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Ann Thorac Surg 2001;71:1959-1963
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication March 1, 2001.

Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery/F25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: gillinom{at}ccf.org

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Reoperative coronary artery bypass grafting (CABG) in patients with contraindications to sternotomy or cardiopulmonary bypass (CPB) presents a technical challenge. In this study we reviewed patient selection, operative technique, and early results in patients having redo-CABG to the circumflex artery system by a thoracotomy without CPB.

Methods. From January 1996 through December 1999, 21 patients with contraindications to conventional redo-CABG had target vessel revascularization off-pump by thoracotomy. A posterolateral thoracotomy approach was used.

Results. No patient required sternotomy or CPB. There was no hospital mortality. Postoperative cardiac morbidity included non-Q wave myocardial infarction (5%), need for intraaortic balloon pump support postoperatively (5%), and atrial fibrillation (5%). Two grafts were studied early and two were studied late (more than 6 months later). One venous graft was found to be occluded early. Survival at 2 years was 95%. Ninety percent of surviving patients were in New York Heart Association functional class I or II.

Conclusions. This approach was associated with no mortality, low morbidity, and favorable early symptomatic improvement. This is the approach of choice in cases of reoperative CABG to the circumflex system when resternotomy or CPB are undesirable, and the culprit coronary vessels are accessible through a thoracotomy.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Reoperative coronary artery bypass grafting (CABG) through a thoracotomy is a well-established technique [1–6]. Most early applications of this approach included femorally based cardiopulmonary bypass (CPB) to facilitate anastomoses [4–6]. Recent technological advances have resulted in widespread application of "off-pump" techniques for primary CABG [7, 8]. In addition, there is growing experience with off-pump redo-CABG through a thoracotomy, particularly in patients requiring isolated revascularization of the circumflex or left anterior descending (LAD) coronary arteries [1–3]. This approach is of particular benefit in patients with accessible targets for whom resternotomy or CPB present particular hazards. However, these operations are not easy; success requires careful patient selection and important modifications of operative technique. This study was undertaken to review patient selection, operative technique, and early outcomes for patients having off-pump redo-CABG through a thoracotomy to the circumflex system by posterolateral thoracotomy.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Study population
From January 1996 through December 1999, off-pump redo-CABG through a thoracotomy was performed in 34 of 1,373 patients (2.5%) having isolated reoperative CABG. Twenty-one patients had a posterolateral thoracotomy for circumflex revascularization and 13 had an anterior thoracotomy for LAD revascularization. The 21 patients having a posterolateral thoracotomy for bypass to branches of the circumflex system are the subject of this report. There were 17 men and 4 women aged 48 to 79 years (mean 64 ± 10 years). Left ventricular systolic function as evaluated by pre- or intraoperative echocardiography was normal in 43%, mildly depressed in 5%, moderately depressed in 38%, and severely depressed in 14% of patients. One patient (5%) was in New York Heart Association functional class I, 8 (38%) in class II, 8 (38%) in class III, and 4 (19%) in class IV. Preoperative comorbidities included hypertension (57%), diabetes (29%), renal dysfunction (10%), carotid stenosis of more than 70% (14%), and severe peripheral vascular disease (14%). Twenty patients had elective surgery, and 1 required urgent operation for unstable angina and had an intraaortic balloon pump placed preoperatively.

The mean interval from the previous CABG was 93 ± 62 months. The present operation was the patient’s second procedure in 52% of cases, the third operation in 38%, and the fourth operation in 10%. Seventeen patients (81%) had at least one patent internal thoracic artery (ITA) graft. Five had a patent right internal thoracic artery (RITA) crossing the midline to the left coronary system.

All patients in this study had symptomatic coronary artery disease unresponsive to maximal medical therapy. Twenty patients had chronic stable angina, whereas 1 had unstable angina as previously mentioned. Complete revascularization was the goal in all patients. Patients were considered for an off-pump posterolateral thoracotomy approach for redo-CABG only if they had accessible target(s) and technical or patient factors rendering CPB or sternotomy undesirable. The specific indications to perform reoperative CABG through thoracotomy without CPB included patent graft at particular risk for resternotomy (n = 17), calcified ascending aorta (n = 3), serious comorbidities (n = 5), and diffuse atherosclerosis (n = 4). Several patients had more than one indication for this approach.

