artery to the coronary artery by MIDCAB via a left minithoracotomy. The left subclavian artery was selected as the proximal anastomotic site because this artery was less diseased and was easier to reach. The SVG-to-coronary artery anastomosis was facilitated by firm adhesion between the epicardium and the pericardium, which reduced the motion of the epicardium itself. These results suggest that the procedure is safe and promising in selected cases of redo CABG.     

Minimally invasive axillary-LAD saphenous vein bypass

The left internal mammary artery (LIMA) is the arterial conduit of choice for minimally invasive coronary bypass to the left anterior descending (LAD). However, in redo cases when the LIMA is not available, the use of a saphenous vein graft as an extra-anatomic bypass from the axillary artery to the LAD offers a lower risk alternative than conventional reoperative trans-sternal surgery [Knight 1997]. We report on 3 patients who underwent axillary-LAD saphenous vein bypass. At six months, follow-up by Duplex ultrasound showed patent grafts in all three patients.     

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.     

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。     

Multiple coronary aneurysms due to Kawasaki disease in young man--successful triple coronary bypass grafting by utilizing the right gastroepiploic artery, internal thoracic artery and saphenous vein

A 28-year-old man developed acute anteroseptal myocardial infarction. Emergency coronary angiography revealed multiple coronary aneurysms, associated with complete obstruction of left anterior descending artery (LAD) and 50 to 99% stenosis of the right and the circumflex coronary artery (CX). Coronary artery bypass graftings were performed seven weeks after successful emergency intracoronary thrombolysis. The saphenous vein graft was anastomosed to CX, the internal thoracic artery to LAD, the right gastroepiploic artery to RCA just above the bifurcation. Post-operative course was uneventful. On sixth post operative week cardiac catheterization was performed. The study showed all three bypass grafts and native coronary artery to be patent. The patient is now followed up under anticoagulant therapy.     

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.     

Saphenous vein bypass from the aorta to the anterior interventricular vein.

A patient is described who had myocardial revascularization with saphenous vein grafts. One of the grafts was inadvertently anastomosed to the anterior interventricular vein instead of the anterior descending coronary artery. He also underwent saphenous vein bypass to the right coronary artery and resection of a left ventricular aneurysm. The patient remained free of angina up to 3 1/2 years after operation, at which time he was seen with tachyarrhythmia and a continuous murmur. Coronary arteriography revealed patent bypass grafts to both the distal right coronary artery and the anterior interventricular vein. Whether the patient benefited from the graft to the anterior interventricular vein remains indeterminable because of the successful bypass to the right coronary artery and the left ventricular aneurysmectomy. He did experience clinical improvement for 3 1/2 years, and the symptom when he was seen at our institution was tachyarrhythmia, not chest pain. Additionally, his exercise tolerance had improved markedly. We believe the potential advantages of bypass from the aorta to the coronary veins is still unexplored.     

Effects of Enflurane-Nitrous Oxide Anaesthesia and Surgical Stimulation on Regional Coronary Haemodynamics in a Patient with LAD Bypass Graft

Central and regional coronary haemodynamics were studied in a patient with a left anterior descending artery (LAD) graft and angiographically visible collaterals from a normal right coronary artery. A three-thermistor thermodilution catheter was used for measuring total coronary sinus blood flow and great cardiac venous blood flow, the latter being a good representative of blood flow through the LAD. Enflurane-nitrous oxide anaesthesia induced marked coronary vasodilatation and redistribution of blood flow from the LAD to other areas draining into the coronary sinus. The most likely mechanism for the redistribution of blood flow in this patient was steal via the collaterals between the LAD and the right coronary artery. During surgical stimulation, the flow through the LAD was further compromised due to pronounced coronary vasoconstriction, probably mediated by catecholamine release.     

Competitive flow between a vein and an arterial graft at transit-time flow measurement

We report the intraoperative finding, at a transit-time flow measurement, of competitive flow between a venous and an arterial graft in a 72-year old woman who underwent uncomplicated coronary artery bypass grafting 3. The blood flow in the left internal mammary artery (LIMA) improved only after temporary occlusion of the saphenous vein graft (SVG) anastomosed to the first diagonal (D1), demonstrating the presence of competitive flow from the SVG-D1 anastomosis into the LIMA-left anterior descending coronary artery (LAD) system. Interestingly the two target vessels suffered from separate critical lesions. The patient's haemodynamics remained stable throughout and no further action was taken. Her recovery was uneventful and the patient was discharged home on postoperative day 6. This case raised questions about the cost benefit of grafting a diagonal target even when it appeared to be disconnected from the LAD on a coronary angiogram.     

