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Ann Thorac Surg 2000;70:1734-1735
© 2000 The Society of Thoracic Surgeons

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Three-dimensional computed tomography for reoperative minimally invasive coronary artery bypass

^a Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan
^b Department of Radiology, University of Tokyo, Tokyo, Japan

Address reprint requests to Dr Ohtsuka, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
e-mail: ohtsuka-tho{at}h.u-tokyo.ac.jp

	Abstract

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We have been using three-dimensional computed tomography (3-D CT) in reoperative coronary artery bypass grafting performed by using a minimally invasive approach. Preoperative 3-D CT scanning can provide beneficial anatomical information about old patent grafts as well as the internal thoracic artery. Thus a mini-thoracotomy can be created at an optimal site, leaving the old graft untouched, and the length of the harvested internal thoracic artery, necessary for the bypass, can be assessed using this new modality.

	Introduction

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The use of three-dimensional (3-D) computed tomography (CT) to examine the patency of coronary artery bypass grafts has been reported [1, 2]. Because 3-D images of studied objects can be digitally edited from any angle, this technique allows clear 3-D interpretation of the pathway of patent coronary artery bypass grafts as well as their anatomical relationship to the heart and thoracic wall.

This study describes the application of 3-D CT for preoperative anatomical assessment of old patent grafts and the left internal thoracic artery (LITA) in patients undergoing reoperative minimally invasive coronary artery bypass grafting (MICABG).

	Technique

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Three-dimensional images of a patient’s chest, including the heart, vascular system, and bony compartments of the thorax, were digitally depicted from contrast agent-enhanced images obtained from a CT scanner (HiSpeed Advantage QX/i, General Electrical Company, Waukescha, WI) 60 seconds after infusion of the contrast agent. Scanning was accomplished during a 30-second breathhold using a slice thickness and interval of 2.5 mm and 1.5 mm, respectively. Basically, multi-angle 3-D images of the patient, rotated every 15 degrees from the front view, were reconstructed by a volume rendering method using a workstation (Advantage Windows version 3.1, General Electrical Company, Waukescha, WI). This workstation is commercially available and it can be applied to standard CT scanners.

Three-dimensional CT was done preoperatively for 3 patients scheduled for reoperative MICABG to the left anterior descending artery (LAD). Preoperative angiography showed that the old vein graft to the LAD was diseased in 2 patients, and the LAD developed a new lesion just distal to the previous anastomosis in 1 patient. In each patient the LITA had been unused.

The pathways of the LITA and the patent vein graft, including its relationship to the heart and thorax, were evaluated by reference to the 3-D images viewed from multiple angles. Figure 1 shows a preoperative 3-D left-anterior-oblique image of a patient, who underwent reoperative MICABG to the LAD using the unused LITA obtained through a small left anterior thoracotomy. In this patient, 3-D rendering demonstrated that the old patent saphenous vein graft was anastomosed to the proximal LAD, crossing the right ventricular outflow tract. The previous anastomosis was located 6 cm lateral to the left sternal edge and just underneath the fifth rib. Preoperative angiography revealed that the LAD had developed a new tight stenosis just distal to the previous anastomosis. Therefore, we made a 5-cm anterior thoracotomy at the fifth intercostal space to create an anastomosis at the midportion of the LAD leaving the old vein graft untouched. Postoperative angiography revealed that a patent LITA graft was correctly anastomosed to the LAD in this patient.

View larger version (184K): [in this window] [in a new window]   Fig 1. Preoperative 3-D computed tomographic left-anterior-oblique image of a patient undergoing reoperative minimally invasive coronary artery bypass grafting to LAD using LITA (arrows). Old saphenous vein graft (arrowheads) overlying right ventricular outflow tract was anastomosed to LAD 6 cm lateral to left sternal edge and just underneath fifth rib. Length of LITA graft necessary for bypass between root of subclavian artery and target site for anastomosis (asterisk) was measured as 17 cm long along mediastinum. (4, 5, and 6 = fourth, fifth, and sixth ribs, respectively.)

	Comment

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In MICABG procedures using a mini-thoracotomy, this preoperative information is valuable for making an operating plan. The optimal placement of a limited thoracotomy can be achieved precisely over the target area for anastomosis (as discussed previously); thus, dissection of adhesions is minimized and the patent graft can be left untouched. In addition, preoperative information about LITA harvesting can be obtained from 3-D CT images. The LITA shows distinct enhancement on a 3-D image (Fig 1), and therefore the length of the LITA graft necessary for creating a bypass can be estimated on the image by measuring the distance along the mediastinum between the root of subclavian artery and the anastomosis target site. In this patient a LITA graft approximately 17 cm long overlying the mediastinum was found to be necessary from the 3-D image, and using a thoracoscope the LITA was taken from just above the first rib down to the lower margin of the sixth rib, which was measured as 19 cm long on the image. During the actual procedure, the dissected LITA was found to have a surplus length of about 2 cm beyond the anastomosis portion.

In conclusion, preoperative 3-D CT scanning can provide beneficial anatomical information about the old patent graft and the LITA when carrying out reoperative MICABG. An optimal mini-thoracotomy site can be chosen leaving the old graft untouched, and the length of the harvested LITA necessary for the bypass can be assessed using this new modality.

	References

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1. Achenbach S., Moshage W., Ropers D., Nossen J., Bachmann K. Noninvasive, three-dimensional visualization of coronary artery bypass grafts by electron beam tomography. Am J Cardiol 1997;79:856-861.[Medline]
2. Moshage W., Achenbach S., Seese B., Bachmann K., Kirchgeorg M. Coronary artery stenosis. Radiology 1995;196:707-714.[Abstract/Free Full Text]
3. Keon W.J., Heggtveit H.A., Leduc J. Perioperative infarction caused by atheroembolism. J Thorac Cardiovasc Surg 1982;84:849-855.[Abstract]
4. Lytle B.W., McElroy D., McCarthy P., et al. Influence of arterial coronary bypass on the mortality in coronary reoperations. J Thorac Cardiovasc Surg 1994;107:675-683.[Abstract/Free Full Text]
5. Gillinov A.M., Casselman F.P., Lytle B.W., et al. Injury to a patent left internal thoracic artery graft at coronary reoperation. Ann Thorac Surg 1999;67:382-386.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Toshiya Ohtsuka Yutaka Kotsuka Shinichi Takamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ohtsuka, T. Articles by Takamoto, S. Search for Related Content PubMed PubMed Citation Articles by Ohtsuka, T. Articles by Takamoto, S.