Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015 AFRICA 25
Redo off-pump coronary artery bypass grafting via a left
thoracotomy
Ibrahim Duvan, Sanser Ates, Burak Emre Onuk, Umit Pinar Sungar, Murat Kurtoglu, Yahya Halidun Karagoz
Abstract
Background: In this study, we retrospectively reviewed our
experience in a meticulously selected group of patients under-
going redo off-pump coronary artery bypass graft (CABG)
surgery from the descending aorta to the circumflex artery
(Cx) and its branches.
Methods: Between January 2001 and October 2013, 32
patients at our hospital underwent redo off-pump CABG
from the descending aorta to the Cx and its branches via a
left posterolateral thoracotomy. Of these patients, 27 were
male (84.3%) and five were female (15.7%), with a mean age
of 61.66 ± 8.63 years. All patients had a patent left internal
thoracic artery-to-left anterior descending coronary artery
(LITA–LAD) anastomosis. Thoracotomy was performed
through the fifth intercostal space. The saphenous vein or
radial artery was prepared as a graft at the same time as
the left posterolateral thoracotomy from the contralateral
extremity, without any positional problem.
Results: The main reasons for surgery in this group of patients
were new lesion formation in 19, graft occlusion in six, and
both in seven patients. The average operating time was 143.90
± 36.93 minutes, respiratory assist time was 5.08 ± 1.88 hours,
intensive care unit (ICU) stay was 21.3 ± 4.41 hours and
hospital stay was 5.06 ± 2.74 days. Thirty-eight bypasses were
performed. The follow-up period was 56.17 ± 39.2 months.
Six patients were lost in the follow-up period and four patients
died. Twenty-two were alive and free of cardiac problems.
Conclusion: Redo off-pump CABG via a left posterolateral
thoracotomy provided a safe and effective surgical approach
with lower rates of postoperative morbidity and mortality
in patients who required revascularisation of the Cx and its
branches.
Keywords: coronary artery bypass grafting, re-operation, circum-
flex artery, thoracotomy
Submitted 10/12/13, accepted 20/10/14
Published online 2/12/14
Cardiovasc J Afr 2015; 26: 25–28
DOI: 10.5830/CVJA-2014-064
Re-operative coronary artery bypass graft (CABG) surgery
is more complicated than the initial CABG and it may also
be more hazardous because of risk factors related to median
resternotomy, such as cardiac injury and damage to the patent
grafts due to sternal adhesion. 1 Deciding on the appropriate
treatment for recurrent coronary artery disease (CAD), especially
conditions such as non-left anterior descending coronary artery
(LAD) ischaemic lesions during the existence of patent left
internal thoracic artery-to-left anterior descending coronary
artery (LITA–LAD) anastomosis is a dilemma.2
If the patient is unresponsive to medical therapy, and
percutaneous transluminal coronary angioplasty (PTCA) and/
or stenting is not appropriate for revascularisation, alternative
surgical strategies, excluding resternotomy and cardiopulmonary
bypass (CPB), may be themost appropriate way of revascularising
the branches of the circumflex artery (Cx) or right coronary
arteries (RCA) (non-LAD territories).3-5 In selected patients,
off-pump redo CABG for the branches of the Cx via a
posterolateral thoracotomy may reduce the risks due to median
resternotomy and dissection of the heart.
This procedure to avoid resternotomy and CPB has become
an established and popular way of revascularising recurrent
coronary artery disease in the lateral aspect of the heart. In this
article, we share our experience of 32 patients who underwent
redo CABG for the Cx and its branches via a left posterolateral
thoracotomy.
Methods
Between January 2001 and October 2013, 32 off-pump CABG
re-operations via a posterolateral thoracotomy for the branches
of the Cx system were performed at the Department of Cardiac
Surgery of Guven Hospital in Ankara, Turkey. During this time,
450 patients underwent isolated redo off-pump CABG and our
study group constituted 7.1% of this population. There were 27
men and five women, aged 61.66 ± 8.63 years, with a mean of
40–76 years (Table 1).
Co-morbidity factors of the patients were pre-operative
hyperlipidaemia, family history, smoking, hypertension,
diabetes mellitus, chronic obstructive pulmonary disease and
cerebrovascular disease. The period between the first and redo
operation via thoracotomy was 103.03 ± 63.33 months (20–264).
Only one patient was operated on three times, the others
were operated on twice. There were 2.16 ± 1.019 anastomoses
performed in each of the previous operations and the total
number of anastomoses was 67, whereas the number of patent
anastomoses was 44. All of the LITA-to-LAD anastomoses
were patent and 10 of the RCA and two of the Cx system
anastomoses were also patent.
Patients had symptoms of angina, depending on a problem
in the Cx system, and unfortunately medical therapy was
unsuccessful. Six had already been revascularised by both PTCA
Department of Cardiac Surgery, Guven Hospital, Ankara,
Turkey
Ibrahim Duvan, MD,
Sanser Ates, MD
Burak Emre Onuk, MD
Umit Pinar Sungar, MD
Murat Kurtoglu, MD
Yahya Halidun Karagoz, MD