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Ann Thorac Surg 1996;62:1801-1807
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Third-Time Coronary Artery Bypass Operations: Surgical Strategy and Results

Division of Cardiothoracic Surgery, Joseph P. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia

Accepted for publication June 28, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Increasingly, patients are returning for a second, third, and even fourth coronary artery bypass graft (CABG) procedure.

Methods. This report reviews the in-hospital and long-term outcomes for 102 patients undergoing a third or fourth CABG at Emory University from December 1977 to April 1994.

Results. The mean interval from the first to second CABG was 5.2 ± 3.5 years and from the second to the third CABG 6.8 ± 4.1 years. The mean age was 60 ± 9 years, 91% were male, 33% had hypertension, 16% diabetes, 86% class III or IV angina (Canadian Cardiovascular Society), 4.4% congestive failure (New York Heart Association), and 73% three-vessel disease. The in-hospital mortality rate was 9.8%, with a perioperative myocardial infarction rate of 8.8% and a stroke rate of 1.9%.

Conclusions. These perioperative mortality and myocardial infarction rates are several times higher than those reported for initial revascularizations or first-time redo CABG operations. However, the 5- and 10-year survival rates of 79% and 59%, respectively, and a myocardial infarction-free survival of 62% at 5 years, the benefits of a third-time CABG procedure are apparent for this high-risk group of patients.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Reoperative coronary artery bypass grafting (CABG) continues to increase in frequency, with an estimated 50,000 reoperations performed in the United States this year [1–3]. These patients often present with symptoms related to the progression of atherosclerotic disease within the bypass grafts and the native coronary circulation. The incidence of reoperation after primary CABG is approximately 3% at 5 years, 11% at 10 years, and greater than 17% at 12 years [2].

The patient undergoing the third or fourth CABG procedure presents unique challenges. These include the progression of the coronary artery disease, lack of suitable conduit, dense mediastinal adhesions, and epicardial scar, which obscures the coronary anatomy. Refinements in surgical technique, cardiac anesthesia, myocardial protection, and postoperative care have resulted in an increasing number of patients undergoing repeat myocardial revascularizations. This report reviews our experience in patients undergoing a third CABG procedure at Emory University.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
This is a retrospective study of 102 consecutive patients who have undergone a third (101 patients) or fourth (1 patient) CABG procedure from December 1977 to April 1994. Patients who underwent associated cardiac procedures were excluded from the study. The data were obtained from the computerized cardiac data bank at Emory University, as well as a review of patient charts, including operative reports, progress notes, and discharge summaries. Patient follow-up was performed on a yearly basis by the cardiac data bank, either by telephone or a mailed questionnaire. Follow-up was complete in all the patients.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The 102 patients included in the study (93 men and 9 women) represent 0.5% of the patients who had a CABG operation at Emory University from December 1977 to April 1994. The preoperative clinical descriptors of the patients are listed in Table 1. The mean age (± standard deviation) of the study population was 59.7 ± 8.9 years (range, 37 to 77 years). The mean ages during their first and second CABG were 48.5 ± 7.8 years (range, 26.1 to 67.9 years) and 53.7 ± 9 years (range, 32 to 74.3 years), respectively. The mean interval between their first and second operations was 5.2 ± 3.5 years, and the mean interval between their second and third operations was 6.8 ± 4.1 years. Approximately 50% of the patients had their first two operations performed at Emory University.

Operative Technique
A repeat median sternotomy incision was performed in all patients. The femoral artery was exposed before sternotomy in 39 patients. In 19 of these patients, the femoral artery was cannulated for arterial inflow for cardiopulmonary bypass. Five of the femoral artery cannulations for bypass were performed emergently: 3 patients had bleeding due to injury to a prior vein graft during sternal reentry, 1 patient degenerated into ventricular fibrillation during the sternotomy, and 1 patient was transported from the cardiac catheterization laboratory in cardiac arrest. In the 19 patients with femoral artery cannulations, the venous return cannula was placed into the right atrium in 16 patients and emergently via the femoral vein in 3 patients.

The technique for myocardial protection during the aortic cross-clamp ischemic arrest interval varied over the course of the study and the preference of the surgeon. Currently, we use either cold blood cardioplegia or oxygenated crystalloid cardioplegia. An initial dose of the hyperkalemic cardioplegia solution is administered through the aortic root to arrest the heart. This is followed by the continuous, retrograde administration of cardioplegia solution through an indwelling coronary sinus catheter. Coronary sinus pressure is continuously monitored to maintain a pressure of approximately 40 mm Hg, which usually relates to a cardioplegia flow rate of 150 to 200 mL/min. A single cross-clamp interval is used for construction of both distal and proximal anastomoses.

