We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

Long-term hemodialysis remains a major risk factor for coronary artery bypass grafting (CABG). In our institution, a surgical strategy for these high risk patients is the complete coronary revascularization with off-pump CABG (OPCAB) using an arterial graft. However in cases of advanced functional disorder, we choose hybrid strategy or reduction strategy, namely the target of surgical intervention is just the key vessel. Aggressive usage of continuous hemodiafiltration (CHDF) to control water and electrolytic balance intra- and post-operatively is an alternative. This study aimed to elucidate whether our strategy is appropriate for hemodialysis patients. We enrolled 608 consecutive patients who underwent CABG between August 1999 and December 2006. Among them, 25 (4.1%) had received regular hemodialysis. As a control group, 100 patients were selected randomly among 583 patients excluding 25 hemodialysis patients. All patients had at least one major complication, and 13 had several major complications. The number of preoperative complications in hemodialysis patients is significantly higher than that of control group. Mean patient age was 66.3±8.7 years. The mean number of diseased vessels was 2.32±0.7, and that of anastomosis per patient was 2.4±1.2. All patients completed the procedure without cardiopulmonary bypass (CPB) as a result. Complete revascularization was performed in 22 (88%). The causes of non-completion were a hybrid strategy with PCI in one patient in the early period and a reduction strategy in 2 on account of social indications. Perioperative mortality was 0%, while the major complication was extended pleural effusion in 3 patients and slowly progressive sternal osteomyelitis in one. Mid-term results showed 2 cardiac deaths. The surgical outcome was equivalent in the hemodialysis group and the control group, though each preoperative state was not equal. Our strategy for patients undergoing chronic hemodialysis attained excellent perioperative and mid-term outcomes. We consider OPCAB produced better outcomes. CHDF is an important tool for use in surgical intervention in these patients.