Repeat Median Sternotomy After Prior Ante‐Aortic Crossover Right Internal Thoracic Artery Grafting

Reoperative median sternotomy following the use of a right internal mammary artery pedicle graft crossing the midline to the left anterior descending artery

BACKGROUND AND AIM

The purpose of the present study was to examine the outcomes of cardiac reoperations for the patients with a previously placed pedicled graft of the right internal thoracic artery (RITA) to the left anterior descending artery (LAD).

METHODS

Of 1002 consecutive patients who underwent isolated coronary bypass surgery, 612 patients received pedicled grafts of skeletonized RITA to the LAD crossing the midline over the aorta. Of this cohort, seven patients underwent cardiac reoperations via a median resternotomy including aortic valve replacement, mitral valve plasty, and total arch replacement. Covering the RITA with pericardium and mediastinal tissue had been routinely performed in the initial operation.

RESULTS

Preoperative computed tomography (CT) angiography showed the RITA at a safe distance from the sternum in six patients. No graft injury occurred during dissection. The patient who underwent emergent total arch replacement died from global brain ischemia at postoperative day 11. The remaining six patients recovered well without major complication and survived at 7.5 ± 4.5 years after reoperations.

CONCLUSIONS

Cardiac reoperation via a median sternotomy can be performed at acceptable risk in patients with the RITA graft crossing the midline. Specific maneuvers should be applied in the first coronary artery bypass grafting to keep the RITA at the level of the aortic plane and prevent migration toward the sternum. Preoperative CT angiography is an important tool to understand the surgical anatomy and determine the safety of reoperation.

Multislice CT Evaluation of Coronary Artery Bypass Graft Patients

Continuous improvement in multislice computed tomography technology has further enabled advances in coronary artery bypass graft imaging. Multidetector platforms and retrospective electrocardiography gating have enabled sensitivities and specificities in the 95% to 99% range while avoiding the morbidity associated with invasive catheter angiography. Identification of bypass graft stenoses and bypass graft aneurysms/pseudoaneurysms is important in evaluation of these patients. Recognition of coronary artery bypass graft anatomy is particularly important to minimize the complications associated with reoperative cardiac surgery. The 3-dimensional demonstration of chest wall anatomy and its relationships to these coronary bypass grafts makes multislice computed tomography a superior technology in this patient population. Confident evaluation and assessment of the patient after coronary artery bypass graft surgery will become an increasingly important tool to the practicing radiologist.

Evaluation of the cardiac surgery patient with MSCT

Advances in MSCT have enabled assessment of cardiac function and anatomy, and ECG gating has allowed increasingly accurate depiction of coronary artery grafts and native coronary arteries. These capabilities now offer a comprehensive evaluation of the preoperative surgical patient. This essay outlines the important imaging issues and opportunities in the evaluation of the cardiac surgery patient.