Systemic cooling is instituted with commencement of cardiopulmonary bypass. A moderate degree of hypothermia (29° to 34°C) is employed. The degree of cooling is determined, in part, by an assessment of the patient's cerebrovascular status and the potential risk of an intraoperative stroke. Greater systemic cooling is used in those patients with a potentially increased stroke risk.

In those patients with a patent internal mammary artery (IMA) graft from a previous operation, an effort is made to occlude the IMA pedicle before giving the initial dose of cardioplegia. This is often accomplished by clamping a bulk of tissue containing the IMA pedicle with a second soft-jawed aortic clamp. Rarely is the patent IMA dissected out and clamped directly. If clamping of the IMA pedicle is not feasible, and the IMA must be left open during the ischemic arrest interval, then a lower degree of systemic cooling is employed (28° to 30°C).

Conduits
The mean number of grafts placed was 2.8 ± 1.1 grafts/patient; the types of graft are listed in Table 2. Twenty-five patients had an IMA used during one of their first two operations. Fifty-five patients (54%) undergoing their third CABG procedure had at least one IMA mobilized for use as a new graft: 31 left IMA, 16 right IMA, and 8 bilateral IMAs. The right IMA was used as a free graft in 18 patients. Other conduits used for bypass grafts included greater saphenous veins in 67 patients, lesser saphenous veins in 11 patients, a combination of greater and lesser saphenous veins in 5 patients, a gastroepiploic artery in 3 patients, and a cephalic vein and an allograft in 1 patient each. Mean bypass time was 133.3 ± 67.3 minutes, and mean aortic cross-clamp time was 56.6 ± 29.3 minutes. Average hospital stay was 10.8 ± 10 days per patient.

Perioperative Complications
Perioperative myocardial infarctions, defined as either the development of new Q waves or an elevation of the MB fraction of creatine kinase accompanied with either elevation of ST segments or the onset of new conduction disturbances developed in 9 patients (8.8%). Mediastinitis, which required debridement and muscle flap closure, developed in 2 patients. Superficial wound infections occurred in 4 patients: in 3 patients at the saphenous vein harvest site and in 1 patient in the soft tissue of the epigastrium. These infections were all successfully treated with local drainage, dressing changes, and antibiotics. Six patients were diagnosed with pneumonia by abnormal chest radiograph, positive sputum culture, fever, and elevated white blood cell count. Five patients underwent reexploration for bleeding. The perioperative complications are listed in Table 3.

Follow-up at 5 years in patients undergoing their third myocardial revascularization revealed a survival rate of 79% and a myocardial infarction-free survival of 62% (Fig 1). Twelve additional patients (11.8%) died in the late follow-up period, whereas 17 of the patients (16.7%) experienced a subsequent late myocardial infarction. Ten (83%) of the twelve deaths in follow-up were due to a cardiac cause. The mean time from the last operation to death was 4.2 ± 3.5 years.

View larger version (21K): [in this window] [in a new window]   Fig 1. . Actuarial curves for survival and myocardial infarction (MI)-free survival after third or fourth myocardial revascularization.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Several reports have analyzed the factors associated with an increased risk of requiring reoperative CABG procedures. The Coronary Artery Surgery Study report [5] described the significant factors associated with the need for a reoperation to be young age (p < 0.0001), female sex (p < 0.0001), less extensive initial coronary disease (p < 0.0001), less left ventricular impairment (p < 0.0001), less evidence of congestive heart failure (p = 0.006), and fewer coronary vessels bypassed at the first operation (p < 0.0001). Cosgrove and associates [2] evaluated 1,000 patients undergoing myocardial revascularization and reported that significant predictors of repeat CABG procedures included young age, absence of IMA used at initial revascularization, incomplete revascularization, New York Heart Association functional class III or IV, and single-vessel or double-vessel disease. Our review supports these studies, in that the mean age of our patients undergoing a third CABG operation was 59.7 years, and only 24.5% of the patients had an IMA used previously. Forty-five percent of the patients had an EF of 0.50 or greater, and only 4.4% presented in congestive heart failure.

