Redo CABG

Coronary artery reoperations are more complicated than primary operations.

INCIDENCE OF REOPERATION

Studies from the Cleveland Clinic incidence of reoperation of 3% by 5 years

10% by 10 years,
25% by 20 postoperative years
Factors associated with an increased likelihood of reoperation have been
predicting a favorable long­term survival ;

young age
normal LVEF
single­or double­vessel disease
no internal thoracic artery ITA graft
symptom status
GRAFT FAILURE
thrombosis
pathology and causes of saphenous
vein graft (SVG) failure has
different pathologies at different
intervals after operation.
Few months, diffuse endothelial
disruptions with associated mural
thrombus. :thrombosis
More than 2 to 3 months after stenosis ooccns
operation have developed a .
proliferative intimal fibroplasia.
This is a concentric cellular process,
and it is diffuse, extending the entire
length of the graft causes stenoses
or occlusions .
3 to 4 years after operation Vein
graft atherosclerosis
atherosclerosis
Patients with late stenoses in vein grafts to the LAD coronary artery had
worse survival when compared with either patients with native coronary LAD
stenoses or patients with no stenotic vein grafts.
INDICATIONS FOR REOPERATION
TECHNICAL CONCERN OF CORONARY REOPERATIONS

1. Sternal reentry2. Stenotic or patent vein or arterial bypass grafts3. Aortic

atherosclerosis4. Diffuse native­vessel coronary artery disease5. Coronary
arteries located a mid old grafts and epicardial scarring
6. Lack of bypass conduits
Steps

The most common structure injured during reentry is a bypass graft.

The incision is made to the level of the sternal wires oscillating saw
Divide the anterior table of the sternum
Ventilation is stopped,
Assistants elevate each side of the sternum with rake retractors
Posterior table of the sternum is divided in a caudal­cranial direction.
Wires are removed
Sharp dissection with scissors is used to separate each side of the sternum
Once the sternum has been divided, it is important that the assistants retract in an upward
(The right ventricle is injured more often by lateral retraction while it is still adherent to the underside of the sternum
than it is by a direct saw injury. )
High­risk situations, it can be helpful to perform a small anterolateral right thoracotomy before the repeat median
sternotomy. Underlying structures, such as the aorta, patent bypass grafts, and the right atrium and ventricle, can be
dissected away from the sternum via this approach
Another technique for sternal reentry is
heparinize, cannulate and initiate cardiopulmonary bypass before median
sternotomy.
The advantages :heart was emptied and fall away from sternum.
Cardiopulmonary bypass already has been initiated for protection
if an injury occur.
The disadvantages :extensive mediastinal dissection must be carried out in a
heparinized patient.
Use in situations in which adherence of aortic aneurysm to the sternum or a patent
RIMA ­to ­LAD graft creates a specific danger .
Once sternum has been divided, the pleural cavities are entered.
A general principle of dissection during reoperation is that
starting at the level of the diaphragm and proceeding in a
cranial direction is usually the safest approach.
Dissect along the level of the diaphragm to the patient’s
right side until we enter the pleural cavity and then detach the
pleural reflection from the chest wall in a cranial direction to
the level of the innominate vein.
The innominate vein is dissected away from both sides of the
sternum with scissors.
Once the right side of the sternum is separated from the cardiac
structures, it’s usually prepare a RIMA graft.
Once the RIMA dissection is completed to the superior border
of the first rib, incision in the parietal pleura to separate the
proximal IMA from the area of the phrenic nerve.
Freeing the left side of the anterior chest wall from the
underlying structures (which may include a patent ITA graft) is
undertaken now.
This’s difficult if there is a patent IMA graft which adherent to
the chest wall.
It’s best to enter the left pleural cavity at the level of the
diaphragm and proceed in a cranial direction.
Be careful. at the level of the sternal angle, a patent ITA graft may
approach the midline and be adherent to the sternum or the aorta.
The danger to a patent left ITA graft during sternal reentry and mediastinal
dissection is entirely related to the location of the graft at the time of the
primary operation.
At a primary operation, the pericardium should be
divided in a posterior direction
and the IMA graft should be placed in that
incision.
The IMA graft then will lie posterior to the lung
and will not be pushed toward the midline by the
lung or become adherent to the sternum.
If an atherosclerotic vein graft to the right
coronary artery lies over the right atrium.
Manipulation of atherosclerotic vein grafts can
cause embolization of atherosclerotic debris into
coronary arteries
If vein graft to the RCA lies in an awkward position over RA, it is best to
leave the RA alone and use the femoral vein and SVC cannulation to
establish venous drainage.
Once cardiopulmonary bypass has been established, the aorta has been
cross­clamped, and cardioplegia has been given, the atherosclerotic vein
graft then can be disconnected.
 Goal of dissection of the ascending aorta is to obtain enough length for
cannulation and cross ­clamping and to avoid “aortic subadventitial
dissection”.
The correct level of dissection on the aorta is found either by following the
right atrium to the aorta in a caudal­to ­cranial direction
or by identifying the innominate vein and leaving all the tissue beneath the
innominate vein on the aorta.
Division of the pericardial reflection on the left side in a posterior direction
will lead to the plane between the aorta and the pulmonary artery.
Once the left side of the aorta is identified, surgeon can dissect posteriorly
on the medial aspect of the left lung toward the hilum.
The tissue between these two dissection planes will include a patent LIMA
graft, if present, and clamping that tissue will produce occlusion of the ITA
graft.
Cannulation

