Objective: To describe patient selection criteria, surgical technique and early outcomes in patients undergoing reoperative coronary artery bypass surgery (RECABG) through a left thoracotomy without cardiopulmonary bypass (CPB).
Methods: Eight patients with patent grafts to the left interventricular coronary artery (four of whom had also patent grafts to the right coronary artery) requiring revascularization of the circumflex coronary system had redo-CABG without CPB through a left posterolateral thoracotomy.
Results: There were no in-hospital mortality or serious postoperative complications. All patients are angina-free.
Conclusions: An off-pump redo-CABG through a left posterolateral thoracotomy may reduce risks attributable to resternotomy in patients who met the selection criteria.
Objetivo: Descrever a seleção de pacientes, a técnica cirúrgica e os resultados imediatos de reoperação de revascularização miocárdica sem circulação extracorpórea através de toracotomia póstero-lateral esquerda.
Método: Oito pacientes com pontes pérvias para a artéria interventricular anterior (quatro dos quais também tinham pontes pérvias para a artéria coronária direita) foram submetidos à reoperação sem circulação extracorpórea através de toracotomia póstero-lateral esquerda.
Resultados: Não houve mortalidade hospitalar ou complicação pós-operatória significativa. Todos os pacientes estão assintomáticos.
Conclusões: Em pacientes selecionados, reoperação de revascularização miocárdica sem circulação extracorpórea e através de toracotomia esquerda pode reduzir os riscos da resternotomia.
Although the outcomes of reoperative coronary artery bypass grafting have been improved along the years , some clinical situations, such as the internal thoracic artery grafts, carry a higher risk during resternotomy. In 1982, Cheung et al;  and Faro et al.  independently described the experience in performing left thoracotomy for circumflex coronary artery revascularization in patients who had undergone previous cardiac surgery. The use of left thoracotomy for myocardial revascularization, besides to have been proven as a simple technique, has been sporadically reported [4-15]. Our first experience was with a patient who required coronary artery bypass grafting concomitant with an aortic coarctation . Since then, other 8 patients have undergone surgery.
The aim of the present study is to attract attention upon to this technical option of coronary surgery.
Between February 2003 and April 2005, 8 patients underwent reoperative off-pump coronary artery bypass grafting (CABG), at the Heart Institute of Pernambuco, Recife, PE, Brazil, through left thoracotomy. Of the 8 studied patients, 7 were male and 1 was female. The ages ranged from 60 to 85 years (mean age of 69.6 years). The main data related to the previous surgery (date and CABG performed) are listed in Table 1.
The time between the frist and the second surgery varied from 4 to 23 years (mean of 12 years). All patients had angina pectoris. Basically, the choice of the technique was due to the presence of the patent grafts, especially the internal thoracic artery grafting to the anterior interventricular branch of left coronary artery, and the need to revascularize the circumflex branch of left coronary artery. Besides the revascularization of the circumflex branch of left coronary artery, the anterior interventricular branch of left coronary artery (case 3) and the diagonal branch of left coronary artery (case 4).
After general anesthesia, a tracheal intubation with a Carlen double-lumen, flexible endobronchial tube, which allowed the left lung collapse after the thoracotomy, was performed. With the patient still in supine position, a saphenous vein was obtained from the right leg. The patient was then moved to a lateral recumbent position and a left posterolateral thoracotomy through the 5th intercostal space was performed.
Once the thorax was opened, the ventilation to the left lung was suspended and the pericardium was incised longitudinally anterior to the phrenic nerve (Figure 1). Heparin was administered in a dose of 4.0 mg/kg body weight. When the artery to be revascularized was identified, it was sutured with continuous 4-0 polypropylene suture to interrupt the blood flow (Figure 2). A suction stabilizer (Octopus II, Medtronic, Inc.; Minneapolis, Minn) was used to stabilize the artery in order to construct the anastomosis with the use of the saphenous vein (Figure 3). The anastomosis was performed with a continuous 7-0 polypropylene suture (Figure 4). The proximal saphenous vein grafting anastomosis was made to the descending aorta in 7 cases (Figure 5), and to the left subclavian artery in 1 case. Partial occlusion clamping and continuous 6-0 polypropylene suture was used. Once the shapenous vein grafting was concluded, the left lung was reexpanded, the heparin was reverted with an equal dose of protamine sulfate, and the thorax was drained and closed by layers.
