Single left coronary artery with separate origins of proximal and distal right coronary arteries from left anterior descending and circumflex arteries – a previously undescribed coronary circulation

A single left coronary artery with right coronary artery arising from either left main stem (LMS) or left anterior descending artery (LAD) or circumflex artery (Cx) is an extremely rare coronary anomaly. This is the first report of separate origins of proximal and distal RCA from LAD and circumflex arteries respectively in a patient with a single left coronary artery. This 57 year old patient presented with unstable angina and severe stenotic disease of LAD and Cx arteries and underwent urgent successful quadruple coronary artery bypass grafting. The anomalies of right coronary artery in terms of their origin, number and distribution are reviewed.     

Anesthetic management of concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy

This case report describes an anesthetic management of a patient who received successful concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy. A 66-year-old man presented for left lower lobectomy. His medical history included angina pectoris under control with isosorbide and nifedipine. Preoperative coronary angiography revealed multiple stenosis [100% at right coronary artery (# 2), 99% at left anterodescending artery (# 7) and 90% at left circumflex artery (# 11)]. Concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy were scheduled. Anesthesia was maintained with combined total intravenous anesthesia (propofol and fentanyl) and continuous thoracic epidural anesthesia. Postoperative pain was well controlled with continuous epidural analgesia (TEA) and patient control analgesia (PCA). There were no signs of postoperative respiratory complications and myocardial ischemia. Combined total intravenous and continuous thoracic epidural anesthesia has multiple benefits for concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy.     

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.     

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.     

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

Coronary artery bypass grafting without cardiopulmonary bypass: MIDCAB and OPCAB

Minimally invasive direct coronary artery bypass grafting via left anterior small thoracotomy (MIDCAB) and coronary artery bypass grafting without cardiopulmonary bypass (OPCAGB) are accepted technique as less invasive than conventional coronary artery bypass grafting (CABG). We reported our experience with these procedures. From 1996 to December 1999, 176 patients underwent MIDCAB or OPCAB with the internal thoracic artery. The left internal thoracic arteries were used for grafting of the left anterior descending artery (LAD) in 131 patients, LAD and diagonal branches sequentially in 8 patients, using free radial artery conduits for grafting of the right coronary artery (RAC) or left circumflex (LCx) in 7 patients, using radial artery conduits as Y-graft from LAD for grafting of the RAC or LCx in 24 patients, and bilateral internal thoracic artery grafting was performed in 4 patients. One patient (0.6%) died in the hospital. One patient (0.6%) had perioperative myocardial infarction. No patient had cerebrovascular accident and sever wood infection. One-hundred-seventy-four patients (98.8%) had resolution of their angina symptom.     

Coronary artery bypass grafting for a patient with Tangier disease

A 56-year-old man with Tangier disease suffering from angina pectoris due to triple-vessel coronary artery disease evidenced extremely low blood high-density lipoprotein of 1 mg/dl, a specific laboratory indicator of this rare genetic disorder of lipid metabolism, considered to accompany juvenile arteriosclerosis. Because of the calcified ascending aorta, we conducted combined minimally invasive coronary artery bypass (CAB) for the left anterior descending coronary artery and percutaneous transluminal coronary angioplasty for other coronary artery lesions initially instead of conventional coronary artery bypass grafting. Angina recurred, however, due to refractory restenosis of the left circumflex coronary artery lesion. Two years later, we redid the CAB, grafting the free right internal thoracic artery from the functional left internal thoracic artery sequentially onto obtuse marginal and posterolateral coronary arteries. The patient returned to work angina-free.     

Myocardial revascularization using bilateral internal mammary arteries for total occlusion of LMCA in an adult case: sequelae of Kawasaki's disease in childhood

A 43-year-old female patient suffering from effort angina underwent coronary artery bypass grafting. Coronary arteriogram demonstrated complete occlusion of the left main, proximal circumflex (Cx), and proximal left anterior descending coronary arteries (LAD) and a nonocclusive fusiform calcified aneurysm of the proximal right coronary artery (RCA). The left coronary artery system opacified via collateral vessels from the RCA. No other abnormalities were found in the entire aorta and its major branches. Myocardial revascularization was performed using the right IMA to bypass to the Cx and the left IMA to bypass to the LAD successfully. Prior to the operation, she had neither coronary risk factors nor inflammatory signs, though she had experienced fever of unknown origin lasting about a week when she was 11 years old. Accordingly we supposed that such coronary arterial lesions might have arisen from Kawasaki's disease in her childhood.     