Patient Selection
Patients to be considered as candidates for reoperative CABG procedures usually experience disabling angina despite maximal medical therapy or markedly positive ischemia at low levels of exercise testing. Cardiac catheterization should delineate at least one stenotic, graftable, major vessel that perfuses viable myocardium. A reduced EF of 0.20 may be acceptable in a patient without additional significant risk factors, but the operative risk is likely increased [3, 4]. If the viability of the myocardium in the target areas is indeterminate, studies should be undertaken to detect regional myocardial blood flow or metabolic activity indicative of viable myocardium [7, 8]. Revascularization of ischemic myocardium will improve coronary perfusion and consequently may improve ventricular function. Extensively scarred myocardium has little chance of recovery, and attempting revascularization in this situation is usually not helpful.

Preoperative Evaluation
The preoperative evaluation of patients undergoing a repeat CABG procedure is similar to that of patients undergoing their initial revascularization. Particular note should be made of any associated manifestations of atherosclerosis. Carotid artery disease, indicated by a history of transient ischemic attacks or stroke, necessitates further workup. Peripheral vascular disease, identified by absent peripheral pulses, might affect the use of the femoral artery for cannulation or insertion of an IABP. Examination of the lateral chest radiograph and lateral views of the coronary angiogram can help assess the proximity of the heart to the posterior table of the sternum. Ensuring that the preoperative coagulation profile and platelet count are within normal limits will reduce perioperative bleeding. Preoperative heparin infusions should be continued into the operating room to minimize ischemic episodes, which could occur with acute graft closure.

Operative Management
Anesthesia and invasive hemodynamic monitoring techniques are similar to those employed for any coronary revascularization in high-risk patients. All patients undergoing a redo sternotomy will have transcutaneous pacing/defibrillator pads positioned on the left lateral chest wall and back before being draped. Patients with decreased EFs will often have a transesophageal echographic probe placed intraoperatively for the early detection of new myocardial ischemia, as determined by changes in regional wall motion. Two units of packed red blood cells are available in the operating room before the sternotomy is made. A large-gauge (9F) introducer is placed into the right central venous system to allow continuous venous access should the mediastinal structures be inadvertently injured. A right heart catheter is used for hemodynamic monitoring.

The patient is positioned supine on the operating room table, and the lower extremities are prepared circumferentially to allow access to both the greater and lesser saphenous veins. Rarely are the arms prepared into the field. An oscillating saw is used to divide the sternum for reentry. Often the sternal wires are cut but left in place while the sternal tables are cleaved. A thoracotomy approach has been reported to provide satisfactory exposure in selected cases [9]. In patients undergoing their third CABG procedure, it is often advisable to expose the femoral artery before performing the sternotomy. Elective femoral artery cannulation before sternotomy may be performed if the preoperative evaluation suggests the heart is adherent to the sternum, or if excessively dense adhesions are encountered during the mediastinal dissection. Currently, we either percutaneously cannulate one femoral artery with a guidewire or exposure it surgically. However, in the earlier years of the study femoral artery identification was performed only in selected cases. Consequently, only 39 patients underwent exposure of their femoral artery; 19 patients had subsequent cannulation of their femoral artery, of which 5 patients were emergent.

After division of the sternum, the heart and pericardium are freed from the posterior table of the sternum and chest wall with sharp dissection and electrocautery. Entering the pleural space may expedite mobilization of the heart from the sternum. Adhesions between the heart and pericardium are sharply divided with efforts initially directed to mobilizing the right atrium and ascending aorta for bypass cannulation. To facilitate this exposure, an initial plane of dissection is created between the inferior surface of the heart and the diaphragm. Cardiopulmonary bypass is instituted before the dissection of the left side of the heart to minimize hemodynamic instability associated with manipulation of the left ventricle. Precise dissection is particularly important at the superior aspect of the sternum to prevent injury to the phrenic nerve and IMA pedicle. Nonpulsatile cardiopulmonary bypass is then established with moderate hypothermia (29° to 34°C) for most cases.

Cardioplegia
Our initial dose of blood cardioplegic solution is administered via the aortic root to arrest the heart, followed by continuous cardioplegia administered retrograde through the coronary sinus for the remainder of the cross-clamp period. Often in patients undergoing multiple reoperative CABG procedures, all native coronary arteries have become completely occluded and therefore cardioplegia must perfuse the myocardium antegrade via stenotic vein grafts. Other authors have suggested that the antegrade administration of cardioplegia risks the embolization of atheromatous debris from the stenotic veins distally into the coronary artery [10, 11]. Although this is a risk, it is our view that the main source of embolic debris is likely from the intraoperative manipulation of stenotic vein grafts rather than the antegrade flow of cardioplegia. Also, we believe that the improved myocardial protection associated with antegrade cardioplegia outweighs the risk of embolism.

