In the recent years, the incidence of re-do CABG
surgery has declined due to the increased use of
multiple arterial grafts. Patients initially undergoing
CABG with arterial grafts frequently have shortage
of arterial grafts for their second revascularization
procedure.[
1] Hence, the re-cycling techniques may
help optimizing arterial revascularization in young
patients, in particular, with a longer life expectancy.
One possibility of re-cycling is to use the patent
internal thoracic arteries (ITAs) as an inflow
for the new Y composite configuration. This
represents the most commonly applied technique in
some practices like Barra et al.[2] and Tector et al.[3]
The second possibility is the re-implantation of the
distal ITA anastomosis on the same coronary vessel
(15%). The main objective is to bypass a stenosis
in the coronary artery distal to the anastomosis or
due to a peri-anastomotic lesion. This technique
obliges an adequate length of the preexisting left
ITA. Pasic et al.[4] demonstrated excellent mid-term
patency (2.6 years) for ITA re-implantation of
12 patients.
During re-do CABG, Dohi et al.[5] dissected the
LIMA, re-used it in situ for the circumflex artery,
and used the RIMA to the LAD. This possibility was
the appropriate choice for our patient with a slight
modification made by anastomosing the LIMA to the
fist diagonal branch and the RIMA to the LAD.
Although Antona et al.[6] were able to obtain an
IMA pedicle long enough to reach the heart. In
certain cases, the anastomosis of the salvaged graft on
the same coronary artery may cause excessive tension
on the anastomosis itself. For such cases, the “short”
IMA can be re-routed to a more accessible coronary
artery which needs revascularization or it can be
elongated with an interposition of great saphenous
vein or with other arterial conduits.
Another method may be skeletonizing the LIMA.
At a re-do operation, Uwabe et al.[7] skeletonized the
LIMA and re-used it in situ to the LAD. Using the
skeletonized method for re-harvesting LIMA made the
graft reach to a more distal portion without tension.
Re-cycling is generally performed on a highly
selected group of re-do CABG patients. Certain
factors are mandatory for the re-cycling process such
as a well-developed ITA with a minimal diameter
>2.5 mm as confirmed by coronary angiography,
patent IMA grafts without significant stenosis and
sufficient LIMA length. Re-sternotomy has to be
done very carefully to avoid any damage to the ITA
graft. Young patients (<60 years) with a longer life
expectancy, presenting for re-do CABG surgery with
patent ITA may benefit from salvage and re-use of the
ITA grafts.[8] As our patient met the necessary criteria
mentioned above, LIMA was successfully re-cycled
and used. Another point to attract attention is the
possibility of follow-up using Doppler ultrasound.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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