Rescue Percutaneous Coronary Intervention for Graft Failure Immediately After Coronary Artery Bypass Grafting: Case Report and Review of Literature

Do chronic total occlusive lesions affect patency of coronary bypass grafts to the right coronary artery?

OBJECTIVES

To evaluate the impact of chronic total occlusion (CTO) lesions on the patency of bypass grafts to the right coronary artery territory.

METHODS

Two hundred patients undergoing primary isolated coronary artery bypass grafting with revascularization to the right coronary artery territory between April 2015 and July 2022 were retrospectively analyzed. Study patients were divided into two groups according to their right coronary artery lesion: patients with CTO lesions (n  =  76) and those without CTO lesions (n  =  124). Graft flow of the right coronary artery territory was evaluated by intraoperative transit time flow measurement and patency of the bypass graft was evaluated by multidetector row computed tomography.

RESULTS

A total of 200 patients (76 patients with CTO and 124 patients without CTO) were included in this study. Intraoperative transit time flow measurement demonstrated that there was no significant difference in the median mean graft flow (30 ml/min vs. 25 ml/min; p  =  0.114), pulsatility index (2.1 vs. 2.4; p  =  0.079), and diastolic filling rate (65% vs. 64%; p  =  0.844) between patients with CTO and those without CTO. Postoperative multidetector row computed tomography demonstrated that the patency of bypass grafts to the right coronary artery territory was similar between the groups (94.7% in patients with CTO vs. 96.0% in those without CTO; p  =  0.733). In patients with CTO, the patency of bypass graft tended to be worse in subgroup with rich collateral blood flow (Rentrop grade 3).

CONCLUSIONS

Chronic total occlusion lesions do not affect the patency of bypass grafts to the right coronary artery territory.

Salvage percutaneous coronary intervention for failed graft itself three days after minimally invasive direct coronary artery bypass

Minimally invasive direct coronary artery bypass is preferred due to its less invasive nature; however, it carries the risk of graft failure owing to inherent technical challenges. We present a case where minimally invasive direct coronary artery bypass grafting was performed and graft failure was detected via coronary angiography 3 days post-operation. Successful percutaneous coronary intervention was subsequently performed on the failed graft itself to salvage myocardial cellular damage. Consequently, the combination of minimally invasive direct coronary artery bypass and percutaneous coronary intervention, both less-invasive revascularization approaches, effectively achieved the primary treatment objective.

Enhancement of flow measurement for graft verification

Background

We aimed to evaluate multiple transit-time flow measurements during coronary artery bypass grafting.

Methods

Transit-time flow measurements were performed first on the arrested heart both with and without a proximal snare on the target coronary artery, second, after weaning from cardiopulmonary bypass, and third, before chest closure.

Results

Among the 214 grafts considered, 9 (4.2%) were patent and 6 (2.8%) were failing. In the failed grafts, an abnormal transit-time flow was found during the first measurement, in 5 (2.3%) cases with a proximal snare and in one (0.47%) without a snare. In these cases, technical errors with the distal anastomoses were found and immediately corrected. A problem with the proximal anastomosis was found in one graft during the second measurement and corrected right away. Bending due to excessive length was found in 2 (0.93%) grafts during the third measurement, and graft repositioning was performed. The first transit-time flow measurement showed that mean graft flow was significantly decreased with a proximal snare compared to without a proximal snare, throughout the entire coronary territory. Pulsatility index during the first transit-time flow measurement was higher with a proximal snare than without one.

Conclusions

The 3-time transit-time flow measurement strategy makes it possible to verify and immediately correct technical problems with coronary bypass grafts.

Acute coronary angiography after coronary artery bypass grafting

OBJECTIVES

Coronary angiography is the golden standard when myocardial ischemia after CABG occurs. We summarize our experience of acute coronary angiography after CABG.

DESIGN

All 4446 patients (mean age 68 ± 9 years, 22% women) who underwent CABG 2007 to 2012 were included in this retrospective observational study. Incidence, indications, findings, measures of acute angiography after CABG was assessed. Outcome variables were compared between patients who underwent angiography and those who did not.

RESULTS

Eighty-seven patients (2%) underwent acute coronary angiography. Patients undergoing angiography had ECG changes (92%), echocardiographic alterations (48%), hemodynamic instability (28%), angina (15%), and/or arrhythmia (13%). Positive findings were detected in 69% of the cases. Only ECG changes as indication for angiography had a moderate association with positive findings, but the precision increased if other sign(s) of ischemia were present. Thirty-day mortality (7% versus 2%, p = 0.002) was higher and long-term-cumulative survival lower (77% versus 87% at five years, p = 0.043) in angiography patients.

CONCLUSIONS

Acute angiography is a rare event after CABG. Postoperative myocardial ischemia leading to acute coronary angiography is associated with increased short-term and long-term mortality.