Redo coronary artery bypass grafting can be technically challenging, presenting the surgeon with the difficulty of sternal re-entry with patent grafts, more advanced coronary disease, and typically sicker patients. This video features a case of a left thoracotomy to spare a patient undergoing a redo CABG from repeat sternotomy. A significant, unstentable obtuse marginal was revascularized from the descending thoracic aorta with a saphenous vein graft (SVG).
Patient Presentation
A seventy-three-year-old woman was referred for redo coronary artery bypass grafting. She had undergone CABG x5 (Radial – LAD, Radial Y-Graft – D2, Radial – OM1, SVG sequential to mid-RCA, and PDA (the LIMA had not been used as it was a small, atretic vessel)) ten years prior. She had been well and symptom free until two months prior, when she developed worsening exertional angina and associated shortness of breath and fatigue. Repeat coronary angiography revealed four patent grafts; however, a radial graft to a large obtuse marginal branch had occluded. An attempt to stent the native left main and circumflex coronary artery was unsuccessful because of severe calcification of the left main, so she was referred for redo CABG.
At the first operation, her pericardium had been left open because of hemodynamic instability when it was closed. Given the risks of a repeat sternotomy in this setting, and the lesser insult posed by left thoracotomy, this approach was chosen.
Surgical Technique and Video
The patient was intubated with a double lumen tube. The lower limbs were prepped and draped, and the long saphenous vein was harvested from the right thigh via an open, no-touch technique. The thigh incision was then closed in layers. Following this, the patient was turned to the right lateral decubitus position and redraped.
A sixth intercostal space left postero-lateral thoracotomy was performed. The seventh rib was shingled to facilitate access. Then, the left lung was isolated. Adhesions between the lung and the pericardium were divided, and the left lung was packed to the superior end of the thoracic cavity to keep an open operative field.
The pericardium was visualized, and the phrenic nerve was identified. The pericardium was opened posterior to the phrenic. Then the pericardial adhesions were taken down. Retraction sutures were placed on pericardium. Next, the radial graft was identified, and it was atretic and small. Heparin was then administered. The distal target was identified, and the lateral wall was stabilized with a Maquet off-pump coronary stabilizer.
The artery was opened and shunted with a 1.75mm intracoronary shunt. The SVG to coronary artery anastomosis was fashioned using 7-0 Prolene. The CO2 blower was utilized to improve exposure.
An area of the descending aorta in proximity to the pericardial opening was prepared for the proximal anastomosis. The aorta was cross-clamped with a side-biting vascular clamp. The venous conduit was fashioned to length. The aorta was incised, and a punch was used to fashion the aortic opening. The anastomosis was then performed using 6-0 Prolene. Hemostasis was checked, and the lung was reinflated under vision to ensure no kinking of the graft.
Outcome and Discussion
The patient made a good recovery and was discharged home six days after operation. At follow-up, she had no angina and her exercise tolerance had returned to her excellent baseline level of function.
Redo CABG to the lateral wall can be safely performed via left thoracotomy, obviating the risks of a redo sternotomy in the setting of other patent grafts. It is less time-consuming than a redo sternotomy and avoids the risk of damage to patent grafts, as well as issues with bleeding from dissection of pericardial adhesions. Additionally, utilizing an off-pump technique also avoids the morbidity associated with redo on-pump surgery, decreasing coagulopathy and reducing the risk of stroke and the need for cannulation for cardiopulmonary bypass.
References
- Ghanta RK, Kaneko T, Gammie JS, Sheng S, Aranki SF. Evolving trends of reoperative coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. JTCVS. 145 (2): 364-372. 2013.
- Nishi H, et al. Safe approach for redo coronary artery bypass grafting – preventing injury to the patent graft to the left anterior descending artery. Ann Thorac Cardiovasc Surg. 16 (4): 253-258. 2010.
- Bakaeen FG, Akras Z, Svensson LG. Redo coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg. 34 (S3): 272-278. 2018.
- Zoury, FM, Gillinov AM, Lytle BW, Smedira NG, Sabik JF. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg. 71 (6): 1959-1963. 2001.
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