Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure.

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.     

Treatment of acute aortic dissection involving the right coronary artery and aortic valve

A complication of acute dissection of the ascending aorta is involvement of the aortic valve and right coronary artery. A case is presented in which the treatment of this lesion involved placement of a composite valve graft with reattachment of the left main coronary artery using a small Dacron tube graft and a saphenous vein bypass to the right coronary artery.     

Off-pump coronary bypass using interposed radial artery graft

We describe a patient with severely diseased ascending aorta and small internal mammary arteries, who underwent off-pump coronary artery bypass to the left anterior descending coronary artery and right coronary artery using composite arterial grafts consisting of the pedicled proximal internal mammary artery and interposed radial artery graft. The interposed radial artery graft provides advantages, such as making coronary anastomosis on the beating heart easier and to increasing the flow potentiality of the internal mammary artery.     

Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient

We performed surgical repair of a giant left coronary ostial aneurysm after aortic root replacement using composite valve graft (modified Bentall procedure) in a patient with Marfan syndrome. Aneurysmal formation in the left main stem itself is very rare. In order to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis, the left main trunk was reconstructed using an interposition Dacron graft. In aortic root surgeries in Marfan patients, the size of the side hole on the composite graft should be kept relatively small to fit the diameter of the native coronary arteries for prevention of coronary buttons from forming aneurysms at the level of the coronary button anastomosis. In addition, close observation to the coronary button anastomosis is indispensable in postoperative check-up.     

Surgical treatment for anomalous origin of left coronary artery from pulmonary artery.

Anomalous origin of the left coronary artery from the pulmonary artery carries a poor prognosis; most patients die early in life from myocardial infarction and congestive heart failure. During a 12-year period at the Texas Heart Institute, 13 patients with this congenital malformation ranging in age from 1 to 24 years underwent operation. The anomalous coronary artery was sutured or ligated, or both, close to the pulmonary artery in 3 patients, 2 before 1965. Aortocoronary bypass was performed in the remaining 10 patients, using an autogenous saphenous vein graft in 9 and a Dacron tube in 1. More recently a distal end-to-side anastomosis has been employed and is not the preferred method. If necessary, a pump oxygenator may be used to complete the procedure. The only death was that of the first patient in the series who underwent ligation of the left coronary artery and mitral annuloplasty for severe mitral insufficiency; Of the 12 patients available for long-term follow-up study, all but 1 were asymptomatic. Follow-up angiographic studies showed the graft to be patent in 7 patients; the longest period of graft patency was 8 years. Definitive operative therapy is preferable to simple ligation because it eliminates the left-to-right shunt from the right coronary artery to the pulmonary artery and establishes a double coronary artery system.     

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting

BACKGROUND: Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization. METHODS: From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique. RESULTS: There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses). CONCLUSIONS: A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.     

非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

Role of radial artery graft in coronary artery bypass grafting

The use of the radial artery (RA) as a coronary artery bypass graft has assumed a revival and thus a multitude of issues have arisen surrounding the routine and widespread use of this conduit in myocardial revascularization. There has been no uniformity regarding harvest techniques, assessment of the adequacy of hand collateral circulation, antispasm protocols, selection of target vessels, and the site of proximal anastomosis. It is widely believed and practiced that the RA should be harvested as a pedicle graft and preferably be used to bypass critically stenosed (>70% stenosis) coronary arteries. It is used either as a free graft with proximal anastomosis to the ascending aorta or as a composite arterial graft along with the left or right internal thoracic artery. The patency of RA grafts depends on the severity of the target coronary artery stenosis and target artery location rather than its use as an aortocoronary conduit or composite graft. In this article, we reviewed the current knowledge regarding the use of RA grafts as a coronary bypass conduit in an attempt to suggest a few acceptable strategies concerning the above issues in a given clinical scenario.     

