Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): the first 200 cases

A review of nomenclature in minimally invasive coronary artery bypass grafting-the anarchy of terminology

OBJECTIVES

Since the development of minimally invasive coronary surgery, nomenclature has rapidly grown to distinguish each unique method. The goal of this review was to provide a comprehensive overview of the different terms used for minimally invasive coronary bypass grafting through the years.

METHODS

A literature search was performed in August 2024 using the PubMed electronic database. To extract the best search results: "minimally invasive" and "coronary artery bypass grafting" were used as either keywords or MeSH terms. The term robotic was specifically included for a second search. Eligible articles for this review were articles using an abbreviation to describe minimally invasive coronary artery bypass grafting.

RESULTS

A total of 2118 publications on non-robotic minimally invasive coronary procedures and 392 on robotic-assisted techniques were reviewed, describing 40 unique terms for the procedure. Procedures were grouped based on left internal mammary artery harvest and anastomosis methods: mini-thoracotomy for both harvesting and coronary anastomosis (n = 586), endoscopic harvest with mini-thoracotomy (n = 37), robotic harvest with mini-thoracotomy (n = 144) and closed-chest revascularization (n = 140). Minimally invasive direct coronary artery bypass grafting was the most studied technique (486 publications, non-robotic and robotic), followed by closed-chest totally endoscopic coronary artery bypass (n = 124).

CONCLUSIONS

In conclusion, a wide variety of terms are used within the field of minimally invasive coronary surgery. A total of 40 different terms have been published, each describing certain specifics of the procedure. For anyone involved in the field of minimally invasive surgery, it is important to understand the differences and similarities of these procedures.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review

OBJECTIVE

We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD).

METHODS

A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date.

RESULTS

A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days).

CONCLUSIONS

MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Comparison of early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using minimally invasive or conventional off-pump techniques: a propensity-matched study based on SYNTAX score

Background

This study was designed to compare early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using either minimally invasive or conventional off-pump techniques.

Methods

From January 2017 through January 2021, 582 patients with multi-vessel lesion coronary artery disease underwent either minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) or conventional off-pump coronary artery bypass grafting (OPCABG) treatment by our team at Anzhen Hospital. Patients in the MICS CABG group were propensity score-matched with those in the OPCABG at a 1:1 ratio (MICS CABG = 172; OPCABG = 172), using epidemiological data, preoperative clinical characteristics, and SYNTAX score as covariates. Perioperative outcomes and 6-month computed tomography angiography findings were compared between these groups.

Results

No significant differences between groups were observed with respect to 30-day postoperative mortality, myocardial infarction, and stroke incidence. Surgical data indicated that the MICS CABG procedure was able to cover all three main arterial territories with a relatively low need for circulatory assistance. The MICS CABG procedure was associated with a longer operative duration, but was also associated with higher postoperative hemoglobin and activities of daily living index values as well as a shorter duration of postoperative hospitalization (P < 0.05). No differences in 6-month graft patency were observed between groups.

Conclusions

MICS CABG is a safe, less invasive alternative to OPCABG when performing complete revascularization provided patients are properly selected, yielding similar in-hospital outcomes and 6-month graft patency rates together with an earlier return of physical function.

The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting.

METHODS

A retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared.

RESULTS

The maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0-100) mg vs. SI 100 (0-225) mg, P = 0.0001; pethidine: CINB 0 (0-25) mg vs. SI 25 (0-50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3-26.0) h vs. 22.0 (19.0-45.0) h, P = 0.011.

CONCLUSIONS

CINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.

Surgical Challenges in Multi-Vessel Minimally Invasive Coronary Artery Bypass Grafting

Objectives

Minimally invasive coronary artery bypass grafting (MICS CABG) has emerged as an alternative treatment for patients with multi-vessel coronary artery disease, but there are certain surgical challenges inherent in the adoption of this approach. The present study was conducted to provide insight regarding the outcomes associated with our first 118 cases, to discuss the surgical difficulties encountered in these patients, and to outline the potential countermeasures.