Coronary artery spasm producing Prinzmetal's angina and myocardial infarction in the absence of coronary atherosclerosis. Surgical treatment

This report describes a patient with typical Prinzmetal's variant angina, myocardial infarction, ventricular arrhythmias, and complete heart block who had a single left coronary artery and no coronary atherosclerosis. At the time of coronary arteriography, spasm was documented in the midportion of the dominant circumflex vessel. Saphenous vein bypass grafting was accomplished to the distal circumflex artery with temporary relief of all symptoms. There was, however, a recurrence of typical Prinzmetal's variant angina, and on restudy the vein graft anastomosis was seen to be closed at the area where competitive flow would be expected. Saphenous vein bypass grafting appears not to be the treatment of choice in patients with Prinzmetal's variant angina in the absence of high-grade atherosclerotic lesions.     

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.     

Simultaneous coronary artery bypass grafting and ascending aorta bifemoral bypass in small aorta syndrome.

A 55-year-old man with severe coronary artery disease and aortoiliac occlusive disease with small aorta syndrome was admitted to our department with angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery with a markedly hypoplastic infrarenal aorta only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in-situ right internal mammary artery graft, an autologous saphenous vein graft, and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and bifemoral arteries were patient. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease, especially in those with small aorta syndrome.     

Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle.

BACKGROUND: Single-vessel coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality rate. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass for total revascularization of the left ventricle using multiple arterial grafts. METHODS: Limited lateral thoracotomy was performed in the fourth or fifth intercostal spaces, exposing the left anterior descending coronary artery and left circumflex coronary artery. Two or three arterial grafts were harvested. Revascularization of the left anterior descending coronary artery and the left circumflex coronary artery were performed in 20 patients without cardiopulmonary bypass through the limited lateral thoracotomy using complex performed arterial grafts. In 4 patients, triple- and quadruple-vessel grafting was performed. RESULTS: The mean coronary cross-clamp time was 14.5+/-4.0 minutes for the left anterior descending coronary artery and 16.8+/-5.1 minutes for the left circumflex coronary artery. No early deaths or postoperative complications occurred. There were no late deaths or angina during the mean follow-up of 7.0 months (range, 2 to 22 months). Postoperative coronary angiography demonstrated widely patent grafts in all patients. CONCLUSIONS: Minimally invasive approach through a limited thoracotomy in multiple coronary artery bypass graftings are technically feasible and may be an alternative approach in the complete revascularization of the left ventricle. Mechanical immobilization of the coronary artery enhances early graft patency and is an essential part of this procedure.     

A case of bilateral internal thoracic artery bypass grafting in sudden death survivor with multivessel coronary spasms

We report a 58-year-old male with a history of cardiac arrest due to coronary artery spasm, preoperative coronary arteriograms showed multivessel coronary spasm after the administration of ergonovine maleate associated with triple vessel fixed stenotic lesions. Under the use of cold diltiazem potassium-blood cardioplegic solution to prevent perioperative coronary spasm, coronary artery bypass grafting was performed. The right internal thoracic artery (ITA) was anastomosed to the left anterior descending artery and the left ITA to the circumflex artery. A saphenous vein graft was anastomosed to the right coronary artery. The postoperative course was uneventful. In postoperative coronary angiography with ergonovine stimulation, neither ITA grafts showed spastic changes, and the coronary artery distal to the anastomotic sites were well perfused through the ITA grafts. The patient has been free of angina without administration of calcium antagonist and been doing well for 2 years and 5 months since the operation.     

Iatrogenic coronary artery stenosis following aortic valve replacement.

Until recnetly, coronary arterial perfusion was one of the best methods to protect myocardium during aortic valve replacement. However, the insertion of perfusion cannulas may produce immediate traumatic lesions and late stenosis of the coronary arteries, with grave consequences. Two patients with normal coronary arteries prior to operation developed obstruction of the maximal left main coronary artery following aortic replacement. One of these patients represents the first case of iatrogenic coronary arterial stenosis in which the aortic valve was replaced with a porcine bioprosthesis. Accelerating angina pectoris and ventricular arrhythmias were the presenting clinical manifestations. Aorta-coronary bypass grafting to the left anterior descending and circumflex coronary arteries was successfully performed in one patient, while the other patient died before investigative procedures could be undertaken. Any patient whose aortic valve has been replaced and who develops angina pectoris a few months after operation should be suspected of having developed stenosis of the proximal coronary artery. Coronary angiography should be perfomed promptly. Once the lesion is recognized, the operaiton should be performed posthaste because these lesions are life threatening owing to their proximal location and rapid evolution.     

Off-pump coronary artery bypass grafting in a patient with paroxysmal nocturnal hemoglobinuria.