Intraoperative right coronary artery obstruction due to aortic root prosthesis mismatch after aortic valve replacement—A case report

Iatrogenic intraoperative coronary artery ostial occlusion is quite rare and a dangerous complication of aortic valve replacement. Intraoperative vigilance and prompt intervention are required to manage this fatal complication. A case report of a 48‐year‐old female with normal coronaries who underwent aortic valve replacement and had right ventricle distension is described here. It seemed that the cause which led to right coronary ostial obstruction was due to prosthesis aortic root mismatch and it required bypass with a vein graft. Computed tomographic angiography of aortic root showed abutting of right coronary ostium by the aortic valve prosthesis     

Availability of the in situ right gastroepiploic artery for coronary artery bypass.

The right gastroepiploic artery (GEA) has been successfully used as a coronary bypass graft recently. We examined the in situ GEA graft length required from the pyloric portion to the site of coronary anastomosis at the time of operation. Measured GEA length was 17.0 +/- 1.7 cm for the posterior descending artery anastomosis in 17 patients, 17.8 +/- 1.7 cm for the main right coronary artery anastomosis in 13 patients, 22.0 +/- 2.3 cm for the posterolateral branch anastomosis in 7 patients, and 21.0 cm for the left anterior descending artery anastomosis in 1 patient. We examined 228 randomly selected abdominal angiograms and measured the internal diameter of the right GEA at every 2-cm interval from its origin. Probability of availability of the in situ GEA graft for each site of anastomosis was 97% to the right coronary artery and 88% to the anterior descending or the circumflex artery when the internal diameter of GEA was 1.5 mm or greater. From an anatomical standpoint, we concluded that the GEA can be assumed available without preoperative angiography.     

Management of aortic dissection that involves the right coronary artery.

A report on the follow-up of 11 patients who suffered from aortic dissection involving the right coronary artery and who underwent surgical treatment is reported. In two patients, the left coronary ostia was also affected. In seven patients, the dissection was acute and in four, chronic. The ascending aorta was substituted by a Dacron graft in all patients, and right coronary artery saphenous vein bypass or Gore-Tex graft to the coronary ostia or right coronary artery was performed in nine, and reimplantation of both dissected coronary in two. There were three early postoperative deaths (27.3%) caused by low-output syndrome and myocardial infarction. There were two late deaths. The six surviving patients were followed-up from 78 to 96 months (mean 83 months). This experience suggests that although carrying a high risk, the involvement of the coronary ostia in aortic dissection can be successfully managed if made before irreversible complications arise.     

Combined coronary artery bypass grafting and repair of aneurysm of the descending aorta.

The outcome of patients with thoracic or thoracoabdominal aortic aneurysm is often determined by the concomitant coronary artery disease. Two patients with thoracic and thoracoabdominal aortic aneurysm and concomitant single-vessel coronary artery disease underwent combined myocardial revascularization and repair of aortic aneurysm. The operations were performed through a left thoracotomy and thoracoabdominal incision with distal aortic perfusion using a partial femoro-femoral bypass and selective right lung ventilation. Coronary anastomoses were performed on the beating heart, and the aneurysm was replaced with a woven Dacron tube graft.     

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 report of Bentall procedure for annulo-aortic ectasia associated with right coronary artery dissection

A 30-year-old man who had annuloaortic ectasia associated with aortic insufficiency owing to marked annular dilatation was treated by replacement of the ascending aorta and aortic valve with a composite graft. It was necessary to transpose the origin of the coronary artery because of the development of dissection to right coronary ostia. We have applied the Bentall procedure with aorta coronary bypass between the right coronary artery and the aortic prosthesis with the use of saphenous vein graft. His post operative course is uneventful and engaging full work 18 month after operation. This technique is useful for the case of annuloaortic ectasia associated with difficulty coronary anastomosis such as coronary artery dissection, obstruction or dislocation.     

Coronary angioplasty for congenital obstruction of the left main coronary artery

We present three children who underwent coronary angioplasty for the surgical treatment of a congenital obstruction of the left main coronary artery. An azygos vein patch or graft was a feasible and useful material for reconstructing congenital ostial stenosis and atresia of the left main coronary artery.     