Methods

Between January 2017 and January 2020, 118 patients underwent multi-vessel MICS CABG. These patients were stratified into two groups based upon whether they did or did not experience surgical challenges, and early clinical outcomes were compared between these groups to assess the incidence of technical difficulties and associated factors.

Results

Surgical challenges arose in 38 of the 118 cases in this study, including 13 cases of exposure-related difficulties, 11 cases of proximal anastomosis-related difficulties, 15 cases of distal anastomosis-related difficulties, 4 cases of LITA-related difficulties, and 3 cases of lung-related difficulties. Relative to the other 80 patients, those patients for whom intraoperative technical challenges arose experience significant increases in operative duration (4.94 ± 0.89 vs. 5.59 ± 1.11 h, P=0.001), intraoperative blood loss (667 ± 313 vs. 892 ± 532 mL, P=0.005), length of the ICU admission (17.59 ± 3.51 vs. 22.59 ± 17.31 h, P=0.015), and the duration of postoperative hospitalization (5.96 ± 1.23 vs. 6.71 ± 1.92 days, P=0.012). There were no significant differences between these groups with respect to the mean graft number, major complications such as stroke or organ dysfunction, or one-year graft patency.

Conclusions

There is a substantial learning curve associated with performing off-pump MICS CABG to treat multi-vessel disease. Surgical challenges encountered during this procedure may increase the operative duration, intraoperative blood loss, ICU admission, and the duration of postoperative hospitalization. However, these issues do not appear to compromise the efficacy of complete revascularization, and early clinical outcomes associated with this procedure remain acceptable.

All we need to know about internal thoracic artery harvesting and preparation for myocardial revascularization: a systematic review

Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties. Harvesting and preparation of ITAs for revascularization is a technically demanding procedure with multiple challenges. Over the last few decades, various methods and techniques for ITAs harvesting have been introduced by different surgeons and applied in clinical practice with different results. Harvesting of ITAs in pedicled or skeletonized fashion, with electrocautery or harmonic scalpel, with open or intact pleura, with clipping the end or keeping it perfused; papaverine delivery with intraluminal injection, perivascular injection, injecting into endothoracic fascia, and papaverine topical spray are the different techniques introduced by the number of researchers. At the same time, access to the ITAs for harvesting has also been studied. Access and harvesting through median sternotomy, mini anterolateral thoracotomy, thoracoscopic, and robotic-assisted harvesting of ITAs are the different techniques used in clinical practice. However, the single standard method for harvesting and preparation of ITAs has yet to be determined. In this review article, we aimed to discuss and analyze all these techniques of harvesting and preparing ITAs with the help of literature to find the best way for ITAs harvesting and preparation for myocardial revascularization.

Off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in a patient with total laryngectomy and a permanent tracheostoma

Median sternotomy is the standard approach for coronary artery bypass grafting. Herein, we performed off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in an unstable angina pectoris patient with total laryngectomy and a permanent tracheostoma. In this patient, median sternotomy had high risks of surgical-site infection and tracheal injury. To avoid these risks, we selected left anterior thoracotomy. Initially, it was difficult to expose the ascending aorta and postdescending branch. With extension of the skin incision to the median area and division of the 5th and 6th ribs and costal arch, we could expose the anastomotic sites, including the ascending aorta and postdescending branch, without median sternotomy conversion. We performed multiple coronary artery bypass graft procedures safely. This approach might be an additional surgical option in patients with total laryngectomy and a permanent tracheostoma.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

Robot-assisted coronary artery bypass grafting improves short-term outcomes compared with minimally invasive direct coronary artery bypass grafting

BACKGROUND

Robot-assisted coronary artery bypass grafts (RACAB) utilizing the da Vinci surgical system are increasingly used and allow the surgeon to conveniently harvest internal mammary arteries (IMAs). The aim of this study was to compare the outcomes of off-pump RACAB and minimally invasive direct coronary artery bypass grafting (MIDCAB) in the short and medium term.

