TY  - CHAP
M1  - Book, Section
TI  - Reoperative Coronary Artery Bypass Surgery
A1  - Barreiro, Christopher J.
A1  - Arnaoutakis, George J.
A1  - Shake, Jay G.
A2  - Yuh, David D.
A2  - Vricella, Luca A.
A2  - Yang, Stephen C.
A2  - Doty, John R.
PY  - 2014
T2  - Johns Hopkins Textbook of Cardiothoracic Surgery
AB  - EpidemiologyAmong  the  200,000  coronary  bypass  operations  performed  annually  in  the  United  States,  reoperative  coronary  artery  bypass  surgery  (redo-CAB)  accounts  for  approximately  5  percent  of  all  isolated  coronary  artery  bypass  grafting  (CABG)  procedures.  Recent  data  from  the  Society  of  Thoracic  Surgeons  database  show  that  there  has  been  a  decrease  in  the  number  and  percentage  of  redo-CAB  procedures  (2000,  N  =  8929,  or  6.1  percent;  2009,  N  =  8189,  or  4.3  percent).PathophysiologyReoperative  coronary  artery  surgery  is  performed  for  patients  in  whom  there  is  definite  demonstrated  myocardial  viability  with  associated  symptomatology.  A  multivariate  analysis  demonstrated  that  preoperative  angina,  use  of  vein  grafts  only,  previous  myocardial  infarction,  incomplete  revascularization,  female  gender,  and  smoking  at  a  younger  age  were  independent  risk  factors  for  recurrent  angina  and  a  potential  need  for  reoperation.Clinical  featuresIn  more  recent  years,  the  reoperative  candidate  population  has  evolved  to  include  older  patients,  with  diminished  left  ventricular  function,  triple-vessel  coronary  artery  disease  (CAD),  and  graft  failure  becoming  the  predominant  etiologic  factors.  Recently,  however,  there  appears  to  be  an  increase  in  number  of  reoperative  candidates  with  progression  of  their  native  disease  distal  to  their  patent  conduit  graft  sites.DiagnosticsDiagnostic  tests  include  those  used  to  assess  viable  myocardium  and  those  used  for  planning  the  operation.  The  tests  frequently  used  for  detecting  viable  myocardium  include  thallium  scintigraphy,  dobutamine  echocardiography,  magnetic  resonance  imaging,  and  positron  emission  tomography.  Coronary  angiography  is  the  gold  standard  for  determining  the  need  for  revascularization  and  the  appropriate  targets.  Standard  computed  tomography  (CT)  can  be  used  to  assess  the  substernal  structures.  However,  with  the  development  of  multislice  CT  and  three-dimensional  (3-D)  reconstruction,  accurate  pictures  of  the  cardiac  anatomy  and  the  relationships  of  bypass  grafts  to  mediastinal  structures  as  well  as  the  sternum  can  be  demonstrated  vividly.TreatmentReoperative  surgery  for  CAD  requires  knowledge  of  mediastinal  structures  and  a  staged  entry  into  the  chest  with  the  use  of  an  oscillating  saw  and  scissors  for  division  of  the  outer  and  inner  tables,  respectively.  Femoral  artery  and  vein  cannulation  may  be  necessary  if  it  is  anticipated  that  cardiac  structures  are  in  jeopardy  of  being  injured  upon  reentry.  Careful  dissection  in  the  area  of  previous  vein  grafts  that  may  be  atherosclerotic  is  important,  as  downstream  debris  from  these  vein  grafts  is  the  most  common  cause  of  mortality  in  this  high-risk  group  of  patients.  
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/19
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1104589204
ER  -