Reoperative off-pump coronary artery bypass surgery for restenosis after percutaneous coronary intervention as a part of hybrid revascularization chronic renal failure on hemodialysis; report of a case

60-year-old man on chronic hemodialysis had hybrid revascularization. Percutaneous coronary intervention (PCI) for right coronary artery (RCA) combined with left internal mammary artery-left anterior descending artery anastomosis through left anterior small thoracotomy were performed. But, frequent re-stenosis after PCI necessitated 4 repeated PCI. Finally, the patient agreed to re-do, and underwent reoperative off-pump coronary artery bypass through midsternotomy. Right internal mammary artery-saphenous vein lengthened composite graft was successfully anastomosed to heavily calcified RCA without heart-lung machine. Strategy of revascularization for hemodialysis patient was discussed.     

Anomalous origin and distribution of coronary arteries. Review of 38 patients who underwent operation.

Between October 1961 and December 1973, 38 patients with an anomaly in origin (15 patients) or distribution (23 patients) of the main coronary artery or one of its branches underwent operation at the Texas Heart Institute. The left coronary artery originating from the pulmonary artery occurred most frequently-in 13 of 15 patients. An aortocoronary artery bypass was performed in 12 patients with the saphenous vein used in ten of the 12, initially in 1965; and a Dacron tube graft in the other two. Of the 15 patients, only one died during the early period after operation. A follow-up of ten years revealed 11 asymptomatic patients; to date the longest period of patency of a saphenous vein graft is seven years in an 11-year-old girl. Of 23 patients with an unusual coronary artery distribution, 22 had tetralogy of Fallot, 20 of whom underwent total correction. In 21 of the 23 patients the left anterior descending coronary artery originated from the right coronary artery and crossed the right ventricular outflow tract. In two patients this abnormally distributed artery was injured through a vertical right ventriculotomy; both patients died from myocardial failure during the early postoperative period. Subsequently a transverse right ventriculotomy, either alone or combined with a right ventricular outflow and/or pulmonary artery patch enlargement was performed in 16 patients, and a double outlet right ventricle was created through insertion of a Dacron tube graft in two patients. With this method injury to the abnormal left anterior descending coronary artery was avoided and all 18 patients survived the operation. On the basis of our experience and today's advanced techniques, it is believed that most patients, including some under two years of age, can undergo correction of a left coronary artery originating from the pulmonary artery through insertion of a saphenous vein graft between the aorta and left coronary artery. During the surgical correction of cardiac anomalies necessitating a right ventriculotomy, a transverse or double incision in the right ventricular outflow tract in most patients will prevent injury to an abnormally distributed coronary artery branch; sometimes insertion of a Dacron tube graft between the right ventricular outflow tract and pulmonary artery is necessary.     

Right-sided reverse T composite arterial grafting to complete revascularization of the right coronary artery

Complete arterial revascularization for the right coronary artery is underused mainly due to technical issues. Herein we report on a new approach for complete arterial revascularization of arterial revascularization for the right coronary artery branches. Complete arterial revascularization for the right coronary artery revascularization was performed in 8 patients using a reverse T composite arterial graft. None of the patients suffered perioperative myocardial infarction. All patients underwent noninvasive coronary imaging, displaying an early patency rate of 100%. Complete arterial arterial revascularization for the right coronary artery revascularization using a reverse T graft offers a new paradigm with enhanced technical flexibility in performing all arterial myocardial complete revascularizations in selected patients.     

Right coronary ostial aneurysm following a bentall procedure

We report a case of a 69-year-old female with a previous Bentall procedure who developed a right coronary ostial aneurysm. The aneurysm was excluded with a Dacron patch and the right internal mammary artery was used to restore flow to the coronary artery.     

Graft-to-coronary-artery shunt during off-pump coronary artery bypass grafting

We have developed a simple technique for temporary shunt from the saphenous vein graft to the coronary artery during off-pump coronary anastomosis. The ends of a 2-mm diameter tube were inserted into the distal end of the saphenous vein graft in which proximal anastomosis had been established and into the right coronary artery crux. Blood flow sufficient to maintain adequate hemodynamics was obtained through the shunt tube while suturing around the tube. We successfully employed this technique in 5 patients with acute coronary syndrome. We suggest that this technique may represent an addition to the armamentarium for off-pump anastomosis to the right coronary artery.