Paroxysmal nocturnal hemoglobinuria has not been described in patients undergoing off-pump coronary artery bypass grafting. A 65-year-old man who underwent percutaneous coronary stenting to the proximal left anterior descending artery for unstable angina was readmitted to our hospital complaining of recurrent chest pains. A coronary angiography revealed in-stent restenosis and new lesions of the distal left anterior descending artery as well as the left circumflex artery branch. He was found to have paroxysmal nocturnal hemoglobinuria which contributes to serious surgical complications including infection, bleeding, hemolysis and acute renal failure. After pancytopenia was treated with administration of granulocyte colony stimulating factor and transfusion of the washed red blood cells preoperatively, off-pump coronary artery bypass grafting was performed. Cardiopulmonary bypass was avoided in order to reduce activation of complements. His postoperative course was uneventful. Combination of appropriate perioperative management and off-pump cardiac surgery yielded an effective result in treating this patient without major complications.     

Off-pump coronary artery bypass grafting in a patient with paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria has not been described in patients undergoing off-pump coronary artery bypass grafting. A 65-year-old man who underwent percutaneous coronary stenting to the proximal left anterior descending artery for unstable angina was readmitted to our hospital complaining of recurrent chest pains. A coronary angiography revealed in-stent restenosis and new lesions of the distal left anterior descending artery as well as the left circumflex artery branch. He was found to have paroxysmal nocturnal hemoglobinuria which contributes to serious surgical complications including infection, bleeding, hemolysis and acute renal failure. After pancytopenia was treated with administration of granulocyte colony stimulating factor and transfusion of the washed red blood cells preoperatively, off-pump coronary artery bypass grafting was performed. Cardiopulmonary bypass was avoided in order to reduce activation of complements. His postoperative course was uneventful. Combination of appropriate perioperative management and off-pump cardiac surgery yielded an effective result in treating this patient without major complications.     

Coronary artery bypass grafting using a bifurcating radial artery

A 61-year-old man with angina pectoris was admitted for elective coronary artery bypass grafting. The left anterior descending artery, and the two posterolateral branches (PLA1 and PLA2) of the circumflex artery required bypass grafting. At operation, the distal portion of the left radial artery was found to bifurcate, both branches having an equal size. We decided to use the bifurcating radial artery as a conduit for bypass grafting to the branches of the left circumflex artery. One distal end of the radial artery was subsequently anastomosed to the PLA1 branch and the other distal end was anastomosed to PLA2. Postoperative coronary angiography showed both branches of the radial artery to have good patency.     

Reoperations with the Right Gastroepiploic Artery without Cardiopulmonary Bypass

A bstract The right gastroepiploic artery (RGEA) has been utilized as the bypass conduit on the inferior surface of the heart with a minimally invasive approach. Fourteen patients had reoperative coronary bypass surgery for severely symptomatic single-vessel disease of the right coronary artery. All surgeries were performed since May 1996. A small mid-line incision including splitting of the lower sternum gave excellent exposure. The inferior surface of the heart was dissected to expose and stabilize the target vessel. The heart rate was controlled with a diltiazem drip. Cardiopulmonary bypass was not necessary in any case. The right coronary artery was bypassed in three patients, the posterior descending artery branch in ten patients, and the terminal circumflex of the left coronary artery in one. After grafting, patency of the anastomosis was demonstrated by Doppler echocardiogram. Two patients had left anterior descending artery (LAD) grafts with LIMA (left mammary artery) and RGEA grafts performed simultaneously with two port access incisions. No patient had perioperative mortality or complications. No patient had recurrent angina. Doppler color echocardiographic imaging studies before discharge confirmed patency of the graft in 13 of 14 cases. In one case, the gastroepiploic artery could not be visualized. Angiographic visualization was positive in seven cases; seven patients were not studied yet. The gastroepiploic artery is an excellent conduit for vascularization of the inferior aspect of the heart. The operation can be done with a minimally invasive technique and without the use of cardiopulmonary bypass. This approach seems especially applicable in selective reoperative cases.     

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.     

Aorto-coronary saphenous vein bypass grafting in a patient with a single coronary artery arising from the right aortic sinus

A patient who presented with severe angina was found to have an ectopic origin of the entire left coronary system, the left main coronary artery arising from the proximal third of the right coronary artery. Atherosclerotic obstructive lesions were present in the right coronary artery, the left anterior descending artery, and the obtuse marginal branch of the left circumflex coronary artery. The three obstructed vessels were bypassed, using autologous saphenous veins. The patient continues to do well 24 months after his operation. We believe that coronary artery bypass should be carried out in symptomatic patients with abnormal coronary anatomy and atherosclerotic disease.