Coronary Artery Bypass Grafting through Thoracoabdominal Spiral Incision in a Patient with Tracheotomy and Severe Obesity

Abstract

A 60-year-old man with type 2 diabetes mellitus and severe obesity(height 170 cm, weight 160 kg, BMI 55)was admitted to our hospital because of acute inferior wall myocardial infarction due to acute thromboembolism of the right coronary artery(RCA). Because of three-vessel coronary diseases, we planned coronary artery bypass grafting after the medical therapy. The patient was intubated, then suffered congestive heart failure and pneumonia, and had a tracheotomy because of obesity hypoventilation syndrome. When his general condition improved after 14 months of medical therapy, we performed the operation. At that time, his weight had decreased to 107.5 kg, and BMI decreased to 37.2. We decided that tracheotomy was necessary to avoid respiratory complications. We chose a thoracoabdominal spiral incision for 2 reasons. Firstly we needed to avoid wound contamination by the tracheotomy stoma. Secondly we decided that the left internal thoracic artery(LITA)and the right gastroepiploic artery(RGEA)were sufficient for bypass grafts to the left anterior descending artery (LAD), the diagonal branches(D1), the posterolateral artery(PL)and the posterior descending artery(PD). Before the operation, epidural anesthesia was performed for postoperative analgesia to prevent respiratory dysfunction. In the right semi-lateral position at 30°, a 4th intercostal space thoracotomy was performed, and the LITA was harvested. The skin incision was extended to the midline of the abdomen and the RGEA was harvested. The end of the LITA was anastomosed with the free RGEA as I composite and the composite was anastomosed to the LAD, the D1, the 14 PL and the 4 PL without cardiopulmonary bypass. Without any perioperative blood transfusion, the patient was discharged with no perioperative complication, including mediastinitis. With this incision, we achieved secure prevention of wound contamination by the tracheotomy stoma, harvesting of a sufficient length of the LITA and