Reoperative myocardial revascularization

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The swift evolution of myocardial revascularization in the past decade has concealed the precise estimate of reoperative grafting. The number of patients selected for reoperation has risen steadily since 1971 and accounted for 4.0% of bypass procedures performed at the Cleve-land Clinic in 1976. Today revascularization is more complete and, consequently, technically more complex; yet the risk of the primary operation is low and graft patency rates are consistently high, at least for the first few post-operative years. The major reoperative indications are (1) progressive atherosclerosis in un-grafted vessels, (2) graft failure, (3) combinations thereof, and (4) previous Vineberg procedure or incomplete revascularization. The fore-most consideration is technically favorable vessel size and arterial runoff as indicated by arteriograms. Occlusion of a vein autograft constructed to an anatomically small or diffusely atherosclerotic coronary vessel is not necessarily the reason for reoperation. The decision is based on the patient’s level of physical discomfort, the number and quality of coronary vessels involved, and the presence or absence of additional and irreversible ventricular damage. When use of the mammary artery is contemplated, the angiographer can inject one or both internal mammary arteries during catheterization to confirm their viability.

Attention to technical detail is crucial in the reoperative revascularization. For safety, a femoral artery can be exposed before reentry. An oscillating saw is usually favored and the sternal tables must be mobilized bilaterally by sharp dissection before insertion of the retractor. Only the right heart structures are mobilized before cannulation. Through 1975 we used normothermic . . .



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