Minimally Invasive Redo Coronary Bypass Graft To The Left Anterior Descending Artery: A Novel Approach To A Hostile Sternum
Luke J Rogers MBChB FRCS (CTh)1,2, Mohammad Reza Rezaei MD1,2, Piroze M Davierwala MD, FAHA1,2 
1 Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
2 Department of Surgery, University of Toronto, Toronto, ON, Canada

 

PREOPERATIVE CARE

• 71-year-old male with exertional angina (CCS III/IV)

• Prior CABG ( ̴30 years ago): LITA-LAD and Vein graft-Diagonal branch

• CV risk factors: Hypertension, Type 2 Diabetes, Prior stroke

• Transthoracic Echocardiogram: Normal biventricular function, LVID(s/d) 3.1/4.6 cm

• Coronary angiogram: Proximal LAD occlusion, atretic LITA and multiple tandem lesions in vein graft-Diagonal branch (Figure 1)

• CT Chest: High-risk features for re-sternotomy – RV and PA root adherent and even engrained at one point to posterior sternal table (Figure 2 - yellow arrows

• Patient wish: Avoid a re-sternotomy

• Therapy plan: Minimally invasive CABG through bilateral mini-thoracotomies, thereby, avoiding a re-sternotomy in a hostile sternum and ensuring arterial revascularization with an ITA based graft for the LAD (composite RITA/RA I-graft)

 

INTRAOPERATIVE STEPS

• Position: Supine with a horizontal shoulder pack

• Intubation: Double-lumen endotracheal tube to allow intermittent selective ventilation bilaterally and a brief period of apnoea for cross-over of composite graft from the right to left thoracic cavity

• Incisions: Bilateral mini-thoracotomies for assessment of feasibility of procedure – RITA harvest, passage of the composite graft across the mediastinum (Figure 2 - red circle & hatched curve) and LAD anastomosis

• Conduit harvest: Simultaneous harvest of RITA and left radial artery

• Proximal anastomosis: End-side anastomosis between end of RITA and left radial artery

• Distal anastomosis: Passage of composite I-graft through anterior superior mediastinum to left thoracic cavity followed by end-side anastomosis between Radial artery and LAD

• Chest closure: bilateral intercostal extra-pleural catheters for pain control and bilateral pleural chest tubes

 

POSTOPERATIVE CARE

• CVICU: Hemodynamically stable without need for any inotropic support

• Analgesia: Multimodal including continuous Ropivacaine infusion through bilateral extra-pleural catheters and patient-controlled analgesia (PCA)

• Extubation: 48 hrs postoperatively, due to pre-existing COPD

• Ward: On Postoperative day 4

• Pre-discharge CTCA: Patent composite I-graft with no kinks/stenoses (Figure 5)

• Discharge medications: Dual antiplatelet therapy and calcium channel blocker (Amlodipine) in addition to preoperative medications.

 

3-month follow-up:

• No anginal symptoms or shortness of breath

• No limitation to daily activities

• All surgical sites healed well without any concerns

 

Conclusions

This approach achieved ITA-based arterial revascularization of the LAD without the need for re-sternotomy and its potential complications in a hostile sternum

without cardiopulmonary bypass and aortic manipulation.