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Ann Thorac Surg 1995;60:1063-1066
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Coronary Artery Reoperation Through the Left Thoracotomy With Hypothermic Circulatory Arrest

Department of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan

Accepted for publication May 2, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The left thoracotomy approach to avoid injury of the patent old graft and the myocardium with mid sternal reentry at coronary artery reoperation.

Methods. The left thoracotomy approach was used in 13 patients. There were 11 men and 2 women with a mean age of 63 years, ranging from 39 to 75 years. Three patients were having their third coronary bypass operation. In 11 patients, distal anastomoses were performed under circulatory arrest with moderate hypothermia. In the other 2 patients, distal anastomoses were performed on a beating heart. No aortic cross-clamp was applied in all patients. The mean number of distal anastomoses was 1.8; the grafted vessels were 11 anterior descending, 3 diagonal, 8 circumflex, and 1 posterolateral coronary arteries. Used grafts were 17 saphenous veins, 4 left internal thoracic arteries, and 2 gastroepiploic arteries. Inflow sites of the free graft were descending aorta in 10 patients and left subclavian artery in 3 patients.

Results. All patients were alive and well at the mean follow-up of 16 months, and all grafts were patent.

Conclusions. The left thoracotomy approach is safe and effective for reoperation on the left coronary artery system, and circulatory arrest is convenient and safe for performing distal anastomosis.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
With increasing numbers of coronary artery reoperations, various surgical techniques have been attempted to perform the reoperation safely. For those patients who have patent old grafts and suspected severe adhesion of anterior mediastinum, the left thoracotomy approach has been reported as an effective alternative. We performed coronary artery reoperation through a left thoracotomy in 13 patients in 2 years, and satisfactory results were obtained with routine use of hypothermic circulatory arrest for performing distal anastomoses.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
From June 1992 to October 1994, 13 patients underwent coronary artery reoperation through a left thoracotomy at Mitsui Memorial Hospital. There were 11 men and 2 women with a mean age of 63 years, ranging from 39 to 75 years (Table 1). Three patients were undergoing their third coronary artery operation. The mean duration from the primary operation to the present reoperation was 6 years, ranging from 6 months to 19 years. Two patients had double-vessel disease, 7 patients had triple-vessel disease, and 4 patients had left main disease. Mean preoperative left ventricular ejection fraction was 0.48, ranging from 0.36 to 0.72. There was one urgent operation under the support of intraaortic balloon pumping. Associated diseases were insulin-dependent diabetes in 2 patients, femoroiliac artery stenosis in 2 patients, and chronic renal failure with hemodialysis and abdominal aortic aneurysm in 1 patient each. In 7 patients remarkable calcification was found in the ascending aorta by preoperative computed tomographic scan or chest roentgenogram.

Surgical Procedure
The patient is positioned in the semispiral right lateral decubitus position, and the saphenous vein or the gastroepiploic artery (free graft) is harvested while the femoral artery and vein are exposed. Then the left fourth (6 patients) or the fifth (7 patients) interspace thoracotomy is made. Entering the chest through the fourth intercostal space with detachment of the fifth rib is preferable when the left subclavian artery is planned to be the inflow site of the graft. The left internal thoracic artery (ITA) is taken down if usable, and its proximal dissection is not necessary above the second rib because the ITA easily reaches the left anterior descending artery (LAD) in this position with shorter length than with a median sternotomy because sternal retraction is not necessary.

The femoral artery and the femoral vein are cannulated under systemic heparinization. In 2 patients who had stenosis in the iliac artery, arterial cannulation was made at the descending aorta. No vent is necessary unless aortic valve insufficiency is present because sufficient venous drainage can be obtained with insertion of a long venous cannula from femoral vein up to the right atrium. We currently prefer to use a 28French thoracic catheter (Argyl Inc) or a 28F to 33F long femoral vascular cannula (Dideco, Mirandola, Italy) for this purpose as a long venous cannula. When it is difficult to pass the cannula through the iliac bifurcation, we use a Forgarty balloon catheter, inserting through the cannula into the iliac vein and the inferior vena cava as a guide, and then the cannula is safely introduced into the inferior vena cava and the right atrium.

Proximal anastomosis of the free graft is made to the descending aorta or to the left subclavian artery before institution of cardiopulmonary bypass. Then cardiopulmonary bypass is instituted and the body is cooled down to 25°C, the pericardium is opened, and target coronary arteries are exposed. The target coronary artery is easily detectable by tracing the old vein graft if it is present. Injury to the phrenic nerve should be avoided at the time of pericardial incision.