Preexisting Vein Grafts
The third CABG procedure presents the surgeon with dense mediastinal and epicardial adhesions, which require significant dissection. It is imperative that manipulation of stenotic but patent vein grafts be minimized, to reduce the risk of atherosclerotic emboli producing a perioperative myocardial infarction [11]. Several authors have recommended the "no-touch" technique for the mediastinal dissection, with early ligation of vein grafts to minimize distal embolization of atherosclerotic debris [10–12]. We agree with the "no-touch" technique approach to existing vein grafts with careful dissection of epicardial adhesions and gentle retraction of the heart. However, ligation of old vein grafts can propagate emboli both centrally, into the ascending aorta, and distally, into the coronary arteries. In addition, ligation of old vein grafts may eliminate a major route for the delivery of cardioplegia to the ischemic myocardium. We believe it is best to minimize manipulation of vein grafts and leave them in place. Occasionally, we will incise an old vein graft distally, at the anastomotic site, and interpose a new vein graft end-to-end. The stump of the old vein graft is then oversewn to prevent embolization of atheroma or thrombus propagation.

Controversy exists concerning the management of angiographically patent but minimally stenotic vein grafts. Kouchoukos' group [12] studied 16 vein grafts removed during redo CABG and compared the angiographic interpretation with the respective pathologic findings. All vein grafts exhibited less than 30% luminal irregularities by preoperative angiography. However, they found that angiograms underestimated the degree of atherosclerosis in 13 (81%) of the vein grafts studied pathologically. In 9 grafts (56%) with normal angiographic findings, moderate or severe atherosclerotic changes were seen on pathologic examination. They concluded that vein grafts older than 5 years should be replaced [12]. This approach is supported by other authors, who report the accelerated progression of atherosclerosis in vein grafts greater than 5 years old [2, 6]. We favor this philosophy; however, we individualize our approach to preexisting vein grafts considering both the angiographic pattern and gross appearance. Most often this involves preservation of the old vein graft and the placement of a new aortocoronary vein graft in parallel. Vein grafts free of luminal irregularities by angiography and grossly normal in appearance are left in situ and not rebypassed. Vein grafts that have minimal angiographic irregularities but are grossly atheromatous are supplemented with a new, parallel aortocoronary vein graft, particularly in patients less than 60 years of age. Vein grafts with less than 80% stenosis are replaced with a new vein graft, with the old graft preserved or incised and oversewn at its distal anastomoses. Internal mammary artery grafts are rarely used to rebypass only partially stenosed vein grafts due to the concern of competitive flow with subsequent closure of the IMA. However, if the proximal stenosis in the old vein graft is greater than 90% or the old vein graft is totally occluded, then an IMA would be our preferred graft.

Patent Internal Mammary Artery Grafts
Reoperative CABG procedures in patients with patent IMA grafts have become frequent and require careful forethought. Because an IMA would likely have been used to revascularize an important coronary artery, such as the left anterior descending or right coronary artery, the risk of injury to the patent IMA graft must be weighed against the benefits of redo revascularization to vessels of lesser significance. This is particularly true in the third CABG procedure because the adhesions are more dense and the risk of injury to the IMA is increased.

Upon division of the sternum, the retrosternal dissection is performed in a plane immediately adjacent to the posterior table of the sternum. Sufficient dissection of the left side of the sternum and of the tissue containing the IMA pedicle is performed in a caudad to cephalad direction only to allow placement of the chest retractor. Any further mobilization of the IMA pedicle is best performed on bypass. Routine complete mobilization of the IMA pedicle is not recommended due to the risk of pedicle injury. Attempts to repair a lacerated or transected IMA are rarely successful due its small caliber and fragile composition. However, myocardial ischemia resulting from iatrogenic IMA graft injury may often be temporarily controlled by perfusing the distal limb of the injured IMA via a small catheter connected to the arterial line of the bypass pump. Cardiopulmonary bypass is rapidly instituted and the distal limb of the IMA is perfused in this fashion until placement of the aortic cross-clamp and infusion of cardioplegia. Myocardial revascularization is then performed with a new vein graft to the distal segment of the IMA, or to the coronary artery itself.

New Grafts
A major challenge in the patient undergoing a multiple reoperative CABG procedure can be the availability of sufficient conduit. In the present series, we performed 2.8 ± 1.1 grafts per patient. Fifty-four percent of the patients had at least one IMA graft used, whereas 25% of the patients had a IMA graft used in one of their previous operations. The majority of patients were revascularized with a combination of greater saphenous veins and IMA grafts, with lesser saphenous veins used infrequently and alternative conduits only rarely.