When the aorta has been dissected out, heparin is given, and cannulation is
undertaken
Cannulation of an atherosclerotic ascending aorta may cause atherosclerotic
embolization leading to stroke, myocardial infarction, or multiorgan failure
Palpation ascending aorta and echocardiography to detect atherosclerosis
before cannulation.
If atherosclerotic disease or calcification of the aorta makes any aortic
occlusion hazardous, the options are off­pump bypass surgery (see Other
Options) or replacement of the aorta with axillary artery cannulation,
hypothermia, and circulatory arrest.
Venous cannulation usually is accomplished with a single two­stage right
atrial cannula.
Standard cannulation for coronary artery reoperation includes aortic
arterial cannulation, an aortic needle for antegrade delivery of cardioplegia
and aortic root venting, a single two­stage venous cannula, and a transatrial
coronary sinus catheter with a self­inflating balloon for delivery of
retrograde cardioplegia. Cannulation is accomplished before dissection of
the left ventricle.
Myocardial Protection

Combination of antegrade and retrograde delivery of intermittent cold

blood cardioplegia combined with a dose of warm reperfusion cardioplegia
(“hot shot”) given before aortic unclamping .
During reoperations, however, antegrade cardioplegia may not be effective
for areas of myocardium that are supplied by patent in situ arterial grafts
and may be dangerous because of the risk of embolization of
atherosclerotic debris into the coronary arteries from old vein grafts.
The delivery of cardioplegia through the coronary sinus and through the
cardiac venous system to the myocardium has been a step forward in
myocardial protection during reoperations.4
disadvantage of retrograde cardioplegia : placing a catheter in the
coronary sinuses
monitor the adequacy of cardioplegia delivery by
measuring the pressure in the coronary sinus,
noting the distention of cardiac veins with arterial blood
the cooling of the myocardium
return of desaturated blood from open coronary arteries.
 Cardiopulmonary bypass is begun, the perfusionist empties the heart and
produces mild systemic hypothermia (34°C), and the aorta is cross­
clamped.
Usually initiate cardioplegia induction with aortic root cardioplegia.
After antegrade cardioplegia has been given for 2 to 3 minutes, we shift to
retrograde induction for another 2 to 3 minutes.
Intrapericardial Dissection

After heart has been arrested completely, intrapericardial dissection of the left
ventricle is undertaken,
starting at the diaphragm and extending out to the left of the apex of the heart.
After the apex is identified, the surgeon divides the pericardium in a cranial
direction on the left side of the LAD
A patent LITA­to ­LAD graft will be contained within the strip of pericardium
that lies over the LAD artery. Dissection of this pedicle from the anterior aspect
of the pulmonary artery will allow an atraumatic clamp to be placed across the
patent ITA graft and also will allow the passage of new bypass grafts from the
aorta underneath the patent ITA graft to left­sided coronary arteries.
 The coronary arteries to be grafted can be identified, he lengths that bypass
conduits need to reach those vessels may be assess.
Before the construction of the anastomoses, those patent but
atherosclerotic vein grafts that are disconnected with a scalpel .
The order of anastomosis construction
1.distal vein graft anastomoses
2. distal free arterial graft anastomoses
3. distal in situ arterial graft anastomoses
4.proximal (aortic) anastomoses.
Stenotic Vein Grafts

