Background:

• 64 year old small, thin female
  
• 4x CABG
  
• Procedure performed on-pump
  
• Tiny and tortuous vessels

Image Acquisition Sequence:

• All anastomoses performed: LIMA to LAD; sequential SVG to OM 1 & OM II ; SVG to RCA
  
• SVG to RCA image acquired with direct irrigation of IC-Green™
  
• Proximal image acquired with cross clamp removed and heart beating with IC-Green administered through central venous line

Pre-Operative Cath
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SVG to RCA
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Intra-operative Imaging and Assessment:

SVG to RCA

All anastomoses were performed.  Prior to completing the proximal anastomoses of the saphenous vein graft (SVG) to right coronary artery (RCA) a SPY image was acquired to assess the graft patency.  The IC-Green was administered by the surgeon by directly injecting it through the graft.  Good flow was demonstrated through the graft and vessel.

Proximal

To  verify graft patency in all free grafts, a final image was acquired of the proximal anastomoses.  Before performing this image acquisition the patient was weaned from the pump, but the cannulae were not removed.  The IC-Green was administered through the central venous line.  The SPY image demonstrated two patent anastomoses.  Based on imaging, the CABG procedure was concluded to be successful and uneventful.

Proximals
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Post-Operative Course

After surgery, the patient was transferred to surgical heart unit.  Patient remained hemodynamically stable, but significant ST-T changes were noted in the inferior lead distribution.  Patient was taken to the cath lab for review.  The cath demonstrated the LIMA to LAD to be patent but showed signs of spasm, the SVG to OM branches were patent, the SVG to RCA had sluggish flow.  The Cardiologist thought there was possible ostial stenosis at the origin of the aortic anastomosis.   The surgeon was concerned about poor outflow and determined re-exploration was necessary.

Post-Operative Cath
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SVG Sequential to OM I & II
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SVG Sequential to OM I & II

The patient was brought back into the operating room, and SPY imaging was performed to evaluate all of the grafts.  Imaging confirmed good flow through the sequential SVG graft into both of the obtuse marginal (OM) branches.  

 

LIMA to LAD
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LIMA to LAD

Once again imaging confirmed good flow through the LIMA and good flow and distal run-off through the LAD.  This confirmed the LIMA had been in spasm earlier and now was functioning properly.

Proximals

Finally, image sequences were acquired for the proximal anastomoses.  As expected, the SVG to OM proximal anastomosis demonstrated good flow into the graft.  The SVG to RCA anastomosis demonstrated sluggish flow into the graft, especially compared to the SVG to OM graft.  The SVG was divided a centimeter beyond the origin and anastomotic area and examined with no evidence of obstruction observed.  There appeared to be a small segment of venous valve in the residual portion which was removed.  SVG was re-anastomosed and patient was weaned from pump.

Proximals
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