A Case of Spasmodic LITA Graft after Minimally Invasive Robotic Surgery

1. Background:
   

Minimally invasive robotically assisted endoscopic coronary artery bypass grafting (RA-CABG) surgery is becoming an acceptable alternative method of less invasive surgical coronary artery revascularization for an isolated single coronary artery disease (CAD) specially in the younger patient population. 2.

Methods:
We report the case of a 58 year old male who presented with CCS class II-III angina and was found to have chronic total occlusion (CTO) of the left anterior descending (LAD) artery with retrograde filling. He underwent robotic-assisted beating heart minimally invasive coronary artery bypass grafting, where he had construction of the LAD with the left internal thoracic artery (LITA). The same day, in the hybrid operating room, he had post-operative catheterization which demonstrated a very spasmodic LITA graft with no antegrade flow (Fitzgibbon class 0 flow). He was then treated with high dose anti-spasmodic medications for 24 hours and the repeat subsequent cardiac catheterization on the second post-operative day demonstrated a very patent LITA graft with Fitzgibbon class A flow. 3.

Results:
This is a very unique case that not only illustrates the extreme spastic nature of the LITA graft, which occurs most frequently in the first 24 hours period following bypass surgery, resulting in Fitzgibbon class 0 flow but also nicely demonstrates the role of anti-spasmodic drugs like nifedipine. 4.

Conclusions:
The case highlights that readers need to be aware of this potential situation associated with RA-CABG and hence can avoid a potential unnecessary conversion to open bypass surgery.