Left thoracotomy for coronary artery bypass grafting in a patient with an ileo-coloplasty

A 60 year-old male patient with a history of right ileo-coloplasty for oesophageal carcinoma five years earlier presented with chest pain. Transthoracic echocardiogram showed moderate left ventricular dysfunction (EF = 45%). Cardiac catheterisation revealed high-grade coronary artery lesions affecting the left main trunk, left anterior descending (LAD) artery and the obtuse marginal artery (Fig. 1A, arrows showing haustra of the colon). A computed tomography scan was performed to choose the best surgical approach (Fig. 1B, arrow depicting the neo-oesophagus lying behind the left side of the sternum). The patient underwent off-pump CABG through a left antero-lateral thoracotomy using the fifth intercostal space; he was positioned with the left side elevated to approximately 45°. Under single lung ventilation we successfully dissected the colon from the posterior aspect of the sternum, and subsequently the left internal thoracic artery was harvested under direct vision from a lateral approach. The pericardium was opened antero-laterally, and pericardial stay sutures were placed on both edges allowing good exposure of the target vessels. The left internal thoracic artery was anastomosed to the LAD. Progressive mobilisation of the apex to explore the obtuse marginal artery was followed by a severe hemodynamic instability. The procedure was carried out under femo-femoral cardio-pulmonay bypass to assist the failing heart. The proximal anastomose of the saphenous vein used to bypass the obtuse marginal artery was performed from the LITA in a T-graft configuration because the ascending aorta was found to be too much on the right side and partial clamping was unattainable (Fig. 2).