Bilateral thoracotomy for coronary artery bypass grafting in a patient with unfavorable median sternotomy

In this report, we describe a patient who underwent coronary artery bypass grafting (CABG) through bilateral thoracotomy and distal median sternotomy, because he had received terminal tracheotomy as a treatment to prevent aspiration pneumonia due to Wallenberg's syndrome. On the first day after the terminal tracheotomy, he suddenly complained of severe anterior chest pain. Emergency coronary angiogram revealed complete occlusion of the proximal right coronary artery (RCA), severe stenosis of the left anterior descending artery (LAD) and the large first diagonal branch. Catheter intervention for RCA was attempted but it was unsuccessful, and therefore he was required to have urgent operation. The patient had received total laryngectomy and terminal tracheotomy two weeks before urgent CABG, and the large hole of the tracheotomy was just placed above the incisura juglaris of the sternum. So high risks of sternal infection and severe mediastinitis after ordinary median sternotomy were considered and we applied the bilateral thoracotomy approach. To our knowledge, this is very rare but effective approach to vascularize both right and left coronary artery and to use both left internal thoracic artery (LITA) and gastroepiploic artery (GEA) graft. It seemed that this approach is safe and effective for cardiac surgery in such situations that median sternotomy is not favorable as in the described patient or in patients having reoperation.