METHODS

We performed a retrospective review of 132 patients with single- or multiple-vessel coronary artery disease who underwent minimally invasive off-pump CABG (OPCAB) between May 2009 and May 2014. The patients were divided into two groups based on the surgical approach, MIDCAB and RACAB group. The anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) was performed as regular OPCAB through the incision on the beating heart using regular stabilization devices (Genzyme Corporation). The preoperative, intraoperative, postoperative, and follow-up data, including major adverse cardiac and cerebrovascular events (MACCE), were compared.

RESULTS

The preoperative data were similar. RACAB significantly shorten the intensive care unit (ICU) stay and postoperative compared with the MIDCAB group (P<0.05). There were 12 (19.7%) patients treated with a two-stage hybrid procedure in the MIDCAB group and 34 (47.9%) patients in the RACAB group (P=0.001). Thirty-day mortality was 1.6% in the MIDCAB group. There were 9 (14.7%) MIDCAB patients and 2 (2.8%) RACAB patients (P=0.013) that developed new arrhythmia. The two groups showed comparable mid-term survival (P=0.246), but the MACCEs were significantly different (P=0.038).

CONCLUSIONS

RACAB may be a valuable alternative for patients requiring single or simple multi-vessel coronary artery bypass grafting (CABG). Although the mid-term mortality outcomes are similar, RACAB improves short-term outcomes and mid-term MACCE-free survival compared with MIDCAB.

Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG

The recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery confers the benefits of minimally invasive surgery upon patients, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically, rather than through a median sternotomy, during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. On the other hand, general anesthesia remains a risk in patients who have severe carotid artery stenosis before surgery, as well as in those with a history of severe cerebral infarction or respiratory failure. In this study, the potential of a new awake CABG protocol using only epidural anesthesia was investigated for realizing day surgery and was found to be a promising modality for ultra-minimally invasive cardiac surgery. We herein review robot-assisted cardiac surgery and awake off-pump coronary artery bypass grafting as ultra-minimally invasive cardiac surgeries.

Robot-assisted minimally invasive direct coronary artery bypass grafting. ThoraCAB

BACKGROUND

 The aim of this study was to assess the outcome of robot-assisted minimally invasive direct coronary artery bypass grafting (MIDCAB), which is also termed "ThoraCAB".

METHODS AND RESULTS

 From 2005 to 2013, 35 consecutive patients underwent MIDCAB via a small thoracotomy on a beating heart. Before performing MIDCAB, the internal thoracic arteries (ITAs) were endoscopically harvested through 3 ports using the da Vinci Surgical System in a completely skeletonized fashion. Distal anastomosis was hand-sewn using a vacuum stabilizer, and a coronary artery active perfusion system was used to prevent myocardial ischemia during anastomosis. Successful robot-assisted ITA harvesting was achieved in all patients. There was an average of 1.7±0.8 grafts (range, 1-3 grafts) per patient. No patient needed mechanical ventilation for more than 24h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy.

CONCLUSIONS

 Robot-assisted ITA harvesting is safe and feasible. ThoraCAB is a relatively simple procedure and allows multivessel bypass grafting after a small thoracotomy. Therefore, it is expected that ThoraCAB will become the standard procedure for minimally invasive coronary revascularization and will be used in totally endoscopic CABG in the future. 

The golden age of minimally invasive cardiothoracic surgery: current and future perspectives

Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.

Hybrid coronary revascularization: a review

The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.

Off-pump coronary artery bypass grafting through left antero-lateral thoracotomy (thora-cab) - case report and review of literature

We report the first case of off-pump complete myocardial revascularization through antero-lateral thoracotomy (Thora-CAB) in Middle-East. 69 year old gentleman having angina pectoris for last three years with severe double vessel disease involving the left anterior descending artery (95% proximal lesion) and the circumflex system (80% mid circumflex lesion with significant osteal disease in obtuse marginal) and insignificant disease in right coronary artery with moderate left ventricular impairment underwent Thora-CAB. Post-operatively, he had minimal pain, quick symptomatic improvement and no complications. He was discharged home on 5th post-operative day. This indicates that the thoracotomy approach is safe and practical for CABG. It is well tolerated hemodynamically with no/ minimal post-operative morbidity.

