For The Inoperable Coronary Patient

There are two important questions to ask every time a heart patient is diagnosed with inoperable coronary disease

What makes the patient inoperable?
How can we improve on our surgical solutions to save the life of a high risk or inoperable coronary case?

These are the basic technical challenges when it comes to the inoperable coronary patient, but new technologies have made all the difference for many coronary patients who would have otherwise felt hopeless without the opportunity to improve their condition through surgery.

What is a Coronary Bypass Surgery?

A coronary artery bypass operation is essentially a plumbing intervention on blocked coronary arteries. A pipeline (a vein or an arterial graft) is directly connected between the water main supply (the aorta, the main pipeline in the human body) and a spot on the coronary artery downstream from where the blockage is. All steps in the process are crucial for a positive health outcome, and if they cannot be carried out within your surgeon’s standards or limits, you may be told you are inoperable.

Answers For Inoperable Coronary Patients

Now that you know there are effective solutions available if your heart surgeon says you’re inoperable, let’s dive into different cases that were considered inoperable. Consider this the troubleshooting chapter of your coronary owner’s manual.

Inoperable Case 1: Aorta is Heavily Calcified

Your aorta is heavily calcified, making it ‘crunchy’ and unusable for connecting to the heart-lung machine by use of a clamp, as is done for coronary bypass surgery. If surgery is attempted in the presence of heavy calcification, your aorta may crack and release small crumbs of calcium into your bloodstream, causing serious problems like blocking blood flow to vital organs. In the brain, they can cause a stroke and in the kidneys, kidney failure.

Dr. Ciuffo’s Solution:

In this case, troubleshooting consists of using what we usually describe as a ‘no touch’ technique. We have designed a radically different surgical approach that completely avoids any manipulation of the aorta, but still guarantees an excellent coronary bypass operation. Instead of using the aorta, our ‘water main supply’ will originate from the left and right internal mammary arteries. These vessels run along the chest wall and are already hooked up to the general circulation through the subclavian arteries in your shoulders. This choice avoids the need to use the aorta as the hookup for our pipelines. Beating heart surgery techniques can be used to perform the bypass operation without using the heart-lung machine or any clamp across the aorta. Many surgeons are not properly trained or sufficiently experienced to perform these techniques, so if you’re told that you’re inoperable, it might be time to seek a second opinion from a reputable high risk heart surgery center and inquire at our office to determine if you are a suitable candidate for this option.

Inoperable Case 2: Lack of Conduits or Veins to Work With

There aren’t enough conduits or veins (pipelines) to work with. This situation refers to patients that have run out of usable veins or arteries for a variety of reasons. Here are a few examples:

A 50 year old woman has varicose veins stripped out of both legs.
A diabetic or vascular patient has their veins used for a previous coronary bypass operation or a vascular bypass in the leg.
A patient undergoes a leg amputation.
A dialysis patient has multiple dialysis access operations on his/her arms and legs.

Dr. Ciuffio’s Solution:

In this case, there are grafting options, including harvesting conduits from the:

Arms (radial arteries, basilic vein)
Back of the legs (lesser saphenous veins)
Abdominal wall (epigastric arteries)
Peritoneal cavity (gastroepiploic arteries)
Chest wall (internal mammary arteries)

In extreme cases, where no conduits are available anywhere in the body, human cryopreserved saphenous veins from tissue banks can be thawed and used. Every coronary case is different and should be carefully evaluated by a medical professional to see if a technical option is available to help an individual patient.

Inoperable Case 3: Bad Coronary Targets

The coronary vessels are too severely and diffusely diseased to find a spot to connect the bypass graft. This is a situation most surgeons describe as ‘bad coronary targets’. Here’s the catch: Not every surgeon or cardiologist has the same level of technical and clinical experience. What is too diseased and therefore inoperable for one surgeon could be a pretty straightforward target for someone with specific experience in difficult coronary cases.

Dr. Ciuffio’s Solution:

If a coronary vessel has multiple blockages, it’s possible to perform double grafting on individual vessels. If the entire length of the coronary artery is severely diseased, it can be treated with an endoarterectomy, a procedure designed to remove the atherosclerotic plaque (the grime that’s clogging up the pipe) to reestablish a good target for bypass grafting.

Inoperable Case 4: Patients of Age

The patient, otherwise clear-minded and independent, is too old and/or frail to withstand an open heart operation. A good question to ask your heart surgeon in this situation is, “Am I so old and frail that I can’t survive my severe heart condition and avoid a miserable end to my life?”

Dr. Ciuffio’s Solution:

Keep the spirit of a feisty 86-year-old patient of mine who told me, “I may be old, but I’m not ready to die yet!” If you’re told that open heart surgery is too risky for you, you should be clear on what your chances actually are. For example, you’re told that you have a 20 percent risk of serious complications or death with surgery. Your next question should be, “What are my chances without coronary surgery?” You may have a condition serious enough to jeopardize the chance to celebrate your next birthday. Then, a 20 percent risk with surgery doesn’t sound so bleak. In many cases, medical therapy is much more dangerous than said surgery. You need to know what your options are, and every case is different. Always discuss your case with an expert medical professional. Minimally invasive and high-risk surgery centers can offer surgical options that don’t involve cutting bone and can be performed through a tiny 2” incision without a heart-lung machine.

Inoperable Case 5: High Risk Patients

The patient has any combination of bad lungs, bad kidneys, bad liver and/or a prior open-heart operation. Again, know what your chances are with and without surgery. Relevant examples might include:

You have bad lungs and severe coronary disease. You might be able to breathe better if a good percentage of your breathing problem is caused by a heart condition that could be improved with surgery.
Kidney malfunction may progress more rapidly if you continue with medical therapy when the heart is weak and causes congestive heart failure.
A bad liver can be a high-risk surgical proposition, and you need to understand that liver insufficiency goes through different stages from mild to severe, and associated surgical risk can vary greatly from case to case and stage to stage.

Dr. Ciuffio’s Solution:

In all these cases, an experienced heart surgeon could select the use of beating heart surgery techniques to carry out a high-risk coronary artery bypass grafting operation. This type of surgery avoids the use of the heart-lung machine and protects the kidneys, lungs, and other vital organs from potential damage.

Inoperable Case 5: A Weak Heart

The strength of the heart is commonly measured as Ejection Fraction (EF). A normal EF is 60-65%. The lower the number, the weaker the heart. The response to this condition can vary significantly among heart specialists. Some surgeons might not be comfortable operating on weak hearts because they feel they might not recover well after surgery. High risk heart surgery specialists might offer a more secure outcome by meticulously managing certain heart conditions before, during and after surgery.

Dr. Ciuffio’s Solution:

The high-risk heart patient can be optimized before surgery with adequate preoperative medical intervention with advanced minimally invasive and/or beating heart surgery techniques and can then recover postoperatively with expert management of congestive heart failure and low ejection fraction. In coronary patients, the heart muscle might be weak because of coronary blockages and can be revived and strengthened by the bypasses that reestablish a good blood supply to a heart muscle otherwise starved for oxygen. There are other reasons why your doctor might describe your heart condition as inoperable. Please feel free to contact us to discuss your questions and concerns about inoperable coronary disease.

Second Opinion With Dr. Ciuffo

If you’ve been diagnosed as an inoperable coronary patient for one or more of the reasons listed above, it‘s important that you talk with our expert heart surgeon, Dr. Giovanni Ciuffo for a second opinion. Contact us online or call (712) 294-7055 to schedule an appointment with Dr. Ciuffo.