CLINICAL CASE

CORONARY
REVASCULARIZA
TION
MARLYN ORTIZ JAIMES
CLINICAL CASE
71-year-old patient with a weight of 99 and a height of
1.7 cm with a history of multiple coronary disease,
ischemic heart disease, with precordial pain.
CARDIAC
CATHETERIZA
TION
AD lesion 90% CX 70%
PD 70% scheduled for
coronary
revascularization
ANALYSIS AND PLAN
Atherosclerotic heart disease will undergo coronary
artery bypass grafting on the left side of the coronary
artery.
ANATOMY
The coronary arteries
run along the external
surface of the heart in
all its contours, forming
a kind of crown (hence
its name) and branches
depart from it that carry
blood to the entire
heart muscle. There are They are the right coronary
two coronary arteries: artery (RCA) and the left
coronary artery (LCA).
right and left.
PHYSIOLOGY
ATHEROSCLEROTIC HEART DISEASE
• Accumulation of fats, cholesterol and other
substances in the walls of the arteries.
• Accumulation of atheromatous plaque on the walls
of the arteries that causes the obstruction of the
blood supply. Plaques can break off and cause acute
occlusion of the artery by a clot.
ETIOLOGY OF THE
CORONARY
ARTERIES
Coronary artery disease
is often caused by
cholesterol, a waxy
substance that builds
up inside the lining of
the coronary arteries,
forming plaque. This
buildup can partially or
completely block blood
flow in the large
arteries of the heart.
SURGICA
L
TECHNIQ
UE
 Surgical process
Preparation time steps are performed
Opening time steps (skin incision, tcs, internal
mammary artery harvest as pedicled graft, saphenous
vein harvest as free graft, graft permeabilization,
sternotomy, incision and repair of pericardium) are
performed (At this time, vascular time was not
performed because the surgery was performed mostly
off-pump).
Correction time steps are performed
Coronary preconditioning is performed for anastomosis
of the first graft in the anterior descending artery.
An incision is made in the anterior descending artery to
perform the respective anatomy to the internal
mammary artery as a pedicled graft.
Distal anastomosis of the pedicled graft is performed,
from the internal mammary artery to the anterior
descending artery.
Removal of supplies for preconditioning of anastomosis
is performed
Coronary preconditioning is performed for anastomosis
of second graft in the right coronary artery.
Instruments
 
MB 7 blade 15 (thorax), MB 3 blade 15 (left leg)
electrosurgical scalpel, farbeuf retractors (2 pairs),
compresses, dissection forceps, Metzembaum scissors
(2), ligaclip forceps and ligaclips 100 and 200, silk 4/0,
20cc syringe, arterioromy cannula, heparinized
solution, precut silk 1, Vicryl 2/0, monocryl 3/0, electric
reciprocating saw, bone wax, silk 0
Nelaton 14 probe, 4/0 prolene (replaces the silastic
bands), thread passer or tourniquet, Kelly curved
forceps, octopus.
Electroscalpel, micro-scalpel, potts scissors, fine
microcoronary scissors
Prolene 7/0, vascular needle holder, dissection, May
scissors
Octopus, Sondanelaton, tourniquets
Starfish, nelaton 14 probe, prolene 4/0 (replaces silastic
bands), thread passer or tourniquets, curved Kelly
clamps, octopus.
An incision is made in the right coronary artery to perform the Electroscalpel, micro-scalpel, potts scissors, fine microcoronary
respective anastomosis to the saphenous vein as a free graft. scissors.

Proximal anastomosis of the free graft from the saphenous vein Prolene 7/0, vascular needle holder, dissection, Mayo scissors
to the right coronary artery is performed.

Removal of supplies for anastomosis preconditioning is Octopus, Sondanelaton, tourniquets, starfished

performed
We continue with the free saphenous vein graft to perform two Dissecting forceps
more anastomoses sequentially, to the circumflex artery and
from there to the aorta artery, passing the graft in an infero-
posterior way to the heart
Preconditioning is performed for anastomosis of the third graft Starfish, nelaton 14 probe, prolene 4/0 (replaces silastic bands),
in the circumflex artery. thread passer or tourniquet, curved Kelly forceps, octopus.

When performing coronary preconditioning for anastomosis of Octopus, nelaton probe, tourniquets, starfished, paddles for
the third circumflex graft, the patient presented asystole on resuscitation
several occasions, so we proceeded to remove preconditioning
supplies and to perform manual assistance and resuscitation 3  
times.
 
When there was no adequate response, the decision was made
to start the pump or extracorporeal circulation in order to be
able to continue with the correction.

Emergency vascular time steps are performed (tobacco 2/0 polyester, thread passer, silk 1, EOPA 18 cannula, Derrach
pouches, aortic cannulation, right atrial clamping, single venous clamp, 32/34 single venous cannula, curved Kellys,
cannulation in right atrium, and starting pump) extracorporeal circulation tubing, connectors, tube clamp, rigid
pericardial suction, free cavity aspirator

Once the patient is stabilized, the supplies are repositioned to Starfish, nelaton 14 probe, prolene 4/0 (replaces the silastic
continue with the preconditioning of the third graft anastomosis bands), thread passer or tourniquet, Kelly curved forceps,
in the circumflex artery octopus
Incision is made in the circumflex to perform the
respective anastomosis to the saphenous vein as
sequential free graft and also leave another portion to
anastomose to the aorta.
Anastomosis of the sequential free graft to the
circumflex artery is performed.
Removal of supplies for anastomosis preconditioning is
performed
A small hole is made in the aorta for the final
anastomosis of the sequential free graft.
Proximal anastomosis to the aorta of the last portion of
the sequential free graft is performed.
Closure time steps are performed (Off pump,
decannulate, close incisions, tube to thorax position
along with pluroback(2), pacing wire position, gauze
and compress count, sternal suture, tcs and skin suture)
Completion time steps (Cleaning and healing) are
performed
Electroscalpel, micro-scalpel, potts scissors, fine
microcoronary scissors.
Prolene 7/0, vascular needle holder, dissection, Mayo
scissors
Octopus, Sondanelaton, tourniquets, starfished
Punch
Prolene 6/0, vascular needle holder, dissection, Mayo
scissors
Tube to chest 32, pleuroback, polyester 2/0, pacemaker
wire 0, compresses, gauze, vascular dissection, steel 5,
vicryl 0, monocryl 3/0
Wet and dry compresses, silver dressing, gauze and
transparent dressing without pad and polyester with
pad.