Pulmonary resection post-coronary artery bypass grafting: Feasible, but right-sided procedures demand caution

The study objective was to evaluate the feasibility and technical considerations of pulmonary resection after coronary artery bypass grafting, with emphasis on procedures ipsilateral to an internal thoracic artery graft and the role of preoperative 3-dimensional imaging.

We retrospectively reviewed 75 patients who underwent pulmonary resection after coronary artery bypass grafting between January 2008 and April 2024. Thirty-eight patients underwent pulmonary resection on the same side as internal thoracic artery grafting. Preoperative 3-dimensional reconstructed coronary or contrast-enhanced computed tomography was used to delineate graft anatomy in 23 patients.

Left internal thoracic artery grafts were present in 24 left-sided resections and right internal thoracic artery grafts in 14 right-sided resections. Surgical approaches included thoracotomy (n = 35) and robot-assisted thoracic surgery (n = 3); procedures comprised lobectomy (n = 19), segmentectomy (n = 8), and wedge resection (n = 11). Adhesions between the lung and bypass graft were observed in 26 patients (68.4%); 24 patients underwent successful adhesiolysis, and 2 patients required partial lung resection with selective preservation of a thin parenchymal layer adjacent to the graft while otherwise completing the planned lobectomy. No intraoperative graft injuries or postoperative myocardial infarctions occurred. Prolonged air leak was more frequent in right-sided procedures (21.4% vs 0%; P = .043). The 30-day mortality rate was 0%, and the 90-day mortality rate was 5.4%.

Pulmonary resection after coronary artery bypass grafting is feasible but technically demanding and requires meticulous preoperative planning and careful intraoperative judgment, particularly during adhesiolysis near patent grafts. Preoperative 3-dimensional imaging provides supportive anatomical guidance for graft localization but should be regarded as adjunctive rather than outcome proven. In cases of dense adhesions, avoiding forceful adhesiolysis and selectively preserving a thin parenchymal layer adjacent to the graft, while otherwise completing the planned lobectomy, may represent a pragmatic graft-preserving strategy that maintains oncologic adequacy when negative margins are achieved.