Preoperative investigations included coronary angiography, posteroanterior and lateral chest roentgenogram, transthoracic echocardiogram, and pulmonary function tests. Recently, we obtained preoperative computed tomography (CT) scans of the chest in patients requiring circumflex revascularization to evaluate the descending aorta as a site for proximal anastomosis.

Operative technique
Routine hemodynamic monitoring included a brachial artery line and a pulmonary artery catheter. After double-lumen endotracheal tube placement, a transesophageal echocardiographic probe was inserted. External defibrillation pads (R2 Stat Padz; Zoll, Inc, Burlington, MA) were placed before skin prepping. All conduits were harvested with the patient in a supine position. Graft flow measurements have not been reliable in our hands and were not used routinely. All patients required bypass to the circumflex system and had a posterolateral thoracotomy. After conduit harvesting, the patient was repositioned in a right lateral decubitus position with the pelvis externally rotated (45°) to allow access to the femoral vessels should cannulation for CPB become necessary. Early in our experience, the left femoral vessels were exposed routinely; with increasing experience, we no longer exposed these vessels. The left lung was deflated, and an incision was made in the fourth or fifth intercostal space. When the subclavian artery was used for inflow, the fourth intercostal space was chosen. The thoracotomy was generally extended a few centimeters anteriorly or posteriorly as necessary to gain exposure of the target vessel and the source of inflow (descending aorta or left subclavian artery). Neither a counter-incision nor a different intercostal space entry through the same incision was required. The lung was dissected free and the inferior pulmonary ligament incised. In the presence of a patent left internal thoracic artery (LITA)-LAD bypass, the anteromedial aspect of the lung was dissected from the pericardium only enough to locate the circumflex target. In such instances, the LITA graft was usually not encountered.

The pericardium was palpated to locate old vein grafts when present. In general, the pericardium was opened posterior to the phrenic nerve. Limited dissection was performed to locate the target vessel, tracing old grafts when present. It was important to keep dissection limited; more extensive dissection resulted in troublesome venous bleeding and reduced the natural stabilization provided by adhesions.

Once the target vessel was identified, attention was usually turned to the proximal anastomosis. Advantages to performing the proximal anastomosis first included more accurate measurement and routing of the distended conduit, the opportunity to flush atherosclerotic debris from the graft before completion of the distal anastomosis, and immediate establishment of flow upon completion of the distal anastomosis. If preoperative CT scanning suggested that the descending aorta was relatively free of atherosclerosis, it was chosen as the source of inflow. Before the anastomosis, however, the aorta was assessed further by transesophageal or epiaortic echocardiography. Heparin (10,000 units) was administered and the activated clotting time maintained at longer than 300 seconds. The proximal anastomosis was completed with the aid of a side-biting clamp on the descending aorta. Recently, the proximal anastomosis has been marked with a clip to guide subsequent angiography.

When the descending aorta was severely atherosclerotic, the left subclavian artery was used for inflow. The proximal portion of this vessel was dissected circumferentially and a side-biting clamp placed or, more commonly, the vessel completely occluded with vessel loops. The site of anastomosis was always proximal to the origin of the LITA. Therefore, in the case of a patent LITA-LAD graft, a test occlusion of the subclavian artery preceded opening the vessel. If, after a 5-minute test occlusion, there were no electrocardiographic or hemodynamic signs of ischemia, the artery was opened and the proximal anastomosis completed.

The distal anastomoses were completed using a proximal snare only and a commercially available stabilizing platform (Octopus, Medtronic, Minneapolis, MN; CTS, Guidant, Cupertino, CA; Genzyme, Cambridge, MA). Endovascular shunts were used rarely. Distal anastomoses were completed with running 7-0 polypropylene or interrupted 7-0 silk. A CO₂ blower was used to aid visualization. Grafts originating from the left subclavian artery were routed anterior to the pulmonary hilum (Fig 1A). Grafts originating from the descending aorta were routed either anterior or posterior to the hilum (Fig 1B). With experience, we found it easier to route grafts from the proximal descending aorta anterior to the hilum. Such a course was almost always possible even if the lung was left adherent anteromedially to the LITA or its bed. This method results in a gentle lie with little possibility of kinking. Grafts were examined with the lung inflated before chest closure to ensure a smooth course. Chest tubes were positioned distant from bypass grafts. Intercostal bloc with bupivicaine (0.25%) was performed and full expansion of the lung ensured before routine chest closure. Patients were extubated in the intensive care unit following general postoperative guidelines.

