Repeat Surgery for Coronary Artery Bypass Grafting: The Role of the Left Thoracotomy Approach
DOI:
https://doi.org/10.1532/HSF98.20091046Abstract
Objective: Repeat coronary artery bypass surgery has increased risks compared with the first operation, including low cardiac output and injury to patent grafts. The left thoracotomy approach has been advocated specifically in patients with intact grafts of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) needing lateral wall grafting. We have evaluated this technique in conjunction with an off-pump procedure in all patients.
Methods: There were 55 patients over an 8-year period, and 6 (10.9%) were female. The mean age was 63.2 years (range, 41-82 years), and the age at the time of the previous operation was 51.7 years (range, 31-69 years). Four patients (7.2%) underwent a third operation. Comorbidities were diabetes mellitus (25 patients, 45.5%), renal impairment (8 patients, 14.5%), calcified ascending aorta (9 patients, 16.4%), carotid disease (4 patients, 7.2%), and peripheral vascular disease (11 patients, 20.0%). Fifteen patients (27.2%) had previous coronary stents. Nine patients (16.4%) had a preoperative intra-aortic balloon pump. Predicted mortality (logistic EuroSCORE) was 14.2%.
Results: Forty-three patients (78.1%) had intact LIMA-to-LAD grafts. Twenty-two patients (40.0%) required a major posterolateral thoracotomy, and 33 patients (60.0%) had a minor thoracotomy. Thirteen patients (23.6%) had stents placed as a hybrid procedure during the same admission. Thirteen patients (23.6%) additionally underwent anterior wall grafting (LAD to the first marginal area). The LIMA was used in 7 patients where it had not been used before. There were 91 distal grafts (including 4 sequentials). We performed 54 venous grafts and 26 radial artery grafts. Twenty-one patients (38.1%) had 1 distal graft, 32 patients (58.1%) had 2 grafts, and 2 patients (3.6%) had 3 distal grafts performed (mean, 1.6 grafts/patient). The proximal graft site was the proximal descending aorta in 20.0% of the patients, the distal aorta in 67.5%, and the subclavian artery in 12.5%. In 10 patients (18.2%), the distal branches of the right coronary (posterior descendens or right posterolateral) were grafted. No patient required conversion to cardiopulmonary bypass or sternotomy. No patient needed an intra-aortic balloon pump postoperatively. The mean blood loss (24 hours) was 380 mL (range, 125-1100 mL), the mean ventilation time was 4.8 hours (range, 0-12 hours), the mean intensive care unit stay was 2.7 days (range, 2-8 days), and the mean hospital stay was 6.3 days (range, 5-20 days). There was 1 postoperative death (1.8% mortality). One late death occurred on follow-up. Four patients underwent cardiac catheterization for chest pain, and the grafts were shown to be open.
Conclusion: The procedure is safe, especially in patients with intact LIMA-to-LAD grafts needing lateral and inferior wall revascularization. Multislice computed tomography scanning allows better preoperative planning, especially regarding the site of implantation of the proximal graft, allowing a less invasive incision. The off-pump technique preserves cardiac and pulmonary function. The in-hospital death rate (1.8%) compares very well with the EuroSCORE-predicted mortality (14.2%).
References
Allen KB, Matheny RG, Robison RJ, Heimansohn DA, Shaar CJ 1997. Minimally invasive versus conventional reoperative coronary artery bypass. Ann Thorac Surg 64:616-22.nAzoury FM, Gillinov AM, Lytle BW, Snedira NG, Sabik JF 2001. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg 71:1959-63.nBaumgartner FJ, Gheissari A, Panagiotides GP, Capouya ER, Declusin RJ, Yokoyama T 1999. Off-pump obtuse marginal grafting with local stabilization: thoracotomy approach in reoperations. Ann Thorac Surg 68:946-8.nBenetti FJ, Naselli G, Wood M, Geffner L 1991. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 100:312-6.nBonatti J, Coulson AS, Bakhshav SA, Posch L, Sloan TJ 2000. The subclavian and axillary arteries as inflow vessels for coronary artery bypass grafts - combined experience from three cardiac surgery centres. Heart Surg Forum 3:307-11.nBoonstra PW, Grandjean JG, Mariani MA 1997. Reoperative coronary bypass grafting without cardiopulmonary bypass through a small thoracotomy. Ann Thorac Surg 63:405-7.nBurlingame MW, Bonchek LI, Vazales BE 1988. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovascular Surg 95:508-10.nByrne JG, Aklog L, Adams DH, Cohn LH, Aranki SF 2001. Reoperative CABG using left thoracotomy: a tailored strategy. Ann Thorac Surg 71:196-200.nCalafiore AM, Suma H 1996. Radial artery from left subclavian artery in redo coronary artery bypass grafting. Ann Thorac Surg 62:901-2.nD'Ancona G, Karamanoukian H, Lajos T, Ricci M, Bergsland J, Salerno T 2000. Posterior thoracotomy for reoperative coronary artery bypass grafting without cardiopulmonary bypass: perioperative results. Heart Surg Forum 3:18-22; discussion 22-3.nDe Oliveira SA, Lisboa LA, Dallan LA, Puig LB, Succi GM, Abreu Filho CA 2004. Limited left thoracotomy for reoperative coronary artery bypass grafting without cardiopulmonary bypass for circumflex grafting in patients with patent internal thoracic artery graft. Heart Surg Forum 7:22-6.nDobell ARC, Jain AK 1984. Catastrophic haemorrhage during redo sternotomy. Ann Thorac Surg 37:273-8.nFanning WJ, Kakos GS, Williams TE Jr. 1993. Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 55:486-9.nFaro RS, Javid H, Najafi H, Serry C 1982. Left thoracotomy for reoperative coronary bypass. J. Thorac Cardiovasc Surg 84:453-5.nGandjbakhch I, Acar C, Cabrol C 1989. Left thoracotomy approach for coronary artery bypass grafting in patients with pericardial adhesions. Ann Thorac Surg 48:871-3.nGrosner G, Lajos TZ, Schimert G, Bergsland J 1990. Left thoracotomy reoperation for coronary artery disease. J Card Surg 5:304-8.nKuniyoshi Y, Yamashiro S, Miyagi K, Uezu T, Arakaki k, Koja K 2003. Off-pump redo coronary artery bypass grafting via left thoracotomy. Ann Thorac Surg 9:378-83.nRandolph Bolton JW 1997. Left thoracotomy for reoperative revascularization of the posterior coronary circulation. J Cardiovascular Surg (Torino) 38:404-10.nShennib H, Benhameid O 2005. Sequential subxiphoid and thoracotomy incisions with graft pull though for targeted redo multivessel surgical revascularization. Ann Thorac Surg 80:350-2.nUngerleider RM, Mills NL, Wechsler AS 1985. Left thoracotomy for reoperative coronary artery bypass procedures. Ann Thorac Surg 40:11-5.n
