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Ann Thorac Surg 1999;67:382-386
© 1999 The Society of Thoracic Surgeons

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Original Articles

Injury to a patent left internal thoracic artery graft at coronary reoperation

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery/F25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: gillinom{at}cesmtp.ccf.org

Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. The purpose of this study was to determine the prevalence, outcome, and operative strategies for patients having injury to a patent left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) at coronary reoperation.

Methods. Of 655 patients with a patent LITA graft to the LAD undergoing coronary reoperation from 1986 to 1997, 35 (5.3%) sustained intraoperative injury to the LITA graft.

Results. Strategies to restore flow to the LAD included new saphenous vein graft to the LAD in 15 patients, saphenous vein graft to the LITA stump in 7, saphenous vein graft to the LAD and repair of the LITA graft in 6, and other strategies in 7. All or part of the LITA graft to the LAD was salvaged in 20 patients (57%). Fourteen patients (40%) sustained perioperative myocardial infarction, and 3 patients died (8.6%). The 3 patients who died all had stenosis or thrombosis of the graft to the LAD documented at autopsy.

Conclusions. We conclude that (1) the prevalence of injury to a patent LITA graft is 5.3%; (2) a variety of techniques can be used to restore blood flow to the LAD; and (3) ineffective revascularization of the LAD in this situation is associated with operative mortality. At primary coronary artery bypass grafting, the LITA pedicle should be positioned in the left chest away from the posterior sternal table; this strategy may minimize the risk of LITA graft injury at coronary reoperation.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Use of the left internal thoracic artery (LITA) to bypass the left anterior descending coronary artery (LAD) reduces the probability of reoperation over the next 10 years by a factor of 2 [1, 2]. However, when coronary reoperation is necessary, the presence of a patent LITA–LAD graft creates specific risks, including the possibility of intraoperative injury to the graft and potential difficulties with myocardial protection. Previous studies demonstrate that the use of a LITA graft at primary operation decreases the morbidity and mortality associated with coronary reoperation [3–6]. Nevertheless, injury to a patent LITA–LAD graft at reoperation can have catastrophic consequences [4, 7–9]. The purpose of the present study was to determine the prevalence, outcome, and operative strategies for patients having intraoperative injury to a patent LITA–LAD graft.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Study group
From 1986 to January 1, 1997, 35 patients with a patent LITA–LAD graft had injury to the LITA graft during reoperative coronary artery bypass grafting (CABG), and they form the study group. These patients were identified as follows. Initially, the prospective Cardiovascular Information Registry was used to identify all patients with a patent LITA–LAD graft who had reoperative CABG at the Cleveland Clinic Foundation during this period. There were 655 such patients. The patients’ medical records were then reviewed in detail to identify those patients who had injury to the LITA graft at reoperation. Patients having valvular heart surgical procedures at the initial operation or reoperation were excluded. Similarly, patients having injury to a right internal thoracic artery or a LITA that was not anastomosed to the LAD were excluded.

Patient characteristics
Mean age at the time of reoperation was 61 ± 13 years (range, 32–66 years); 34 patients (97%) were men. Fourteen patients were in New York Heart Association functional class III or IV, and left ventricular function was moderately or severely depressed in 13. The initial operation was performed at The Cleveland Clinic Foundation in 21 patients. Mean number of distal anastomoses at the initial operation was 3.0 ± 1.0, with 1.1 ± 0.2 arterial grafts per patient.

Follow-up
Systematic Cardiovascular Information Registry follow-up every 2 years was supplemented by telephone interview with the patient or referring cardiologist, or both. Complete follow-up information was available in 26 (81%) of 32 hospital survivors. Mean follow-up among survivors was 5.1 ± 2.7 years (range, 0.9 to 10.3 years).