View larger version (82K): [in this window] [in a new window]   Fig 1. (A) View through left thoracotomy. The pericardium is opened posterior to the phrenic nerve. A previously placed vein graft to the circumflex marginal is evident. The new vein graft originates at the subclavian artery and is routed anterior to the pulmonary hilum. (B) Same view as in (A). The new vein graft originates from the descending aorta and follows a smooth course anterior to the pulmonary hilum or from the descending aorta and is routed beneath the pulmonary hilum.

Follow-up
Follow-up was 100% complete and included an outpatient clinic visit 4 weeks after hospital discharge and late telephone interview with the patient or referring cardiologist. Follow-up was closed May 1, 2000.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Procedures and strategy
There were a total of 24 distal anastomoses performed for a mean of 1.1 grafts/patient. Targets approached included branches of the circumflex coronary artery (n = 23) and the LAD diagonal (n = 1). Fourteen conduits (67%) were venous (12 greater and 2 lesser saphenous veins), and 10 (48%) were arterial (radial artery). Recently, we favored using arterial conduits when possible. Inflow was obtained from the descending aorta in 15 patients and the left subclavian artery in 6 patients. The left subclavian artery was used for inflow when the descending aorta was severely atherosclerotic; 5 such patients had a patent LITA-LAD graft, and temporary occlusion of the left subclavian artery caused no hemodynamic compromise.

Complete revascularization was the goal and was achieved in all but 1 patient. The only exception was a patient with patent LITA to LAD and a patent saphenous venous graft to a circumflex marginal branch that had a new bypass graft constructed to a culprit posterolateral circumflex branch. Hemodynamic instability while trying to position the heart precluded performing an additional bypass to a small postero-ventricular circumflex branch. This patient had elevation of his creatinine phosphokinase MB fraction postoperatively (CK-MB peak = 167 mg/dL) and represented the only perioperative myocardial infarction in this series.

Operative morbidity and mortality
There were no hospital deaths. There were no reoperations for bleeding. Three major complications occurred (14%). These included one non-Q wave myocardial infarction defined by a CK-MB fraction of more than 40 mg/dL (5%) as detailed above, one respiratory failure defined as requirement for assisted mechanical ventilation for longer than 48 hours (5%), and the need for postoperative intraaortic balloon pump support (36 hours) in another patient (5%).

Minor complications included two cases of prolonged air leak for 72 hours; there were no other pleural complications. The occurrence of atrial fibrillation was low (5%). However, 2 patients (10%) required internal cardiac defibrillator placement before discharge. Both had positive postoperative electrophysiologic studies performed for a history of malignant preoperative ventricular arrhythmia. Median length of stay was 6.0 days (range 4 to 16 days).

Postoperative angiography
Systematic postoperative angiography was not performed in this series. Two early postoperative angiograms were performed: the first was routine and showed a perfectly patent radial artery; the second was for symptoms and showed an occluded saphenous vein graft to a circumflex marginal branch. That patient underwent successful stenting of the left main and circumflex arteries at the time of angiography. In that particular case, the distal anastomosis was completed before the proximal anastomosis. Although the descending aorta appeared mildly diseased by transesophageal echocardiography, it contained soft atheromatous material. It was nevertheless used for inflow after careful debridement and flushing. The early graft failure may have been caused by embolization of atherosclerotic debris.

Two conduits were studied late (more than 6 months after operation) for symptoms. One venous conduit was perfectly patent and a second was patent but demonstrated a "string sign," possibly due to competitive flow.

Follow-up
Follow-up was complete (100%). At a mean follow-up interval of 15 ± 13 months, there was one late death presumed to be cardiac in origin. Survival at 2 years was 95%. Most of the survivors were in New York Heart Association functional class I (45%) or II (45%). Two patients (10%) were in class III, and none in class IV. Freedom from cardiac-related hospitalization was 85% at 2 years. Most rehospitalizations took place in the first 2 months after the operation.

