Anesthetic and Technical Considerations in Redo Coronary Artery Bypass Surgery Using Sternal-Sparing Approaches

Abstract

REOPERATIVE CORONARY ARTERY bypass grafting (CABG) has decreased significantly in the previous 20 ears, likely because of the increased availability of percutaeous coronary intervention (PCI).1 Reoperative surgery using he classic trans-sternal approach is more technically challengng than primary surgery and is associated with an increased isk of major complications and death.2,3 There is an increased isk of injury to patent bypass grafts, the great vessels, and right entricle during sternal re-entry. Manipulation of the aorta or iseased bypass grafts can precipitate embolization and cause troke or myocardial infarction.2,4,5 Reoperative sternotomy also is associated with prolonged cardiopulmonary bypass (CPB) time, an increased risk of sternal wound infections, and postoperative mediastinitis.2,5 Patients undergoing reoperative sternotomy often have regional ischemia with patent grafts or native vessels to other territories. Although sternotomy provides the best exposure for global access to the myocardium, when only regional access is required, limited-access nonsternotomy approaches are an attractive option. Collectively, these are known as minimally invasive direct CABG (MIDCAB). In addition to the standard monitoring, there are specific anesthetic considerations for nonsternotomy approaches in reoperative coronary surgery. These include the possible use of lung separation techniques and the need for external defibrillator pads. In addition, it is imperative to be prepared for catastrophic events and longer surgical times. An avoidance of CPB affords the benefit of avoiding the coagulopathic derangements that occur on CPB, including platelet, fibrinogen, and coagulation factor dysfunction and dilution. Another common coagulopathic consequence of CPB is fibrinolysis. During off-pump CABG, the use of fibrinolytics usually is not needed. The authors present 3 patients who underwent nonsternotomy approaches to CABG. The surgical approach for each patient was chosen based on vessel involvement.