Data analysis
Univariable comparison of hospital mortality between patients having injury to the LITA–LAD graft at reoperation and those without injury was by ² test. Nonparametric, non–risk-adjusted estimates of freedom from events were obtained by the method of Kaplan and Meier [10]. Unless otherwise stated, continuous variables are expressed as mean ± standard deviation.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Mean interval from initial operation to redo CABG in the 35 patients having injury to the LITA graft was 115 ± 8 months, (range, 16 to 215 months). The indications for reoperation were saphenous vein graft disease (43%), progressive native coronary atherosclerosis (23%), and both saphenous vein graft disease and progressive native coronary atherosclerosis (34%). Preoperative angiography demonstrated that the LAD was occluded in 24 patients (68%). In 2 patients the LITA graft was patent, with a stenosis of less than 50%; and all other patients had perfect patency. Preoperative chest x-ray films were available for review in 26 patients. The most common finding on the chest x-ray film was a LITA graft adherent to the posterior sternal table (17 patients, 65%) (Fig 1). The LITA graft crossed the midline in 8 patients; in 5 of these patients, the LITA graft was also closely opposed to the posterior sternal table.

View larger version (80K): [in this window] [in a new window]   Fig 1. Posteroanterior (top panel) and lateral (bottom panel) chest x-ray films from patient before reoperative CABG. Although the LITA graft does not cross the midline, the lateral projection demonstrates that the LITA graft is adjacent to the posterior sternum.

There were eight late deaths, and the overall 5-year survival rate was 82%. The most common cause of late death was congestive heart failure (4 patients). Recurrent angina developed in 3 patients, but no patient experienced late myocardial infarction.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Coronary reoperations continue to play an increasing role in the practice of CABG [3, 4]. Operative morbidity and mortality are increased at redo CABG, with an operative mortality in most series of reoperations three to five times that for primary CABG [3, 4, 11–13]. Bypass of the LAD with the LITA at primary CABG increases long-term survival and decreases the incidence of late reoperation [1, 2]. At coronary reoperation, the presence of a patent LITA graft to the LAD decreases operative mortality [3, 5, 6]. Proposed mechanisms for this salutary effect include preserved anterior wall function and the absence of atherosclerotic embolizaton from the LITA graft [3–6]. However a patent LITA–LAD graft also creates specific technical challenges at coronary reoperation. These include delivery of cardioplegia to the LAD territory and avoidance of injury to the LITA graft. Use of retrograde cardioplegia with temporary occlusion of the LITA graft provides adequate myocardial protection in most cases [3]. However, dissection and control of the LITA pedicle can be challenging and hazardous, with some investigators reporting injury to the LITA graft in 15% to 40% of coronary reoperations [7, 8].

The risk of damage of a LITA graft at coronary reoperation is related to the care taken at the primary operation to protect that graft. For patients who receive an in situ LITA graft to the left coronary system, one strategy that is effective is to open the pleura and make a vertical slit in a posterior direction just lateral to the pulmonary artery at the point where the graft naturally enters the pericardial cavity [3, 14, 15]. The LITA graft is routed into the pericardium through this slit and lies in a posterior position, just anterior to the phrenic nerve and lateral to the pulmonary artery (Fig 2). This approach keeps the LITA graft from becoming adherent to the posterior sternal table or to the aorta, locations where the LITA graft is most at risk during coronary reoperation. Other techniques for protection from injury at redo CABG include the use of a polytetrafluoroethylene graft to encase the LITA pedicle [16], creation of a pericardial flap, and routing of the LITA graft through a posterior hole in the pericardium [17, 18].

View larger version (84K): [in this window] [in a new window]   Fig 2. At primary CABG, a slit is created in the pericardium, allowing the LITA graft to settle into the left chest away from the posterior sternal table.

Some investigators have suggested establishing peripheral CPB before sternotomy and mediastinal dissection at reoperative coronary surgical intervention [21]. The rationale for this approach is that it may be easier to dissect the decompressed heart, and injury to the heart or patent grafts will be better tolerated and more easily controlled if CPB has already been instituted. Disadvantages of this strategy include increased blood loss during dissection and increased difficulty harvesting the right internal thoracic artery after heparinization. We have rarely used this approach.

