Ann Thorac Surg 2005;80:350-352
© 2005 The Society of Thoracic Surgeons
How to do it
Sequential Subxyphoid and Thoracotomy Incisions With Graft Pull Through for Targeted Redo Multivessel Surgical Revascularization
Hani Shennib, MD*,
Osama Benhameid, MD
Division of Cardiothoracic Surgery, Montreal General Hospital, Montreal, Quebec, Canada
Accepted for publication January 28, 2004.
* Address reprint requests to Dr Shennib, 1650 Cedar Ave, Room L9-122, Montreal General Hospital, Montreal, Quebec H3G 1A4, Canada (Email: hani.shennib{at}mcgill.ca).
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Abstract
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We report on a technique for redo coronary artery bypass using sequential subxyphoid and left thoracotomy access and a vascular graft pull through for proximal anastomosis to the descending aorta. This technique can be used safely on the beating heart when previously implanted grafts to the anterior ventricular wall are patent or whenever resternotomy for redo multivessel coronary artery bypass is undesirable or contraindicated.
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Introduction
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A second surgical revascularization procedure on a patient with a patent left internal mammary artery (LIMA) graft carries the challenge of access to the heart and other target coronary artery vessels without catastrophic bleeding, cardiac arrhythmias and shock, or the interruption of the LIMA [1]. Subxyphoid and left thoracotomy incisions have been proposed as means of accessing branches to the right (RCA) and circumflex coronary arteries [2–4]. Often gastroepiploic artery or extension from the right internal mammary artery is used for grafting the posterior branches of the RCA. Obtuse marginal (OM) branches of the circumflex artery are grafted using arterial or venous grafts connected to the descending aorta. Occasionally, gastroepiploic arteries may not be suitable for grafting. We propose a technique in which a vein or radial artery could be grafted through a subxyphoid laparotomy incision followed by a thoracotomy and pull through of the marked vein graft into the left side of the chest to perform the remainder of the OM bypasses and the proximal anastomosis to the descending aorta. The procedure is done sequentially in the same setting, and on a beating heart, leaving the LIMA and the retrosternal territory untouched.
Five male patients requiring repeat surgical revascularization are described. Patient characteristics are included in Table 1. All patients had a patent LIMA to left anterior descending artery (LAD) and needed revascularization of branches of the RCA and circumflex coronary artery branches. Four patients had a first redo and 1 patient underwent a second redo procedure. All patients had off-pump coronary artery bypass grafting with at least one graft to a posterior branch of RCA and other grafts to one or more OM branches of the circumflex artery through separate targeted subxyphoid and left thoracotomy incisions, pulling through the grafts to the inferior wall. There were no deaths and no complications except for gastrointestinal bleeding in 1 patient.
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Technique
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Initially the patient is positioned supine, allowing the harvest of the choice of graft: gastroepiploic, greater saphenous vein, or radial artery. A 12- to 15-cm incision is made in the upper midline extending along the previous sternotomy incision to allow access to the lower 3 cm of the sternum (Fig 1). The peritoneum is entered, and the retroxyphoid and lower 3 cm of retrosternal space is cleared using a long electrical diathermy tip and a sponge on a stick. That exposes the inferior margin of the pericardium and the diaphragm. The latter is divided vertically exposing the inferior wall of the heart. The edges of the diaphragm are then retracted using stay sutures to the skin. Sharp and cautery dissection is continued to expose the target coronary artery vessel. Usually, it is easy to follow the old graft leading to the branches of the RCA. The target vessel is then stabilized using a suction based mechanical stabilizer. After heparin is given, the vessel is encircled with silicone elastomer tape and the anastomosis performed as usual. The vein graft that previously had been marked linearly with ink and tied at its proximal end with cotton tape is then dropped into the pericardium.
The diaphragm and the abdominal incisions are closed, and the patient is turned to the left lateral thoracotomy position. No drains are left in the abdomen. The left side of the chest is entered through a mid thoracotomy in the sixth space. The diaphragm is pulled down using a retention suture sewn at the dome and pulled through the skin below the incision (Fig 2). The inferior pulmonary ligament is divided, allowing good visualization of the pericardium. The latter is entered parallel and below the phrenic nerve. The circumflex artery and its branches are exposed and stabilized, and the additional distal bypass performed. The graft to the RCA branch is then pulled into the left chest by pulling on the attached tape, carefully ascertaining that it is not twisted by examining the linear mark drawn on it. A side-biting clamp is applied on an appropriately chosen location of the descending aorta. A preoperative computed tomography scan of the chest can often verify the presence of advanced atheroma in certain aortic locations. The proximal anastomoses are performed, and the clamp removed. Most of the time a much shorter length is needed for the OM grafts, as the tendency is to overestimate the distance between the aorta and OM arteries.
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Fig 2. The diaphragm is retracted using a percutaneous traction suture. A side-biting clamp is on the descending aorta (arrow). Three grafts showing the upper two (1 and 2) to the obtuse marginal branches and the lower one (3) to the posterior descending branch of the right coronary artery.
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Comment
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This technique of targeted incisions avoids potential risks of injury to major vessels and to the right ventricle when resternotomy is performed for redo coronary artery bypass surgery. Furthermore, no dissection of the retrosternal space in the region of the LIMA is needed, hence avoiding injury to the one graft that is associated with patient longevity. Using the off-pump revascularization technique, one also avoids necessary dissection around the nonvirgin territory of the aorta and right atrium [5, 6]. Nevertheless, we always prepare the groin for possible peripheral cannulation and cardiopulmonary bypass when positioning the patients, although we have not needed to use that in any of our cases.
The graft pull-through technique allows the use of the descending aorta for arterialization of all the grafts. This procedure is technically simpler and carries potentially fewer risks than a redo sternotomy in the presence of patent grafts to the LAD territory or when resternotomy is contraindicated for other reasons. With the potential increase in the number of cases presenting for repeat surgical revascularization with patent mammary arteries, one would suggest that this graft pull-through technique could be an attractive first-choice procedure.
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References
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- Foster ED, Fisher LD, Kaiser GC, et al. Comparison of operative mortality and morbidity for initial and repeat coronary bypass graftingthe Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1984;38:6.
- Doty JR, Salazar JD, Fonger JD, et al. Reoperative MIDCAB grafting3 year clinical experience. Eur J Cardio Thorac Surg 1998;13:641-649.
- Mishra YK, Wasir H, Khanna SN, et al. Multimodality targeted approach in redo off-pump coronary artery bypass surgery Asian Cardiovasc Thorac Ann 2003;11:7-10.[Abstract/Free Full Text]
- Abraham R, Ricci M, Salerno T, et al. A minimally invasive alternative approach for reoperative graft of the right coronary artery J Card Surg 2002;17:289-291.[Medline]
- Czerny M, Zimpfer D, Kilo J, et al. Redo coronary artery bypass grafting with and without cardiopulmonary bypass in the elderly Heart Surg Forum 2003;6:210-215.[Medline]
- Trehan N, Mishra YK, Malhotra R, et al. Off-pump redo coronary artery bypass grafting Ann Thorac Surg 2000;70:1026-1029.[Abstract/Free Full Text]
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Abstract
Introduction