In the past, general rule has been to replace all vein grafts that are more
than 5 years old at the time of reoperation, even if those grafts are not
diseased angiographically.
Many patients have very limited conduits at reoperation because of the
large numbers of vein grafts used at primary surgery
Inspection of vein grafts at reoperation will identify a graft that looks
normal angiographically and not thickening or atherosclerosis on
inspection. Those grafts are often be left.
Replacing old vein grafts with new
vein grafts may accomplished by
creating the new vein­to­coronary­
artery anastomosis at the site of the
previous distal anastomosis, leaving
only 1 mm or so of the old vein in
place.
When extensive native
coronary atherosclerosis,
the distal anastomotic site
of an old vein graft isthe
best spot for the distal
anastomosis of a new graft.
Only a small rim of the old
graft should be left in
place.
Artery­to ­coronary ­artery bypass grafts have many advantages during reoperations.
they are often available. the tendency of arteries ,in situ arterial grafts do not require a
proximal anastomosis.
If the LIMA has not been used as a graft ,use it as an in situ graft to the LAD artery.
RIMA is often used as a free graft.
Arterial graft proximal anastomoses are a problem at reoperation because the scarring
and thickening of the reoperative aorta often make direct anastomoses of arterial grafts to
the aorta unsatisfactory.
Old vein grafts become occluded, there is usually a “bubble” of the hood of the old vein
graft that is not atherosclerotic and that often is a good spot for construction of a free
(aorta­to­coronary­artery) arterial graft anastomosis
New vein grafts are performed, the
hood of that new vein graft
represents a favorable location for
an arterial graft anastomosis.
Another effective strategy is to use either an old
arterial graft or a newly constructed arterial graft for
the proximal anastomosis of a free arterial graft .
Composite arterial grafts, usually using a new in situ
left ITA graft at the proximal anastomotic site for a
free right ITA graft.
 Radial artery has particular advantages during repeat surgery because it is
larger and longer than other free arterial grafts. The inferior epigastric
artery often is too short to function as a separate aorta­to­coronary­artery
graft during reoperation but can be extremely useful as a short composite
arterial graft
Right gastroepiploic artery (RGEA) has established a good midterm graft
patency rate record and often is useful during reoperation because it is an
in situ graft.
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 The aortic anastomoses of the vein and arterial grafts are performed last
during the single period of aortic cross­clamping.
Sites for aortic anastomoses are often scarring,
Locations of the previous vein graft proximal anastomoses are the best
locations for the new ones.
If patent or stenotic vein grafts have been removed and replaced, reperfusion
is not accomplished by aortic declamping until the aortic anastomoses have
been completed.
The disadvantage of this approach is that it prolongs the period of aortic cross ­
clamping.
Other Options

MIDCAB or off ­pump surgery

MIDCAB : The distal LAD artery are exposed with small anterior
thoracotomy, and LAD or diagonal artery are grafted with LIMA graft.
If the left ITA is not available, a segment of saphenous vein can be
anastomosed to the subclavian artery
If the right ITA is to be used as an in situ graft to the LAD artery, a median
sternotomy is indicated
MIDCAB

The lateral wall of the heart can be exposed through a left

lateral thoracotomy .
Circumflex and distal RCA branches can be grafted with
this approach.
Descending thoracic aorta can use as a site for the
proximal anastomosis ,using a partial occluding clamp.
The disadvantages of this approach are that the
RIMA is difficult to use as an in situ graft
circumflex vessels are deep intramyocardial, difficult to
expose and isolate with the off­pump strategy.
Off ­pump surgery

Median sternotomy,
Use of off­pump techniques may minimize aortic trauma
Disadvantage of off­pump reoperative strategies is that reoperative
candidates often have very distal and diffuse CAD, which leaves
intramyocardial segments as the best areas for grafting.
The aortic anastomoses of vein or free arterial grafts may be difficult