Limited availability of autogenous vein for conduits may be managed by performing sequential anastomoses, with natural side branches of a single saphenous vein graft, or by the creation of a surgical Y anastomosis. Our experience with the use of alternative conduits such as the gastroepiploic artery, radial artery, cephalic vein, or "snake" grafts in this series is limited. In addition, our use of the extended endarterectomy in reoperative CABG has been minimal. Brenowitz and associates [13] reported the use of the extended endarterectomy in approximately 47% of their patients undergoing reoperative CABG.

Proximal Anastomosis
The construction of proximal anastomoses can be problematic. Factors that affect the formation of proximal anastomoses include an extensively atheromatous or calcified aorta, old atheromatous vein grafts, and dense periaortic adhesions from previous operations. Both proximal and distal anastomoses are usually performed during a single aortic cross-clamp interval, which minimizes manipulation of the aorta and the risk of embolic debris. In addition, the use of a single cross-clamp eliminates the need for periaortic dissection required for application of the partial exclusion aortic clamp. If suitable aorta is limited, the proximal anastomosis may be performed using the hood of a previous aortocoronary vein graft anastomosis. These sites are often more pliable and less atheromatous than the surrounding aorta. Additionally, a single vein graft may provide inflow to multiple other vein grafts, anastomosed in an end-to-side manner. The use of the IMA pedicle as an alternative source for proximal anastomoses has been reported, but it is rarely needed [14].

Intraaortic Balloon Pump
An IABP was required in 29 patients (28.4%) in this study, with 22 patients (21.6%) requiring intraoperative placement of an IABP for ventricular support. The in-hospital mortality rate for these 29 patients was 17% (5 patients). Incomplete myocardial revascularization due to severe distal disease may increase the need for an IABP perioperatively for myocardial support. A series by Owen and colleagues [15] reported the use of an IABP in 19% of patients undergoing reoperative CABG without a death. The use of an IABP in patients undergoing a third time procedure has ranged from 11% to 23% of patients [9, 13, 16].

Reexploration for Bleeding
Postoperative bleeding requiring reexploration occurred in 5 patients (4.9%) in our series. This is similar to previously reported studies with a reexploration rate of 1% to 7.6% [9, 16, 17].

Early Results
The overall in-hospital mortality for third CABG operations in the present series was 9.8%. Previous reports of multiple myocardial revascularizations have published mortality rates ranging from zero to 12% [9, 13, 16, 17]. Lytle and associates [4] have reported that risk factors associated with an increased mortality in reoperations include left main stenosis, New York Heart Association class III or IV, advanced age, and incomplete myocardial revascularization [4]. A majority of the ten in-hospital deaths occurred in patients with severe distal native disease, which prevented complete revascularization. Other authors have reported impaired ventricular function as a risk factor for mortality [2, 13]. The average EF for these 10 patients was 0.48 ± 0.16, similar to the overall average EF of 0.49 ± 0.14.

The perioperative infarction rate was 8.8% (9 patients) in this series. This is comparable with previous reports of perioperative infarction rates for multiple reoperative CABG procedures of 5.3% to 12% [9, 13, 16, 17]. This perioperative myocardial infarction rate is approximately four times that of patients undergoing primary revascularization at Emory University [18]. Despite meticulous care, atheromatous debris can be dislodged into the distal coronary arteries from preexisting vein grafts. Minimal manipulation of old vein grafts seeks to reduce this hazard.

Late Follow-up
The 5-year actuarial survival for the entire series is 79%, which is comparable with the results of Brenowitz and associates [13], who reported a 5-year actuarial survival of 76.4%. The observed myocardial infarction-free survival was 62%, and 54% of the patients were free of angina at 5 years. Patients who died in follow-up still survived a mean of 4.2 years after their third CABG operation. More than 83% of the deaths in follow-up were cardiac in origin, attesting to the advanced coronary disease.

Summary
Patients undergoing their third CABG procedure present the surgeon with multiple operative alternatives and significant technical challenges. These include the limited availability of suitable conduits, hazardous sternal reentry, extensive mediastinal scar, and difficulty in achieving complete revascularization of severely diseased coronary arteries. Nonetheless, careful patient selection and a precise surgical technique will yield a satisfactory early outcome and gratifying long-term results. Our in-hospital mortality of 9.8% and overall 5-year survival of 79% with a myocardial infarction-free survival of 62% at 5 years demonstrate the benefit of a third-time revascularization. Therefore, those patients with medically intractable angina, satisfactory distal vessels, and adequate ventricular function should be considered as candidates for reoperative CABG with the expectation of a favorable outcome.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Sixty-first Annual Meeting of the American College of Cardiology, New Orleans, LA, March 19–23, 1995.