Fig. 1 - Aspect of the exposure of theposterolateral surface4 of left ventricle through left thoracotomy
Fig. 2 - Marginal branch of the circumflex artery sutured with 4-0 polypropylene suture
Fig. 3 - Stabilization of the artery to perform the anastomosus with the Octopus stabilizer
Fig. 4 - Distal anastomosis of the occluded saphenous vein graft bypass
Fig. 5 - Final aspect of the saphenous vein graft bypass. It can be observed the anastomoses in the circumflex artery and in the descending aorta
We have not observed any technical difficulties in identifying the artery to be revascularized. Overall, 10 shapenous vein graftings were performed as follows: 8 to the left marginal artery of circumflex branch; 1 to the anterior interventricular branch; and 1 to the diagonal branch of anterior interventricular branch of left coronary artery. Also, due to the pulmonary collapse, there were no difficulties in performing the anastomosis to the descending aorta. The surgery was uneventfully. No hemodynamic instability or electrocardiographic changes were seen in any patient.
There were no deaths; no need to reoperate for bleeding; and no pulmonary or neurologic complications. Only one patient needed to make a new drainage of the left hemithorax due to postoperative pleural effusion.
All patients acknowledged angina relief and are now asymptomatic from the cardiovascular standpoint.
Judging by the existing number of publications, it seems that the CABG technique through left thoracotomy has not been used in spite of its undeniable advantage in some cases, once this procedure can reduce the risks of resternotomy and heart dissection, such as hemorrhage, ITA grafting injury, and embolization by manipulating the saphenous vein bypass grafts.
Among the occasional candidates to this technical option, patients with ITA or saphenous vein patent grafts to the anterior interventricular branch and right coronary artery, and those who require revascularization of the circumflex coronary system are included.
Other indications would be as follows: calcified ascending aorta, sternum osteomyelitis or mediastinitis in the first operation, mediastinal irradiation, requirement of concomitant left lung surgery and previous mitral valve replacement, what makes risky to rotate the heart to approach the posterior arteries [3, 4, 6].
In the Cleveland Clinic experience , 2.5% of the patients eligible to redo-CABG were included in these indications. Our cases fell into the classical indication: a) all the 8 patients has patent grafts to the anterior interventricular branch; although one of them presented anastomotic stenosis, and another one had injury in the diagonal branch of the anterior interventricular branch; b) four patients also presented patent grafts to the right coronary artery; c) all of them has stenotic injury in the circumflex branch requiring revascularization.
Also, it is observed in the review of the literature that the operative technique has varied a lot. The majority of the groups have been using some type of extracorporeal circulation with the femoro-femoral bypass being the most used [2-10]. Some groups have been using hypothermia and ventricular fibrillation to make the anastomoses [2, 4]. The growing familiarity with the off-pump coronary artery bypass grafting technique has showed that there in no need for perfusional support [12, 14, 15]. Our early experience using the technique standardized by Azoury et al.  and Mack et al.  showed that this approach is safe and effective and low operative risks. This approach was associated with no mortality in 21 and 32 patients, respectively.
We emphasized the need to use the double-lumen endotracheal tube, which facilitates the whole operation, especially the access to the descending aorta. There is a consensus that the most difficult part of the operation is to connect the vein to the descending artery [14, 15].
In summary, the advantages in avoiding the resternotomy and the CABG make the redo-CABG through a left posterolateral thoracotomy, especially to the circumflex branch, and in selected patients, an excellent technical option.
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