When a patient with a patent LITA–LAD graft requires coronary reoperation through median sternotomy, a carefully planned stepwise approach is essential. Evaluation of the cardiac catheterization and posteroanterior and lateral chest x-ray films is helpful to determine whether the LITA graft is adherent to the posterior sternal table or crosses the midline. These findings on the chest x-ray film increase the risk of damage to the LITA graft during sternotomy and subsequent dissection [7, 8]. In these situations, we favor exposure of a femoral artery and vein to facilitate urgent institution of CPB should injury to the LITA graft occur. The sternum is divided with an oscillating saw, and adhesions to the posterior sternal table are divided sharply with scissors. The right atrium and ascending aorta are then dissected for cannulation. If adhesion of the LITA graft to the chest wall is severe, CPB may be instituted to accomplish separation of the LITA graft from the posterior sternal table. Once the pedicle is separated from the chest wall, it is often possible to identify the position of the LITA graft lateral to the pulmonary artery. The dissection of the LITA graft on the surface of the heart is accomplished after the aorta is cross-clamped and cardioplegia is given. If the LITA graft has been previously identified, an atraumatic clamp is placed across it. If not, systemic cooling is initiated and maintained until the LITA graft is controlled. To isolate the LITA graft, the safest approach is to dissect along the diaphragm to the apex of the heart and then continue the dissection lateral to the LAD and in a cranial direction. This technique will produce a strip of tissue that contains the LITA graft, and the entire pedicle can be occluded with an atraumatic clamp.

Injury to the LITA graft can occur at virtually any stage of the operation. Although clips on the LITA pedicle suggest the location of the graft, this location is never known with certainty until the LITA graft is identified at operation. With careful surgical technique and increased experience with reoperative coronary procedures, the prevalence of injury to the LITA graft has been reduced to 5%. However, when injury does occur, specific steps are necessary to reduce morbidity and mortality. If injury occurs before institution of CPB, it is generally wise to proceed directly to cannulation and CPB when the injury is recognized [22]. This strategy will help maintain hemodynamic stability during subsequent dissection. Some investigators have proposed direct cannulation and perfusion of the transected LITA graft in this setting, suggesting that this strategy minimizes the ischemic insult to the LAD territory [4]. We have no experience with this technique, and our current preference is rapid institution of CPB, followed by early restoration of blood flow to the LAD territory. Once the heart has been arrested with a combination of antegrade and retrograde blood cardioplegia, the first priority is revascularization of the LAD, with delivery of cardioplegia down the newly constructed graft.

Although the presence of a patent LITA graft to the LAD decreases the morbidity and mortality of coronary reoperation, injury to this graft increases morbidity and mortality [8]. Some investigators have reported an operative mortality rate as high as 50%, when the LITA graft is injured [9]. In the present series, the operative mortality rate was 8.6%, which is higher than our operative mortality for reoperative CABG [3, 13]. In all cases, operative mortality was caused by ineffective revascularization of the LAD. Once successful CPB has been instituted and the heart arrested, the focus of the operation must be on myocardial revascularization that is as complete as possible. Early revascularization of the LAD is a priority. Various strategies can be used to restore blood flow to the LAD. In most cases, a saphenous vein graft is used either as a new graft to the LAD or as an interposition graft from the aorta to the transected LITA; however, the LITA stump may also be attached to another arterial graft as a T or Y graft if anatomy is suitable. If the LITA graft can be repaired, an additional graft to the LAD should be constructed to back up the LITA graft. In general, primary repair of the LITA alone is not recommended. The single patient who had primary repair of the LITA died as a result of thrombosis of the LITA at the repair site. Although 40% of patients sustained a perioperative myocardial infarction after injury to the LITA, only those patients with ineffective revascularization of the LAD died postoperatively, thus emphasizing the critical importance of ensuring adequate myocardial blood flow to the LAD territory.

In conclusion, fear of injury to a patent LITA–LAD graft has resulted in a significant proportion of patients being referred for percutaneous intervention when they develop recurrent ischemia after primary CABG that included a LITA–LAD graft [23]. In fact, the presence of a patent LITA–LAD graft decreases the morbidity and mortality of coronary reoperation [3–6]. Placement of the LITA pedicle away from the midline and the posterior sternal table at primary CABG decreases the risk of injury at redo CABG. With careful planning and surgical technique, the prevalence of injury to a patent LITA graft is approximately 5%. When injury to the LITA graft does occur, one of several strategies can be used to restore blood flow to the LAD. Ineffective revascularization of the LAD in this situation is associated with operative mortality.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We are indebted to Maura J. Schnauffer for technical and statistical assistance and to Luci Mitchin for secretarial assistance.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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