Cardiothoracic Surgery |

Two-Vessel Off-Pump Coronary Artery Bypass Grafting by Left Thoracotomy in a Complex Redo Case FREE TO VIEW

Shinya Unai, MD; Hitoshi Hirose, PhD; Nicholas Cavarocchi, MD; John Entwistle, PhD
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Thomas Jefferson University Hospital, Philadelphia, PA

Chest. 2013;144(4_MeetingAbstracts):97A. doi:10.1378/chest.1703903
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SESSION TITLE: Surgery Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: The risk of redo coronary artery bypass grafting surgery (CABG) is significantly higher than primary CABG.1 Left thoracotomy is an alternative to avoid complications associated with re-sternotomy, although visualization of the target vessels may be limited.

CASE PRESENTATION: An 83-year-old male with a history of three prior sternotomies including CABG, redo CABG, and aortic valve replacement 20, 19 and 12 years ago, respectively, presented with unstable angina. His symptoms continued on intravenous heparin and nitroglycerin. Cardiac catheterization showed left main and triple-vessel disease. Saphenous vein graft (SVG) to the RCA was diseased but patent, and the SVG to the left anterior descending (LAD) artery was occluded. Because of the location and nature of the lesions, catheter intervention was not feasible. Preoperative CT scan showed heavily calcified ascending aorta (Figure 1), but minimal disease in the descending aorta. The patient underwent a left thoracotomy off-pump CABG using the SVG from the descending aorta to obtuse marginal (OM) branch (Figure 2), and left radial artery from the SVG to LAD. The HeartString and Acrobat (Maquet, Inc.) were used for the proximal and distal anastomoses, respectively. Technically, exposure of the OM was straight-forward but exposure of the LAD was a challenge due to prior adhesions. Coronary angiography prior to discharge showed patent grafts.

DISCUSSION: Left thoracotomy off-pump CABG has been used mainly to bypass the LAD territory using the mammary artery with good outcomes.2 However, CABG from the descending aorta using free grafts is uncommon. It is most useful in patients with a hostile chest and/or calcified ascending aorta.

CONCLUSIONS: Redo CABG is a technical challenge, but alternate approaches may minimize risk in these complex cases. Preoperative planning is critical to ensure that all territories can be accessed.

Reference #1: Nishi H, Mitsuno M, Yamamura M, et al. Safe approach for redo coronary artery bypass grafting--preventing injury to the patent graft to the left anterior descending artery. Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 2010; 16: 253-8.

Reference #2: Gauze T, Rosa Fde A, Salvi Junior WF, et al. Left mini-thoracotomy off-pump coronary revascularization. Revista brasileira de cirurgia cardiovascular : orgao oficial da Sociedade Brasileira de Cirurgia Cardiovascular. 2007; 22: 111-5.

DISCLOSURE: The following authors have nothing to disclose: Shinya Unai, Hitoshi Hirose, Nicholas Cavarocchi, John Entwistle

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