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Coronary Artery Bypass Graft X 5

Submitted by:
MARK M. LEVINSON, M.D.
The Heart Surgery Forum[tm]
Email: Mark M. Levinson, M.D.
URL: http://www.hsforum.com/heartsurgery/home.hsf

PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease with angina

POSTOPERATIVE DIAGNOSIS: Same

OPERATIVE PROCEDURE: Coronary artery bypass graft x5

  1. Left internal mammary to the diagonal and left anterior descending
  2. Sequential vein graft from the aorta to the 2nd and 3rd marginal
  3. Saphenous vein to the acute marginal branch of the right coronary

FINDINGS:
The ascending aorta was normal; the heart had normal size and contractility. There was no evidence of infarction. The LAD was a 2-mm vessel proximally and about 1.5 distally. The diagonal was 1.25. Both were free of distal disease. The posterior descending had extensive disease at its takeoff from the distal circumflex and was occluded to a 1-mm probe. This is worse than what was suggested by the angiographic findings. The OM-2 was a 2-mm vessel without distal disease. The first marginal was tiny; the first diagonal was tiny. The acute marginal branch of the right coronary was 1.5 to 2 mm in diameter. The saphenous vein was excellent. The left mammary was excellent.

PROCEDURE:
The patient was supine with standard padding and positioning. Anesthesia was obtained and monitoring lines were established. Cardiac sterile prep and drape were performed. The sternum was opened through a vertical midline incision. The left ankle was opened with a small incision, and the saphenous vein harvested through a series of small incisions using laryngoscope and laparoscopic equipment.

The sternum was divided with a reciprocating saw and the thymus was opened. The pericardium was incised, and the coronary anatomy was inspected. Measurements were taken of the proposed targets. The left chest wall was elevated with a Pemco, and the mammary taken down with cautery. A Blake drain was placed in the left pleural space. The sternal retractor was placed.

The pericardium was distended and the patient was fully heparinized. The aorta was cannulated near the innominate. Retrograde and antegrade cardioplegic cannulas were established along with a double-stage venous uptake cannula. The mammary was dilated and flow was excellent. The LIMA was brought in the left lobe of the thymus and through an incision in the pericardium. The final vein preparations were made and the saphenous tunnel was packed with gauze until the heparin was reversed.

The conduits were excellent. The ACT was over 400; cardiopulmonary bypass was begun. Core temperature was dropped to 28 degrees. The aorta was crossclamped and 500 mL of antegrade followed by 300 mL of retrograde cardioplegia were administered. The root was vented and maintenance cardioplegia was given retrograde every 15-20 minutes with doses of 300 to 350 mL of cold potassium crystalloid.

The large acute marginal branch was grafted first. It was isolated with proximal Silastic tape and opened with a #15 blade and fine scissors. It easily took a 1-mm probe. A segment of vein was beveled and grafted to the acute marginal branch with continuous 7-0 Prolene and confirmed with probes. The graft was brought up to the right lateral ascending aorta where a linear incision was made and the top end created to the vein with continuous 6-0 Prolene.

The heart was flipped up to expose the inferior wall. There was significant palpable disease in the proximal PDA. I opened the PDA in its midportion and could not pass a 1-mm probe into the proximal circumflex, indicating more severe disease than initially appreciated by the angiogram. A segment of saphenous vein was beveled and sewn in a parallel end-to-side manner with continuous 7-0 Prolene. Then the mid-OM-2 was opened, a diamond-shaped anastomosis created to the venotomy using continuous 7-0 Prolene, and the final suture line confirmed with probes. The graft was brought up to the aorta. It appeared that there would not be enough length if the graft was brought anterior to the pulmonary artery. Instead I dissected the tissue between the aorta and the pulmonary artery and opened up the transverse sinus, so there was a wide passage underneath the pulmonary artery. The graft was brought over the left pulmonary vein, behind the LA appendage, and through the transverse sinus to lie on the lower medial left aorta. The length was very adequate, and a tension-free anastomosis to the aorta was created in the manner described above.

Rewarming was begun. Then the diagonal was opened and grafted side-to-side to the left mammary and confirmed probe patent. The distal LAD was opened and grafted to the tip of the left mammary and also confirmed probe patent. There was excellent flow of blood from the LIMA. The heart pinked up and began to beat spontaneously and measured 56 mL of flow in the trunk of the LIMA graft.

