Thoracotomy approach in reoperations

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adequate local tumor control. Combination with systemic chemotherapy could result in improved long-term survival. This understanding forms the basis of our opinion that resection of lung tumors with infiltration of the thoracic aorta should be performed in an en bloc fashion with the routine use of cardiopulmonary bypass. Walter Klepetko, MD Department of Cardiothoracic Surgery Vienna General Hospital Wahringer Gurtel 18-20 A-1090 Vienna, Austria

References 1. Klepetko W, Wisser W, Birsan T, et al. T4 lung tumors with infiltration of the thoracic aorta: is surgery reasonable? Ann Thorac Surg 1999;67:340–7. 2. Trastek V, Pairolero P, Piehler J, et al. En bloc (non-chest wall) resection for bronchogenic carcinoma with parietal fixation. J Thorac Cardiovasc Surg 1984;87:352– 8.

Thoracotomy Approach in Reoperations To the Editor: We read with interest Dr Baumgartner and colleagues’ paper [1] on the left posterior thoracotomy as an alternative approach in reoperative coronary artery bypass grafting. We first used this approach in 1971 using femoral cannulation for cardiopulmonary bypass (CPB) [2]. In the last 4 years, CPB has been avoided in the majority of our cases, maintaining the original conceptual framework of using this surgical approach in 59 reoperations to revascularize the lateral wall of the heart [3]. We have used mainly saphenous vein grafts, performing the distal anastomoses either to the native coronary artery or on to the hood of a previous graft. Proximal anastomoses were performed on the descending aorta. Mechanical stabilization, coronary snaring, and intracoronary shunts were adopted, as described by Baumgartner and associates to optimize operative conditions. Graft patency was tested with transit time flow measurements at the end of the procedure. We found it useful to extend the thoracotomy anteriorly to revascularize the left anterior descending coronary artery and its branches, whenever needed. In this case, the left internal mammary artery was used, when available, in combination with saphenous vein grafts. In a limited number of patients, we adopted a posterolateral thoracotomy approach, together with a subxiphoid incision, to simultaneously revascularize the marginal coronary branches and the right coronary artery territory with the right gastroepiploic artery. An increasing proportion of patients who present for coronary revascularization are at high-risk because of recurrent coronary artery disease after previous coronary bypass operation. Long CPB time has been identified as an important independent risk factor leading to mortality in redo coronary artery bypass grafting [4]. Reoperative myocardial revascularization can be performed without the use of CPB and alternative approaches should be used to revascularize culprit coronary lesions decreasing the risks of resternotomy and manipulation of the heart and old grafts. The purpose of this communication is to congratulate Dr Baumgartner and colleagues for their work, confirming their results with our experience. Furthermore, additional grafts can be placed to the left anterior descending coronary artery/ © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc

Ann Thorac Surg 2000;69:971– 82

diagonal territory or to the right coronary artery through separate incisions. Giuseppe D’Ancona, MD Hratch L. Karamanoukian, MD Jacob Bergsland, MD Tomas A. Salerno, MD Department of Cardiothoracic Surgery Buffalo General Hospital 100 High St Buffalo, NY 14203

References 1. Baumgartner F, Gheissari A, Panagiotides G, et al. Off-pump obtuse marginal grafting with local stabilization: thoracotomy approach in reoperations. Ann Thorac Surg 1999;68:946– 8. 2. Grosner G, Lajos TZ, Schimert G, Bergsland J. Left thoracotomy reoperation for coronary artery disease. J Card Surg 1990;5:304– 8. 3. D’Ancona G, Karamanoukian H, Lajos T, et al. Reoperative coronary artery bypass grafting without cardiopulmonary bypass: surgical techniques and perioperative results. Eur J Cardiothoracic Surg 2000; in press. 4. He GW, Acuff TE, Ryan WH, He YH, Mack MJ. Determinants of operative mortality in reoperative CABG. J Thorac Cardiovasc Surg 1995;110:971– 8.

Reply To the Editor: We thank Dr D’Ancona and associates for their kind comments and discussion of their extensive experience in marginal grafting through a thoracotomy approach in reoperations. One needs to remain cognizant in off-pump procedures that marginal grafting from the thoracotomy route is a good deal more difficult than grafting of the anterior wall vessels because of the distance of the marginal vessels from the lateral chest wall. Furthermore, it is not immune from the other complications of routine coronary revascularization. We recently learned that one of the patients in our study has developed severe, diffuse venous intimal hyperplasia resulting in occlusion of a marginal graft. The technique nonetheless remains useful in specific circumstances, and other groups have succeeded in the approach as well [1]. Fritz J. Baumgartner, MD Pacific Cardiothoracic Surgery Group Los Angeles, CA

Reference 1. Coulson AS, Bakhshay SA, Sloan TJ. Minimally invasive reoperation through a lateral thoracotomy for circumflex coronary artery bypass. Tex Heart Inst J 1998;25:170– 4.

Successful Treatment of Massive Pulmonary Tumor Embolism From Renal Cell Carcinoma To the Editor: Renal cell carcinoma has a propensity to extend into the local venous system. Renal vein and inferior vena cava involvement 0003-4975/00/$20.00