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.     

Accelerated graft disease in a composite saphenous vein with internal thoracic artery in a chronic renal dialysis patient

A 59-year-old man with 18-year history of renal dialysis due to chronic nephritis suffered coronary artery disease, which was complete occlusion of the right coronary artery and diffuse 90% stenosis of the proximal left anterior descending artery. Off-pump coronary artery bypass grafting was performed. Saphenous vein (SV) was anastomosed with left internal thoracic artery (ITA) as a T-graft. Left ITA was anastomosed to the left anterior descending artery. The end of SV was sewn on the posterior descending artery. Coronary and graft angiography performed 2 weeks after the operation showed good patency with good distal run-off of both left ITA and SV. Three months after the operation, he was admitted with unstable angina. Angiography revealed accelerated SV graft stenosis without any change of prior coronary disease. However, angiography 7 months after the operation revealed complete obstruction of the S V graft when he was admitted because of recurrent anginal pain.     

Congenital fistula between the left internal mammary artery (LIMA) and the pulmonary artery: cause of LIMA bypass occlusion?

Congenital fistulas from the left internal mammary artery to the pulmonary artery are rare. We describe a 49-year-old patient with severe aortic valve regurgitation and coronary artery disease. Percutaneous transluminal coronary angioplasty and left anterior descending artery (LAD) stenting had been performed because of a significant proximal LAD lesion. Repeated coronary angiogram 3 months later revealed a patent stent but severe sclerosis up to a 40% stenosis of the LAD after the area of stenting. An aortic valve replacement and a left internal mammary artery (LIMA) bypass to LAD were performed during standard cardiopulmonary bypass (CPB). Because of patient chest pain, a control angiogram was carried out 2 years after surgery and revealed a LIMA-bypass occlusion and a large fistula deriving from the proximal part of the LIMA to the pulmonary artery. The fistula was occluded by coils during an interventional cardiological procedure. Diminished flow in the LIMA bypass due to the fistula in combination with a nonsignificant proximal LAD stenosis are possible reasons for IMA-bypass occlusion. From this case we conclude that angiography of the IMA to detect malformations preoperatively should be mandatory in all cases of arterial coronary revascularization using IMA bypasses.     

A man with saphenous vein graft aneurysms after bypass surgery

Saphenous vein graft (SVG) aneurysms are a rare complication of coronary artery bypass graft surgery. Patients in whom these aneurysms form a fistula with either a cardiac chamber or mediastinal vessel are even more uncommon and present a difficult diagnostic and therapeutic challenge. We present a patient with SVG aneurysms and a fistula to the left atrium.     

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.     

Surgical A-V fistula in aortocoronary snake graft. Preliminary report

In coronary artery surgery, when a poor distal run of can predict an early graft failure, it might be useful to perform the last anastomosis to a low pressure chamber thus creating a small arterio-venous (A-V) fistula. From January throughout December 1984, 4 patients underwent coronary angiography for severe symptoms of angina. The coronary angiography showed multiple stenoses on the left anterior descending (LAD), ventricular branches of the circumflex (CX), and posterior descending of the right coronary artery (PD). At operation the patients received a sequential aortocoronary bypass graft with reversed saphenous vein, plus the creation of a small A-V fistula into the right atrium in order to improve the graft flow and patency. All patients experienced a clinical improvement. No adverse effects have been observed and the patients, controlled clinically with non invasive and in two cases with invasive techniques, showed satisfactory revascularization.     

Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience

PURPOSE: The National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines favor autogenous vein for arteriovenous fistulas (AVFs). This report describes our experience constructing AVFs in the lower extremities of selected patients with the superficial femoral vein (SFV). PATIENTS AND METHODS: This is a retrospective analysis of 25 patients who had AVF construction with SFV from March 1998 to July 2000. In all patients upper extremity access had been exhausted. Eighteen (72%) patients were female, 15 (60%) had diabetes, and 14 (56%) were obese (body mass index > 30 kg/m(2)). The SFV was freed from the supragenicular popliteal level to the profunda femoris vein and divided distally. Eighteen (72%) patients had SFV transposition and distal superficial femoral artery reimplantation; 10 veins were banded to reduce the incidence of postoperative steal syndrome. In seven patients (28%) a composite loop fistula was constructed with a deeply buried 4- to 7-mm polytetrafluoroethylene (PTFE) graft proximally and with superficially transposed SFV distally. One of these seven patients had a PTFE above-knee femoral-popliteal bypass graft with banding of the vein at its takeoff from the distal PTFE graft. RESULTS: Mean follow-up was 9.1 months. One patient died before the fistula could be used. Seven patients (28%) experienced major wound complications. Mean ankle/brachial index before operation was 1.03, and after operation it was 0.81 (paired difference [n = 16] = -0.26.) Mean ankle circumference before operation was 19.5 cm, and after operation it was 20.7 cm (paired difference [n = 17] = +0.87.) Cumulative primary fistula patency at 6 and 12 months was 78% and 73%, respectively. Cumulative secondary fistula patency at 6 and 12 months was 91% and 86%, respectively. There were no fistula infections. One patient eventually had an above-knee amputation after experiencing an acute compartment syndrome. Eight patients required a second operation to alleviate a symptomatic steal syndrome. CONCLUSIONS: The SFV is an excellent conduit for vascular access, whether it is transposed or is part of a composite PTFE-SFV fistula. In this series, fistula infection was nonexistent, thrombosis rates were low, and clinical evidence of venous hypertension was minimal. The major impediment to unrestricted use of SFV in constructing AVFs is a high incidence of clinically significant postoperative ischemia requiring reoperation.     

Surgical treatment to an old patient with right coronary artery aneurysm; report of a case

The patient was 75-year-old woman. The patient was referred to our hospital for operation due to a developing right coronary artery aneurysm. The coronary artery angiography showed that the aneurysm was 3 cm in diameter which had not existed two years previously, and with a 75% distal stenosis. The operation was made during cardiac arrest. A sapheous vein graft was used to bypass to the distal artery first. Then the aneurysm was resected, and both proximal and distal arteries were ligated. The pacemaker was implanted on the third postoperative day for sick sinus syndrome, the patient got a better recovery. Surgical treatment should be recommended to coronary artery aneurysm, and sapheous vein was a good selection for bypass graft when the diameter of native artery was relatively large.     

A quantitative angiographic study of characteristics of internal thoracic artery grafts in coronary artery bypass surgery

In adult patients with atherosclerotic coronary artery disease and in pediatric patients with Kawasaki heart disease, characteristics of internal thoracic artery grafts (ITA grafts) used for coronary artery bypass grafting (CABG) were quantitatively assessed by postoperative angiography. In 142 adult patients with a ITA graft for the left anterior descending artery (LAD), the diameter ratio between ITA graft and recipient LAD at the point close to the anastomotic site (ITA/LAD diameter ratio) was determined by postoperative angiography. This ratio for the adult patients as a whole was 1.04 +/- 0.34. The multivariate analysis (Quantification I) was performed to assess the effects of the following 12 factors on the ITA/LAD diameter ratio: (1) age at the time of operation, (2) sex, (3) time-duration from the operation to angiography, (4) laterality of the ITA used, (5) presence of an undivided major side branch of the ITA graft, (6) presence of blood flow competition between the ITA graft and other grafts, (7) presence of distal stenosis of the recipient LAD, (8) severity of LAD stenosis after the operation, and (9-12) presence of hyperlipidemia, diabetes mellitus, hypertension, or smoking history. The standardized category scores of 25% LAD stenosis, 50% LAD stenosis, and blood flow competition between the ITA and other grafts were -0.815, -0.359, and -0.306, respectively. Insignificant stenosis of the recipient coronary artery was associated with reduction of the ITA/LAD diameter ratio, and this ratio strongly correlated with the severity of LAD stenosis (partial correlation coefficient: 0.627). However, no other factors significantly influenced on the ITA/LAD diameter ratio. In 15 pediatric patients, the length and diameter of 19 ITA grafts and 5 saphenous vein grafts (SVGs) which remained patent in the early (about one month) and late (14 +/- 4 months) postoperative period were determined. Only in the ITA graft, increases in graft length and diameter associated with patient growth were recognized. In the present study, the physiological characteristics of the ITA graft were demonstrated as a viable conduit with flow adaptability and growth potential.