Descending Aorta to Coronary Artery Bypass in a Patient with a Tracheostomy: Columbus´s Egg?

Introduction: Sternotomy in presence of a tracheostomy is associated with a higher risk of mediastinitis or deep sternal wound infection. This risk can be avoided by choosing an alternative surgical approach. Presented is the case of a patient with a tracheostomy who received a venous graft from the descending aorta to the marginal branch of the circumflex artery via a limited left lateral thoracotomy using the off-pump technique.

Background: Presented is the case of a 63 years old male patient with a history of laryngectomy and tracheostomy for laryngeal carcinoma several years ago. Furthermore the patient had a history of systolic hypertension, chronic renal insufficiency and a sick sinus syndrome that had necessitated the implantation of a pacemaker several years ago. The patient had presented 2 years earlier for myocardial revascularization because of a 2-vessel disease concerning the left anterior descending and the circumflex arteries. At that time, the alternative, of a percutaneous intervention with a stenting of both vessels was chosen. Currently, the patient complained of recurrent angina on effort caused by an in-stent stenosis of the circumflex artery. The ischemia was confirmed by a Szintigram and the indication for a coronary revascularization given. To avoid a sternotomy, the decision for a limited left lateral thoracotomy was taken and a coronary bypass was established between the proximal descending aorta and a marginal branch of the circumflex artery in off-pump technique utilizing an intracoronary shunt and a vacuum assisted stabilizer. For the proximal anastomosis to the descending aorta a Heart String was used. Both surgical procedure and postoperative course were uneventful and the patient was routinely discharged from hospital. The patient has remained asymptomatic over the last year.

Discussion: Limited lateral thoracotomy and off-pump coronary artery bypass grafting are feasible and simple approaches in dealing with patients with a previous tracheostomy presenting for myocardial revascularization.