The root was vented while Valsalva maneuvers were repeated, and the left ventricle compressed. After this was done many times and the crossclamp released, the vein grafts filled well and stripped well. There was no proximal or distal bleeding. The patient came back with a nodal rhythm, was paced through temporary V-wires, and finally came back in sinus rhythm. Contractility was excellent. The patient came off bypass without pressors. Flows in the grafts were 74 in the LIMA, 96 in the OM-1 and OM-2, and 22 in the acute marginal branch of the right.

The cannulation sites were all closed and protamine was given to reverse heparin. Hemostasis was satisfactory. I left 2 RV pacing electrodes. The linea alba was approximated with interrupted Polydek. I left 2 mediastinal chest tubes and a right pleural Blake drain. The aortic cannulation site was closed with pursestring and oversewn sutures. The mediastinum was irrigated with antibiotic solution.

The vein tunnel was irrigated with antibiotic solution, the entrance incisions closed with two layers of Vicryl, and the leg was wrapped with an elastic wrap. The sternum was approximated with #6 wire, the midline fascia with interrupted Polydek, and a multilayer Dexon closure on the remaining subcutaneous tissue and skin.

All final sponge, needle and instrument counts were reported as correct.

The patient tolerated the procedure well and there were no complications. The patient will be sent to the CICU in satisfactory condition.

End of Procedure

Many thanks to Mark M. Levinson, M.D. for submitting this report.

PROCEDURE: Reconstruction of Three Arch Vessels with Quadruple Coronary Artery Bypass Grafting

Submitted by:
MARK M. LEVINSON, M.D.
The Heart Surgery Forum[tm]
Email: Mark M. Levinson, M.D.
URL: http://www.hsforum.com/heartsurgery/home.hsf

On May 25, 1994, the patient underwent simultaneous reconstruction of all 3 arch vessels along with quadruple vessel coronary artery bypass grafting (CABG). Simultaneous median sternotomy, left supraclavicular fossa and right groin incisions were made. The right limb of the previous aortobifemoral knitted Dacron graft was isolated. The left subclavian artery (lateral to the sternocleidomastoid muscle) was also dissected and mobilized from the supraclavicular fossa. In the chest, the thymic tissue was fully dissected off the innominate vein (IV) in the same technique as used for total thymectomy. A complete dissection of the superior and inferior borders of the innominate vein was performed, extending laterally to include division of the left internal mammary vein at its entry into the innominate vein. The fully mobilized innominate vein was left intact and simply retracted with an umbilical tape (see below). The innominate artery (IA) and the left common carotid were extensively mobilized, with care to avoid embolization and to protect the left vagus and phrenic nerves. The surgical exposure obtained by this wide preparatory dissection is illustrated in the operative photograph below.

A harsh thrill was palpable in the left common carotid artery. Palpation also revealed a densely calcified plaque in the base of the innominate artery and extending all the way to the IA bifurcation.

After systemic heparinization, the right femoral graft limb was cannulated with a 19 French Medtronic BioMed VAD cannula (with multiple side holes). This cannula was inserted through a 5-0 polypropylene pursestring suture placed in the anterior wall of the knitted 8-mm femoral graft segment using a needle-guide wire-dilator technique. The arterial cannula was then advanced retrograde into the abdominal aorta for a premeasured distance as calculated to position the tip at the level of the celiac artery. A double-staged 51-gauge cavoatrial venous uptake cannula was inserted into the right atrial appendage. Segments of saphenous vein were harvested from the lower left leg.

Prior to the onset of cardiopulmonary bypass, the left subclavian artery (LSCA) was isolated with vascular clamps. The end of a #12 Hemashield tube graft was beveled and sewn onto the side of a longitudinal arteriotomy created in the anterior wall of the LSCA. Then this graft was tunneled underneath the sternocleidomastoid muscle to lay in the upper mediastinum anterior to the left common carotid artery.

Cardiopulmonary bypass was begun and core temperature decreased to 24 degrees C. The ascending aorta was clamped and retrograde cardioplegia administered. Multiple distal coronary targets were grafted, including the 1st and 2nd obtuse marginals, the left anterior descending, and the posterior descending branch of the right coronary artery. As the last 2 distals were being performed, core temperature was taken down to 19 degrees C. The pump was turned off and the tubing clamped. The arterial perfusion line was cut away and connected to a new 24 French perfusion cannula inserted into the superior vena cava (SVC). A vascular clamp was placed on the SVC-right atrial junction and 300-500 mL/min of cold oxygenated blood was perfused retrograde into the cerebral venous system. The aortic crossclamp was removed and the atrial cannula allowed to drain by gravity. Reflux of dark blood from the open ends of the cranial vessels was seen during the entire period of retrograde cerebral perfusion (RCP).

