Coronary artery reoperations are more complicated than primary operations. Patients undergoing reoperations have distinct, more dangerous pathologies; reoperations are technically more difficult to perform; and the risks are greater.1–12 Vein graft atherosclerosis, present in most reoperative candidates, is a unique and dangerous lesion. Reoperative candidates commonly have severe and diffuse native-vessel distal coronary artery disease (CAD), a problem that has had the time to develop only because these patients did not die from their original proximal coronary artery lesions. Aortic and noncardiac atherosclerosis are also often far advanced in many reoperative candidates. Some technical hazards, including the presence of patent arterial grafts and sternal reentry, are unique to reoperations, and others, such as lack of bypass conduits and difficult coronary artery exposure, are common.
After a primary bypass operation, the likelihood of a patient undergoing a reoperation depends on patient-related variables, primary operation-related variables, adherence to strict medical control of risk factors for disease progression after bypass surgery, the possibility of alternative treatments, physician opinion about the feasibility of reoperation, and time. Studies from our institution noted a cumulative incidence of reoperation of 3% by 5 years, 10% by 10 years, and 25% by 20 postoperative years13 (Fig. 26-1). Factors associated statistically with an increased likelihood of reoperation have been variables predicting a favorable long-term survival (eg, young age, normal left ventricular function [LVF], and single- or double-vessel disease), variables designating an imperfect primary operation (eg, no internal thoracic artery [ITA] graft and incomplete revascularization), and symptom status (eg, class III or IV symptoms at primary operation). Young age at primary operation and incomplete revascularization are also markers of a severe atherogenic diathesis.
Study of 4000 patients who underwent bypass surgery from 1971 to 1974 showed that 25% of patients had undergone a reoperation within a period of 20 years after primary operation. (Data from Cosgrove DM, Loop FD, Lytle BW, et al: Predictors of reoperation after myocardial revascularization. J Thorac Cardiovasc Surg 1986; 92:811.)
More recently, however, the proportion of isolated coronary artery operations that are reoperations has decreased. This decrease is related in part to the more aggressive use of coronary artery interventions for patients with previous bypass surgery and probably to more effective risk factor control. In 1990 about 37% of coronary artery revascularization operations were reoperative interventions, whereas in 2002 this figure decreased to 30%14 (Fig. 26-2). Also, surgery has changed in directions that will decrease the rate of reoperation. Use of the left internal thoracic artery (LITA) to graft the left anterior descending (LAD) coronary artery decreases the risk of reoperation compared with the strategy of using only vein grafts, and the LITA-LAD graft has become a standard part of operations for coronary artery revascularization.15 Furthermore, it now appears that use of bilateral ITA grafts decreases the likelihood of death and ...