Robotically Assisted Beating Heart Totally Endoscopic Coronary Artery Bypass (TECAB). is There a Future?

Objective

Since the introduction of beating heart totally endoscopic coronary artery bypass (TECAB), approximately 400 patients have undergone the procedure worldwide. Despite satisfactory results and reduced morbidity, the procedure has not gained wide acceptance. This report describes the authors’ experience of beating heart TECAB with robotic assistance and the potential adoption of this technique for the future.

Methods

Between July 2004 and December 2005, 93 patients underwent successful for beating heart TECAB (47 males and 46 females). Mean age was 67.4 + 12.3 years. Fifteen (13.8%) were excluded or converted intraoperatively to thoracotomy for completion of procedure. The procedure was performed through port incisions for the robotic arms and the endostabilizer. Single or bilateral internal thoracic arteries were used as conduits. Anastomoses were done using surgical U-clips. Eighteen (19.4%) patients underwent planned hybrid revascularization. Eighty-four (90.3%) patients underwent computed tomography or conventional angiography.

Results

Details of 93 completed revascularization cases are summarized in the tables. No in-hospital mortality, myocardial infarction, or CVA was noted. Mean operative time was 272.6 + 128.9 minutes (median, 270 minutes). Mean anastomotic time was 13.8 + 3.7 minutes. Mean length of hospital stay was 3.4 + 2.0 days (median, 3 days). At the time of study, 122 of 122 (100%) grafts were found to be patent.

Conclusions

Single- and multivessel beating heart TECAB with or without hybrid revascularization may offer a less invasive approach in a selected group of patients.

Multivessel Revascularization on the Beating Heart by Anterolateral Left Thoracotomy

BACKGROUND

Off-pump coronary artery bypass is commonly performed through a full median sternotomy; however, the tendency to reduce surgical trauma has stimulated cardiac surgeons to use less invasive techniques for single-vessel disease. The use of thoracotomy for reoperative and valvular surgery has also been reported, but its application in primary revascularization is still uncommon. We report here a series of consecutive patients who underwent complete myocardial revascularization on the beating heart through anterolateral thoracotomy-coronary artery bypass (ALT-CAB).

METHODS

From November 2002 to July 2005, 255 patients (75.7% male, median age 57.9 +/- 10.1 years) underwent complete revascularization using the ALT-CAB approach. Eighty-two patients (32.2%) had low ejection fraction, 145 (56.9%) previous myocardial infarct, and 215 (84.3%) multivessel disease. The mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 3.8 and the Parsonnet score was 7.8.

RESULTS

Complete revascularization was achieved in all patients (mean number of grafts 3.3 +/- 1.0). There were no conversions to cardiopulmonary bypass, and 3 patients died (1.2%). Two hundred thirty-seven patients (93.3%) were extubated in the operating room, and 164 patients (65.1%) were discharged home within 48 hours after surgery. Two patients (0.8%) experienced a stroke and 5 (2%) needed reexploration for bleeding. There was 1 perioperative myocardial infarction (0.4%), and 14 patients (5.5%) experienced postoperative atrial fibrillation. Five patients (2%) required treatment as an outpatient for superficial wound infection, 11 (4.4%) for left pleural effusion, and 11 (4.4%) for transient phrenic nerve palsy, which resolved spontaneously. Follow-up (median, 14.6 +/- 9.7 months) survival was 97.6%. One patient (0.4%), experienced a new myocardial infarction, 9 (3.6%) required new coronary angiography for recurrent of angina, and 3 of these (1.2%) underwent angioplasty.

CONCLUSIONS

Complete revascularization on the beating heart through an anterolateral thoracotomy is safe and feasible in the majority of patients requiring coronary artery surgery.

Use of Bilateral Internal Thoracic Arteries in CABG Through Lateral Thoracotomy With Robotic Assistance in 150 Patients

BACKGROUND

Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system.

METHODS

Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management.

RESULTS

Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 +/- 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 +/- 2.9 days.

CONCLUSIONS

The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease

OBJECTIVE

Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated.

METHODS

Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts.

RESULTS

There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events.

CONCLUSION

Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.