The left common carotid artery (LCCA) was transected above the ostial stenosis, and the stump left open for de-airing later in the case. The (calcified) innominate artery was also transected just above its origin and the stump oversewn with a double layer of running 3-0 polypropylene. A 1.5-cm segment of the proximal innominate artery trunk was removed to create a tunnel for the Dacron graft to lay within the midmediastinum (pretracheal region) . Next, an oval opening was made in the back wall of the 12-mm tube graft, and the transected end of the LCCA was sewn to this opening with continuous 5-0 polypropylene suture. A similar opening was made several millimeters beyond this suture line, and the transected innominate artery sewn to the graft with an end-to-side anastomosis.

A soft, noncalcified area on the greater curve of the midascending aorta was opened with a longitudinal incision, and widened into an oval opening by minimally resecting the incisional edges. The 12-mm conduit was beveled and sewn to the aortotomy with running 3-0 polypropylene suture. The completed repair illustrates the posterior positioning of the composite brachiocephalic graft within the mediastinum as it lies in the tunnel created by removing the proximal innominate artery. The advantages of this technique are described in the discussion section below.

The Dacron graft was de-aired using RCP which filled the conduit with dark blood, displacing luminal air. After thorough de-airing, the graft was clamped near the aortic (inflow) anastomosis. The RCP cannula was removed from the SVC and reconnected to the femoral arterial perfusion cannula. Transfemoral systemic arterial perfusion was begun. To de-air the aorta and arch, the arterial perfusate was allowed to freely escape from the open stump of the transected LCCA at the top of the arch for several minutes. Then the stump of the LCCA was oversewn, the cranial vessel conduit was unclamped and rewarming begun.

While the heart was resuscitating, 3 separate proximal vein graft anastomoses were created to the lower ascending aorta using a standard partial-occlusion technique. Prior to release of the partial-occluding clamp, the brachiocephalic graft was reclamped for 30 seconds to prevent potential emboli from reaching the great vessels. After weaning from bypass, a mild coagulopathy was treated with platelet and fresh-frozen plasma infusions. The patient awoke without neurologic deficits and was discharged on the 11th postoperative day receiving Coumadin and Pronestyl for atrial fibrillation.

End of Procedure

For detailed analyses, indications, photo graphics, followup, etc., of this procedure, please continue to The Heart Surgery Forum. (This surgical procedure was reproduced with the permission of Mark M. Levinson, M.D.)

PROCEDURE: Use of Free (Detached) Right Gastroepiploic Grafts to Achieve Complete Arterial Revascularization in Coronary Artery Disease

Submitted by:
MARK M. LEVINSON, M.D.
The Heart Surgery Forum[tm]
Email: Mark M. Levinson, M.D.
URL: http://www.hsforum.com/heartsurgery/home.hsf

Keywords:
coronary artery bypass grafting (CABG), arterial reconstruction, arterial conduit, right gastroepiploic artery (RGEA), free graft, transdiaphragmatic, coronary artery disease (CAD).

Introduction: In this report, the author presents the surgical techniques for utilizing free, detached RGEA grafts to obtain complete arterial revascularization. The use of the techniques described in this report makes both the proximal and distal RGEA anastomosis easy and versatile. The risk of technical failure at the proximal anastomosis is minimal if performed in the manner described. These techniques should encourage surgeons to expand their attempts at long term surgical relief of angina with complete arterial reconstruction, especially in the younger coronary artery patient population.

PROCEDURE:

Access to the RGEA is quickly gained by extending the lower sternal incision caudally by 3 inches. The timing of RGEA harvest depends somewhat on the makeup of the operation itself. In nonredo cases where IMA grafts will also be used, the mammary arteries are harvested first, but not transected distally. Once the mammary arteries are harvested, the chest wall retractor is removed, a sternal retractor placed and the lower sternal incision extended caudally for access to the RGEA. While attention is placed on RGEA harvesting, the spasm in the IMAs will usually resolve without vasodilating drugs. After harvesting, the RGEA is detached at both ends and stored in Hank's tissue culture medium. Then the patient is fully heparinized, and both IMAs are transected distally and prepared for grafting. For redos, it is sometimes simpler to approach the abdomen first. The availability of a suitable RGEA is then confirmed before opening of the sternum.

After entering the abdomen, the greater omentum is retracted out of the wound and held with Babcock clamps. A Balfour retractor helps exposure. The RGEA is palpated or visualized running in the greater omentum parallel and in proximity to the greater curvature of the stomach. The vessel is dissected free from the omental fat.

