Redo Coronary Artery Bypass Graft Surgery from the Descending Thoracic Aorta to the lateral wall of the Left Ventricle Via left Mini Thoracotomy
Odeaa Al jabbari, Walid K. Abu Saleh, Mahesh Ramchandani.
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
OBJECTIVE: CABG today most commonly makes use of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) with saphenous vein grafts for the remaining vessels. Although the long-term patency of LIMA to LAD is excellent, the development of disease in the vein graft over time is all too common. This frequently results in recurrence of disabling symptoms. PCI for vein graft disease is often fraught with peril.
We present a minimally invasive option for revascularization of the lateral wall of left ventricle.
METHODS: Between 2011 to 2015, 11 patients (9 males 82%), mean age 71 (37- 81) underwent minimally invasive redo CABG from the descending thoracic aorta to an obtuse marginal artery via a left mini- thoracotomy. All patients presented with disabling angina on maximal medical therapy and PCI was considered unsafe option. All had a patent LIMA to LAD . All patients had advanced disease in the vein graft.
RESULTS: None required conversion to sternotomy or the use of cardio pulmonary bypass. Average surgery time was 4 (3 - 5) hours with an average estimated blood loss of 550 cc (400-1500).
Each patient had one graft anastomosis performed to the lateral wall. proximal anastomoses were performed using Cardica PasPort device in 10 patients. all distal anastomoses were hand sewn.
Graft flows were excellent with the mean flow being 52 ml/min (20-110), mean pulsatility index of 2.2 (1.5-2.6) and mean diastolic filling of 70% (60%- 75%). The average hospital stay was 7 days (6-14). There was no in-hospital mortality and at 6 months follow up, all patients were alive, well and symptom free.
CONCLUSIONS: In a select group of patients, redo CABG to the circumflex territory can be performed safely via left mini thoracotomy using the descending thoracic aorta for the proximal anastomosis. This approach avoids the risk of injury to the patent LIMA that median sternotomy would carry. The use of the Cardica Pas-Port device facilitates this approach.
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