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 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.     

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.     

Coronary artery bypass grafting to left anterior descending coronary artery diagnosed by multidetector-row computed tomography

A 64-year-old male received coronary angiography because of chest pain. Although coronary angiography showed total occlusion of right coronary artery (RCA) # 2 and left anterior descending branch (LAD) #6, and a significant stenosis of left circumflex (LCx) #11, it could not visualize LAD distal to LAD # 6. Since coronary multidetector-row computed tomography (MD CT) could visualize the distal LAD, coronary artery bypass grafting (CABG) was indicated for this patient. Left internal thoracic artery (LITA) was anastomosed to LAD and saphenous vein graft (SVG) was used for distal anastomoses to obtuse marginal branch (OM) and 4-posterior descending branch (# 4 PD). Postoperative course was uneventful. LITA anastomosed to LAD and SVG to OM and # 4 PD were visualized by postoperative coronary angiography. MD CT in addition to coronary angiography was demonstrated useful to assess precise lesions of the coronary artery disease in this case.     

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.     

Fate of the graft and native vessel following endarterectomy of the left anterior descending coronary artery.

In 16 patients who underwent endarterectomy of the left anterior descending (LAD) coronary artery combined with saphenous vein bypass grafting between Aug. 1, 1976 and July 31, 1978, the results of preoperative and postoperative angiography were comparable. Most patients had obstruction or severe stenosis of the proximal LAD coronary artery together with a poor runoff as demonstrated angiographically. Eighteen vein grafts were placed in the LAD artery and 15 (83%) were satisfactorily patent. Six of 18 grafted arterial segments became occluded distal to the site of graft insertion, but in most cases there was sufficient proximal runoff to maintain graft patency. In this study intraoperative measurements of graft flow were predictive of graft or distal vessel patency, or both. Careful postoperative assessment of the results of this technique seems warranted.     

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.     

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.     

Left Thoracotomy and Femoro-Femoral Bypass for Reoperative Revascularization of the Posterior Coronary Circulation

Left thoracotomy and femoro-femoral cardiopulmonary bypass has been used for reoperation in five patients requiring coronary bypass graft into the inferolateral surface of the heart. Five patients had refractory angina pectoris and angiographic occlusion of lateral wall native vessels or previous occluded vein grafts and all had positive exercise test. Four of the five had patent internal mammary to the LAD. Following supine positioning and removal of the saphenous vein and isolation of the femoral artery and femoral vein, a left fifth interspace thoracotomy was made, the patient heparinized and cannulated for cardiopulmonary bypass, the pericardium opened, the heart dissected free, and either the internal mammary artery dissected off the left chest wall or saphenous vein grafts used to bypass the appropriate lesions. The proximal inflow was the descending thoracic aorta making tunnels for the vein grafts through the posterior pericardium. All of the patients did well in the postoperative period. This technique is recommended for reoperations in patients with documented inferolateral ischemia as the primary cause of symptomatology with mitigating circumstances against an anterior approach.     

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.     

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.     

Off-pump redo coronary artery bypass grafting

BACKGROUND: Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique. METHODS: Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta. RESULTS: Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days. CONCLUSIONS: In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.     

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.     

Aortocoronary saphenous vein autograft accidentally attached to a coronary vein: follow-up angiography and surgical correction of the resultant arteriovenous fistula.

The fate of aortocoronary saphenous vein bypass graft to the left anterior descending (LAD) coronary vein is reported. The vein graft communicated with the coronary sinus through the proximal LAD vein, producing a functional coronary arteriovenous fistula. The LAD vein was totally occluded distally at follow-up four months after operation. The natural history of congenital fistulas between coronary arteries and the coronary sinus suggested that bacterial endocarditis, pulmonary hypertension, and cardiac failure were all possible future complications in this patient. Operation was performed to revascularize the LAD artery to relieve persistent angina, and to close the fistula. Postoperative angiography showed a patent graft to the LAD artery with complete obliteration of the fistula. The patient is asymptomatic ten months after operation.     

Minimally invasive direct redo coronary artery bypass grafting.

Redo coronary artery bypass grafting due to graft failure and the progression of new lesions has been increasing in frequency recently. We are often forced to revascularize only the left anterior descending artery (LAD) in very elderly patients with a high risk to median sternotomy. We performed reoperative minimally invasive direct coronary artery bypass grafting (MIDCABG) in seven patients. The target sites were as follows: LAD, 7; first diagonal branch, 1; and the graft material was the left internal thoracic artery (LITA), 7; and saphenous vein graft (SVG), 1. Complete revascularization was accomplished in all patients, by including hybrid therapy in three patients and axillo-coronary bypass grafting with SVGs in two patients. Postoperative angiography showed all patent grafts and all patients were discharged. During a mean follow-up period of 2.4 years (range: 0.5 to 3.5 years), all were free from cardiac events, except for one patient who had recurrent angina due to failure of a previously patent graft 3 years after redo MIDCAB. These results suggest that MIDCABG via left antero-lateral thoracotomy is an effective and safe technique in redo cases, as well as an alternative procedure for hybrid revascularization that combines minimally invasive revascularization of LAD with additional catheter interventional therapy.     

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.     

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.     

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.     

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.     

Evaluation of postoperative flow reserve in internal mammary artery bypass grafts

The internal mammary artery has been advocated for use in bypass grafting owing to its superior long-term patency when compared to saphenous vein grafts. Concern exists that the flow through the internal mammary artery may be inadequate during periods of peak myocardial demand. This flow was investigated in 24 consecutive patients with a mean proximal left anterior descending artery stenosis of 87.5% who were selected for coronary bypass using the internal mammary artery. Within 8 weeks of operation, all were evaluated by exercise thallium 201 scintigraphy. Thallium activity, expressed as a ratio of anteroseptal activity to posterolateral wall activity (or inferior wall activity if the posterolateral wall was deemed abnormal), was 0.97 +/- 0.15. A second group of 25 patients, with normal coronary arteries, was similarly evaluated. The mean septal to posterolateral wall thallium activity ratio for these control patients was 1.0 +/- 0.15. A third group of 26 patients who underwent single-vessel percutaneous transluminal coronary angioplasty of the left anterior descending artery and a fourth group of 28 saphenous vein graft recipients were compared by stress thallium scintigraphy. Thallium 201 activity for the vein graft group (0.96 +/- 0.19) was not significantly different from that for the mammary artery group, whereas the flows obtained with a single attempt at angioplasty were significantly inferior (p less than 0.05). The internal mammary artery provides excellent coronary flow at peak myocardial demand and compares favorably to angioplasty and saphenous vein grafting.