15. Incidence and Management of Injury to Patent Left Internal Thoracic Artery Graft at Coronary Reoperation.

A. Marc Gillinov, Bruce W. Lytle, Felip Cassalman, Delos M. Cosgrove

The Cleveland Clinic Foundation

Cleveland, Ohio

Background: A patent left internal thoracic artery graft (LITA) to the left anterior descending coronary artery (LAD) creates specific risks during coronary reoperation.

Methods: Of 655 patients undergoing reoperation, 35 (5.3 percent) had intraoperative injury to the LITA. We reviewed these patients to examine operative strategies and outcomes.

Results: Inoperative injury to the LITA occurred before cardiopulmonary bypass (CPB) in 20 patients, and after institution of CPB in 15. In all patients an attempt was made to restore flow to the LAD.

STRATEGIES TO RESTORE BLOOD FLOW TO THE LAD
 
 
SVG-LAD
SVG-LITA
SVG-LAD
OTHER
TOTAL 
 
Ligate LITA
Stump
Repair LITA 
 
 
Number
15
7
6
7
35
Periop MI
8
1
2
3
14
Death
1
1
0
1
3
SVG=saphenous vein graft              MI=myocardial infarction

The LITA-LAD anastomosis was salvaged in 20 patients (57 percent). Fourteen patients (40 percent) had preoperative myocardial infarction and three patients died (8.6 percent). The three patients that died all had stenosis or thrombosis of the graft to the LAD documented at autopsy. Operative mortality for the 620 patients not having injury to the LITA was 3 percent (p=0.11 vs. those with injury to the LITA).

Conclusion: We conclude that (one) the incidence of injury to a patent LITA is 5.3 percent; (two) the LITA-LAD anastomosis can be salvaged in 57 percent of cases; and (three) ineffective revascularization of the LAD in this situation is associated with operative mortality.

 
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