Through the thoracotomy, LAD, diagonal, and circumflex arteries are well visualized. When the optimal hypothermia, a rectal temperature of 25°C, is obtained and the heart is fibrillated, cardiopulmonary bypass is stopped while each distal anastomosis is performed. Under circulatory arrest, a bloodless field can easily be obtained and widely open coronary arteriotomy makes anastomosis easier than with local isolation by retraction of the coronary artery.

The necessary duration of circulatory arrest for each distal anastomosis is usually less than 10 minutes. When the anastomosis is completed, extracorporeal circulation is instituted again for observing anastomotic leakage and providing blood flow to the brain for a few minutes, then we move on to the next anastomosis. After the final anastomosis is completed, the patient is rewarmed and the heart is defibrillated.

As shown in Table 1, distal anastomosis was performed on a beating heart with (patient 1) and without (patient 2) cardiopulmonary bypass in 2 patients. In the remaining 11 patients, all distal anastomoses were performed under circulatory arrest except one saphenous vein anastomosis to the circumflex artery, which was done with coronary artery local isolation under cardiopulmonary bypass (patient 3). No aortic cross-clamp was applied in all patients.

The mean number of distal anastomoses was 1.8 (range, 1 to 3); the grafted coronary arteries were 11 LAD, 3 diagonal, 8 circumflex, and one posterolateral branch of the right coronary artery. In patients 5 and 9, LAD was ungraftable. The grafts used were 17 greater saphenous veins, 4 left ITAs, and 2 gastroepiploic arteries. All ITAs were used as in situ grafts. All gastroepiploic arteries were used as free grafts, and those proximal ends were anastomosed to the left subclavian artery and to the saphenous vein graft in 1 patient each. Sites of proximal anastomosis of the saphenous vein grafts were the descending aorta in 10 patients and the left subclavian artery in 3 patients.

Duration of circulatory arrest for single distal anastomosis ranged from 5 to 13 minutes, and accumulated circulatory arrest time ranged from 5 to 33 minutes. Mean ventricular fibrillation time was 61.4 minutes, and mean cardiopulmonary bypass time was 127.3 minutes. Cardiopulmonary bypass time was doubled to fibrillation time to cool and rewarm the patient. In patients 8 and 13, those durations were extremely long because of the difficulty to find target coronary arteries (Table 1).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All patients were alive and clinically uneventful at the mean follow-up period of 16 months, ranging from 10 to 34 months. Neither low cardiac output syndrome nor perioperative myocardial infarction was noted. There was no significant creatine kinase-MB elevation or abnormal ST change after operation.

One patient (patient 10) needed reexploration for bleeding. This patient required 45 hours of artificial ventilation due to reexploration for bleeding at the next morning of operation before attempted extubation, and his respiratory condition was not deteriorated. No respiratory complication was noted in any of the patients. Mean postoperative artificial ventilation time was 15 hours, ranging from 3 to 45 hours. In 1 patient (patient 5) who had severe insulin-dependent diabetes, progression of hemianopsia, which had been noted preoperatively, occurred, but no other neurologic disorder was found in any of the patients. No abnormality was found in brain computed tomographic scans postoperatively.

Postoperative angiography was performed in all patients before discharge, and all grafts were patent in the early postoperative period (Table 1; Figs 1, 2).

View larger version (201K): [in this window] [in a new window]   Fig 1. . (Patient 5.) Saphenous vein grafts (composite Y graft) were anastomosed to the diagonal and the circumflex artery distally and to the descending aorta proximally.

View larger version (83K): [in this window] [in a new window]   Fig 2. . (Patient 11.) Saphenous vein graft (sequential graft) was anastomosed to the circumflex and the anterior descending artery distally and to the left subclavian artery proximally (bottom). Note the saphenous vein graft takes off from the subclavian artery below the origin of the left internal thoracic artery (top).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Descending aorta and left subclavian artery are the choice of inflow site for free grafts. We prefer to make the proximal anastomosis first before cardiopulmonary bypass because proper length of the graft can be easily determined by distending the graft on the beating heart and also because coronary bypass can immediately be established after completion of each distal anastomosis.

Regarding the choice of conduit, gastroepiploic [8], inferior epigastric [9], and radial [10] arteries, in addition to the left ITA and saphenous vein, can be applied; the right ITA cannot be used through the left thoracotomy.