Each short gastric branch is isolated and gently grasped with an atraumatic Gerald forceps at its junction with the main RGEA. This maneuver depressurizes each branch prior to division by electrocautery (on a low heat setting). Separate hemostatic clips are not needed initially but may be used to reinforce branches which do not seal completely with cautery. Care is taken to avoid chasing the short gastric vessels onto the stomach with cautery and leaving diathermy injury on the serosa. The RGEA is mobilized from its origin (at the gastroduodenal artery) to its junction with the left gastroepiploic. At its distal fusion point with the LGEA, the RGEA usually divides into small branches. The RGEA is then tied off at both its origin and its termination. The stumps on each end are reinforced with hemostatic clips. The arterial graft is flushed with, and stored in, (Hank's) tissue culture medium. The free graft should measure more than 1 cm to 20 cm, which is adequate to reach any territory in a normal-sized heart.

It is important to perform the crucial proximal anastomosis under the aortic crossclamp. This permits the greatest flexibility in exposure without undue tension on the anastomosis or the delicate tissue of the free graft. After cardioplegic arrest, the ascending aorta is cleared off and a site chosen for the proximal anastomosis. A 6-mm linear incision is created in the lateral ascending aorta with a #15 blade (angulated cephalad towards the 10 o'clock position for both left or right-sided grafts ). Aortic tissue is neither excised nor "punched." To spatulate the anastomosis, a 1-cm linear incision is made down the posterior wall of the free RGEA graft using fine scissors. This incision is about 30% longer than the corresponding aortic incision. For left-sided grafts, a 7-0 needle is passed through the inferior rim of the endothelium of the graft at the 5 o'clock position. For right-sided grafts, the suture begins at the 11 o'clock position near the tip of the beveled graft. The suture is then brought outside-in through the analogous position on the aortic incision. The graft is now placed against the adventitia of the aorta while the lower (caudal) edge of the suture is completed with a running over-and-over technique sewing towards the surgeon's position. Bronchial return in the ascending aorta is controlled with gentle intermittent suction on the root cardioplegia cannula. Although suturing on the lower rim can usually be completed with single pass suturing, it is helpful to continue "around the corner" with double-pass suturing. This maneuver prevents difficult exposure at the last few sutures, particularly in a right sided graft. After the lower suture line is finished, the remaining suture limb is used for the upper (cephalad) suture line. The final proximal anastomosis is immediately verified as watertight by pressurizing the aortic root with an infusion of anterograde cardioplegia. This maneuver also expels air from the graft and permits the surgeon to visually confirm flow out of the distal end.

Next, the target vessel is opened and prepared for suturing. An example of a distal obtuse marginal branch of the circumflex successfully grafted with a free RGEA is shown in this angiogram.

The RGEA graft is untwisted and positioned near the intended target. The appropriate length is chosen after gently filling the heart with volume. Then the RGEA is transected, beveled and sutured to the target coronary. Use of a "pull down" or "parachute" style of suture line can lead to tearing in the delicate tissue of this graft which is very difficult to safely repair. Instead, I prefer to use running 8-0 polypropylene suture which is first tied at the heel, depending on the angle at which the target vessels sits in relation to the surgeon. For the distal RCA or PDA, the suture is started and tied at the 12 o'clock position or toe of the suture line. After completion, the graft is anchored with 2 separate tacking sutures of 7-0 or 8-0 polypropylene.

The remaining operation is completed, the aorta is de-aired through the root vent, and the crossclamp released. Flow in all grafts is confirmed with Transonic Doppler flow probes.

End of Procedure

For detailed analyses, indications, photo graphics, followup, etc., of this procedure, please continue to The Heart Surgery Forum. (This surgical procedure was reproduced with the permission of Mark M. Levinson, M.D.)

PROCEDURE: Cardiac Catheterization Sample 1

Submitted by:
Mary Morken - MT Daily II

Procedure: The patient was prepared and draped in a sterile fashion and 20 mL of 1% lidocaine was infiltrated in the right groin. A #6 French Cordis right femoral arterial sheath was placed and a #6 French JL-5 and JR-4 catheter was used to engage the left and right coronary ostia respectively. A #6 French pigtail was then used for left ventricular angiography. At this time, the decision to perform angioplasty was made, and further dictation is under the angioplasty report. There were very minor irregularities, with a maximum 20% stenosis just after the first diagonal. The remainder of the vessel was free of significant disease.