Address reprint requests to Dr Craver, 1365 Clifton Rd, NE, Atlanta, GA 30322.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Accola KD, Craver JM, Weintraub WS, Guyton RA, Jones EL. Multiple reoperative coronary artery bypass grafting. Ann Thorac Surg 1991;52:738–44.[Abstract]
2. Cosgrove DM, Loop FD, Lytle BW, et al. Predictors of reoperation after myocardial revascularization. J Thorac Cardiovasc Surg 1986;92:811–21.[Abstract]
3. Weintraub WS, Jones EL, Craver JM, Grosswald R, Guyton RA. In-hospital and long-term outcome after reoperative coronary artery bypass graft surgery. Circulation 1995;92(Suppl 2):50–7.[Abstract/Free Full Text]
4. 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]
5. Foster ED, Fisher LD, Kaiser GC, Myers WO. Comparisons of operative mortality and morbidity for initial and repeat coronary artery bypass grafting: The Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1984;38:563–70.[Abstract]
6. Campeau L, Enjalbert M, Lesperance J, et al. Atherosclerosis and late closure of aortocoronary saphenous vein grafts: sequential angiographic studies at 2 weeks, 1 year, 5 to 7 years, and at 10 to 12 years after surgery. Circulation 1983;68(Suppl 2):1–7.
7. Rozanski A, Berman DS, Gray R, et al. Use of thallium-201 redistribution scintigraphy in the preoperative differentiation of reversible and nonreversible myocardial asynergy. Circulation 1981;64:936–44.[Abstract/Free Full Text]
8. Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall-motion abnormalities predicted by positron tomography. N Engl J Med 1986;314:884–8.[Abstract]
9. Watanabe G, Haverich A, Speier R. Third time coronary artery revascularization. Thorac Cardiovasc Surgeon 1993;41:163–6.[Medline]
10. Grondin CM, Pomar JL, Hebert Y, et al. Reoperation in patients with patent atherosclerotic coronary vein grafts: a different approach to a different disease. J Thorac Cardiovasc Surg 1984;87:379–85.[Abstract]
11. FitzGibbon GM, Keon WJ. Atheroembolic perioperative infarction during repeat coronary bypass surgery: angiographic documentation in a survivor. Ann Thorac Surg 1987;43:218–9.[Abstract]
12. Marshall WG Jr, Saffitz J, Kouchoukos NT. Management during reoperation of aortocoronary saphenous vein grafts with minimal atherosclerosis by angiography. Ann Thorac Surg 1986;42:163–7.[Abstract]
13. Brenowitz JB, Johnson WD, Kayser KL, Saedi SF, Dorros G, Schley L. Coronary artery bypass grafting for the third time or more. Results of 150 consecutive cases. Circulation 1988;78(Suppl 1):166–70.
14. Gold JP, Shemin RJ, DiSesa VJ, Cohn LH, Collins JJ Jr. Multiple-vessel coronary revascularization with combined in situ and free sequential internal mammary arteries. J Thorac Cardiovasc Surg 1985;90:301–8.[Abstract]
15. Owen EW, Schoettle BP, Marotti AS, Harrington OB. The third time coronary artery bypass graft: is the risk justified? J Thorac Cardiovasc Surg 1990;111:31–5.
16. Merrill WH, Elkins CC, Stewart JR, Frist WH, Bender HW Jr. Third-time coronary artery bypass grafting: midterm results. Ann Thorac Surg 1993;55:582–5.[Abstract]
17. Blakeman BP, Thomas NJ, Sullivan HJ, Foy BK, Pifarre R. Myocardial revascularization for the third time: clinical characteristics and follow-up. Chest 1990;98:1099–101.[Abstract/Free Full Text]
18. Jones EL, Weintraub WS, Craver JM, Guyton RA, Cohen CL. Coronary bypass surgery: is the operation different today? J Thorac Cardiovasc Surg 1991;101:108–15.[Abstract]

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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): Joseph M. Craver William S. Weintraub Kevin D. Accola Robert A. Guyton Ellis L. Jones Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Craver, J. M. Articles by Jones, E. L. Search for Related Content PubMed PubMed Citation Articles by Craver, J. M. Articles by Jones, E. L.