Although Faro and associates [3] reported 7 cases in which the anastomoses were performed without cardiopulmonary bypass, and we did the same procedure in 1 patient, making the distal anastomosis under the cardiopulmonary bypass might be more widely acceptable. During cardiopulmonary bypass, no vent from the main pulmonary artery or the left atrium was necessary in our series except for 1 patient, in whom we used a left atrial vent prophylactically.

Although coronary artery local isolation by snaring or intraluminal occlusion is commonly used to get a bloodless field to perform the distal anastomosis when the ascending aorta is not cross-clamped, circulatory arrest is a simple and easy method for this purpose. Previous authors [4, 5, 7] and many other experienced cardiac surgeons know that temporary circulatory arrest is useful to facilitate a difficult anastomosis; here we report its routine use during the total period of performance of the distal anastomosis. We have found this method useful in primary coronary artery bypass grafting in patients with severe atherosclerotic ascending aorta, which is unfavorable for aortic clamping, in the past more than 50 patients. With circulatory arrest, no excessive left ventricular distention occurs without venting even when the heart is distorted during anastomosis of the circumflex artery.

The risk of neurologic complication must be the most important concern in this technique. The longest accumulated time for circulatory arrest in our series was 33 minutes for three distal anastomoses (patient 7). In this case, like others, the circulatory arrest time necessary to complete one distal anastomosis was approximately 10 minutes, and full perfusion was restored between each anastomosis for about 5 minutes to check the anastomotic leakage and provide cerebral circulation. Circulatory arrest for about 10 minutes at 25°C hypothermia is known to be highly safe, with absence of structural or functional damage to the central nervous system and other vital organs [11]. Therefore, by using this intermittent circulatory arrest technique, we believe that neurologic damage can be avoided.

With increasing numbers of coronary artery reoperations, one may encounter several situations in which sternal reentry is unfavorable. In particular, having patent arterial or venous grafts crossing the anterior mediastinum is the most dangerous situation for the midsternal reentry at reoperation, and the left thoracotomy is the safest solution to solve this difficult problem. From our experience with this procedure, mortality and morbidity are acceptably low and the graft patency is excellent. The left thoracotomy approach with hypothermic circulatory arrest for distal anastomosis is a safe and effective alternative for coronary artery reoperation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Suma, Cattedra di Cardiochirurgia, Università Cattolica del Sacro Cuore, Largo F. Vito, 1-00168 Roma, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Lytle BW, Loop FD, Cosgrove DM, et al. Fifteen hundred coronary reoperations: results and determinants of early and late survival. J Thorac Cardiovasc Surg 1987;93:847–59.[Abstract]
2. Cheung D, Flemma RJ, Mullen DC, Lepley D Jr. An alternative approach to isolated circumflex coronary bypass reoperations. Ann Thorac Surg 1982;33:302–3.[Medline]
3. Faro RS, Javid H, Najafi H, Serry C. Left thoracotomy for reoperation for coronary revascularization. J Thorac Cardiovasc Surg 1982;84:453–5.[Medline]
4. Ungerleider RM, Mills NL, Wechsler AS. Left thoracotomy for reoperative coronary artery bypass procedures. Ann Thorac Surg 1985;40:11–5.[Abstract]
5. Burlingame MW, Boncheck LI, Vazales BE. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508–10.[Abstract]
6. Gandjbakhch I, Acar C, Cabrol C. Left thoracotomy approach for coronary artery bypass grafting in patients with pericardial adhesions. Ann Thorac Surg 1989;48:871–3.[Abstract]
7. Grosner G, Lajos TZ, Schimert G, Bergsland J. Left thoracotomy reoperation for coronary artery disease. J Cardiac Surg 1990;5:304–8.[Medline]
8. Suma H, Wanibuchi Y, Terada Y, et al. The right gastroepiploic artery graft: clinical and angiographic mid term results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615–23.[Abstract]
9. Buche M, Schoevaerdts JC, Louagie Y, et al. Use of the inferior epigastric artery for coronary bypass. J Thorac Cardiovasc Surg 1992;103:665–70.[Abstract]
10. Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652–60.[Abstract]
11. Kirklin JW, Barratt-Boyes BG. Hypothermia, circulatory arrest and cardiopulmonary bypass. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:61--74.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hisayoshi Suma Yasuhiko Wanibuchi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Suma, H. Articles by Wanibuchi, Y. Search for Related Content PubMed PubMed Citation Articles by Suma, H. Articles by Wanibuchi, Y.