A 0.014, Hi-Torque, floppy, extra-support, exchange-length wire was used to cross the stenosis in the distal right coronary artery. A 3.5 x 20-mm Trackstar balloon was inflated in the right coronary artery in the distal portion. The initial stenosis was 50%-70% with an ulcerated plaque, and the final stenosis was 20% with no significant clot seen in the region. The patient had very dramatic ST elevations in the inferior leads as well as severe throat tightness and shortness of breath with inflations. This would resolve immediately with the inflation of the balloon. The catheters were removed and the sheath was changed to a #8 French Arrow sheath. The patient will be left on heparin overnight because of the clot seen in the vessel.

Impression: 1. Two-vessel coronary artery disease with a 70% obtuse marginal and a 70% right coronary artery lesion. 2. Normal left ventricular function. 3. Successful angioplasty to the right coronary artery with an initial stenosis of 70% and a final stenosis of 10%-20%.

PROCEDURE: Cardiac Catheterization Sample 2

History of Present Illness: This is a 60-year-old white female with a history of hypertension, type 2 diabetes mellitus, and a positive family history for coronary artery disease. She describes increasing dyspnea on exertion over the last 2 months. She denies any chest pain with these episodes of dyspnea. She has a history of an unremarkable pulmonary workup with a normal V/Q scan and normal pulmonary function tests by report. She was referred for right and left heart catheterization. By report, a recent echocardiogram showed normal left ventricular function and a dobutamine echocardiogram was normal with evidence of only cavity obliteration.

Past Medical History: Hypertension, type 2 diabetes mellitus and hypercholesterolemia.

Past Surgical History: Cholecystectomy in 1972. She had an ovary removed in 1982.

Allergies: No known drug allergies.

Medications: Glucotrol XL 25 mg p.o. q.a.m., Prilosec 20 mg p.o. daily, Tenex 1 mg p.o. daily, Zocor 10 mg p.o. daily. and an unknown birth control pill.

Physical Examination: On examination, she is a mildly obese, middle-aged white female in no acute distress. Pulse 85, blood pressure 129/80, respirations 12, and she is afebrile. On pulmonary examination, she is clear to auscultation bilaterally with no evidence of rales or rhonchi. Cardiovascular examination shows a normal S1 and S2 and no murmurs, gallops or rubs noted. Abdominal examination is soft with good bowel sounds. No hepatosplenomegaly. Extremities show no clubbing, cyanosis or edema. There are 1+ pulses throughout.

Laboratory and X-ray Data: 05/13/96: Potassium 4.1, BUN 21, creatinine 0.8. Hematocrit 32.7, platelet count 283,000. PT 11.8 seconds, INR 0.8.

Description of Procedure: The patient was brought to the cardiac catheterization laboratory where she was prepared and draped in the usual sterile fashion. A 1% lidocaine solution was used to anesthetize the right groin area. A #6 French sheath was introduced into the right femoral artery by the Seldinger method and a #7 French sheath introduced into the right femoral vein by the Seldinger method. A #6 French JR-4 catheter was used to engage the left main coronary artery and #6 French JR-4 catheter was used to engage the right coronary artery. A #6 French pigtail catheter was used. A #7 French thermodilution catheter was used for the right heart catheterization. At the conclusion of the study, the femoral sheaths were removed and hemostasis was obtained by direct compression. Then 150 mL of contrast was used. The patient was given a total of 2000 units of intra-arterial heparin with no change in her pedal pulses. Pulmonary artery pressure 21/10 with a mean of 14. Aortic pressures 141/74 with a mean of 102. Cardiac output 5.25 L/min. There was no evidence of a mitral valve gradient.

The left main coronary artery was without evidence of significant coronary artery disease. The first left anterior descending diagonal was a very large vessel which bifurcated twice and is without evidence of significant coronary artery disease. A second left anterior descending diagonal was a small vessel. The left anterior descending coronary artery continued around the apex of the heart. The left anterior descending and its branches were without evidence of significant coronary artery disease. The circumflex marginal coronary artery was a large vessel which bifurcated twice. The 2nd and 3rd circumflex marginal coronary arteries were small vessels. The circumflex coronary artery and all its branches were without evidence of significant coronary artery disease. The right coronary artery and all of its branches were without evidence of significant coronary artery disease.

Impression:

  1. No significant coronary artery disease detected.
  2. Near-normal hemodynamics with no evidence of pulmonary hypertension.
  3. Normal left ventricular systolic function with an estimated ejection fraction of 60% and no evidence of focal wall-motion abnormalities.