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FIGURE 1. Three-dimensional reconstructed computed tomographic images showed that the patent left internal thoracic artery graft crossed over the sternal midline and adhered to the posterior wall of the manubrium. CLINICAL SUMMARY A 63-year-old man was referred to undergo redo CABG for newly developed class 3 angina. The patient had undergone first-time CABG with a LITA to the left anterior descending coronary artery (LAD), a left radial artery graft to the obtuse marginal artery, and the right gastroepiploic artery to the posterior descending artery 8 years before his presentation in our department. The current coronary angiogram showed 90% stenosis of the LITA graft and occlusion of the right gastroepiploic artery. The radial artery graft was patent. The native LAD was totally occluded, so that the blood supply to the whole anterior wall was completely dependent on the diseased LITA graft. Redo double CABG was recommended for the patient. Preoperative computed tomography showed the LITA graft crossing the sternal midline and adherence to the manubrium (Figure 1). To avoid injury to the patent LITA graft, we planned to do a presternotomy dissection of the LITA graft from the sternum by VATS. General anesthesia was induced, and a double-lumen endotracheal tube was inserted. The patient was placed in a supine position, and the left arm was abducted. A camera port was created in the fifth intercostal space in the anterior axillary line (Figure 2, A). A thoracoscope was carefully inserted. There were minimal adhesions in the left side of the thorax. The LITA graft was immediately identified under

journal of thoracic and cardiovascular surgery

Totally endoscopic mobilization of a patent left internal thoracic artery graft from the sternum through the left hemithorax in redo coronary artery surgery: A new approach