No patient required late surgical or catheter-based reintervention. Freedoms from postoperative cardiac events including death, rehospitalization, and coronary reintervention was 80% at 2 years.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Although a tailored approach for selected patients, the prevalence of off-pump coronary reoperation through a thoracotomy is increasing [1–3, 10–13]. This growing popularity is explained by the increased need for reoperation in patients who have undergone previous CABG, the growing familiarity and confidence with off-pump techniques, and recognition that the thoracotomy approach is advantageous in patients at particular risk for resternotomy.

Morbidity and mortality associated with reoperative CABG are higher than those reported for primary CABG [14, 15]. In 1999, operative mortality at The Cleveland Clinic Foundation was 2.3% for reoperative CABG versus only 0.8% for primary CABG. Many reasons may explain the increased risk associated with coronary reoperation. Patient-related factors include increased patient age, greater cardiac dysfunction, and increased prevalence of other comorbid conditions. In addition, technical factors increase the risk of redo-CABG, such as hemorrhage at resternotomy, injury to or embolization from patent grafts, and difficulties with complete revascularization and myocardial protection.

In selected patients, off-pump redo-CABG through posterolateral thoracotomy may reduce risks attributable to sternotomy and dissection of the heart. The risk of catastrophic hemorrhage at sternal reentry remains 0.5% to 1% with an associated mortality of 21% [16]. The risk of injury to a patent ITA graft is 5%, and this event is associated with a mortality of 9% and myocardial infarction in 40% [17]. Embolization of patent but diseased saphenous vein grafts can have serious consequences. Reoperation through thoracotomy reduces the risk of these morbid events.

In addition, this approach eliminates morbidity associated with CPB. Evidence is growing that avoidance of CPB is advantageous [18, 19]. In fact, prolonged duration of CPB is a risk factor for mortality at coronary reoperation [15]. It is likely that the benefits of avoiding CPB are greatest in patients with increased age, diffuse atherosclerosis, and other important comorbid conditions. Patients requiring reoperative CABG generally have advanced atherosclerosis, and they may derive particular benefit from off-pump techniques. Three studies have demonstrated clinical advantages to performing redo-CABG off-pump [12, 20, 21].

Although it is clear that off-pump redo-CABG is feasible, the real question is which patients should undergo these challenging operations. In our practice, the indications for performing off-pump coronary reoperation through thoracotomy are limited. Over a 4-year period, 1,373 patients had isolated reoperative-CABG, and only 34 (2.5%) had an off-pump approach through a thoracotomy; the rest of the patients had stemotomy with CPB. This finding reflects our bias to achieve as complete a revascularization as possible in nearly all patients. A posterolateral thoracotomy provides excellent access to the circumflex system but only limited access to the LAD and right coronary systems. Thus, the ideal patient for this approach should require only one or two grafts to the circumflex system. In addition, the patient should have a relative contraindication to stemotomy or CPB (Table 1). Although it is possible that selected patients may benefit from incomplete revascularization with bypass only of the "culprit" vessel, there are insufficient data to determine which patients might be in this category. Therefore, targeted revascularization by thoracotomy should be considered only for the minority of patients requiring redo-CABG.

Results of this strategy were good, with no operative mortality and low operative morbidity. The infrequent occurrence of atrial fibrillation was gratifying, and paralleled results reported by others [12, 20, 21]. Larger studies are necessary to confirm this finding. Early symptomatic improvement and freedom from cardiac events were satisfactory.

In summary, with the advantages of avoiding resternotomy and CPB and technical improvements that facilitate anastomosis on the beating heart, off-pump redo revascularization of circumflex targets through a posterolateral thoracotomy is an excellent approach in patients with accessible targets for whom resternotomy or CPB are undesirable. However, complete revascularization should be the goal in nearly all patients, and this difficult operation should be reserved for only selected patients.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We gratefully acknowledge the technical assistance of Maura Schnauffer and Debbie Gladish in organizing the data, and we thank Eugene H. Blackstone, MD, and Caroline Apperson-Hansen for assistance with statistical analyses.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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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): Fouad M. Azoury A. Marc Gillinov Bruce W. Lytle Nicholas G. Smedira Joseph F. Sabik Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Azoury, F. M. Articles by Sabik, J. F. Search for Related Content PubMed PubMed Citation Articles by Azoury, F. M. Articles by Sabik, J. F. Related Collections Minimally invasive surgery