Late recurrence of artgirza: This is a reflection of progress of disease in the native coronary arteries distal to the grafts or narrowing or blockage of one or more of the grafts. This occurs more frequently when only saphenous vein grafts are used as conduits. Such patients should have angiogram followed by either angioplasty or surgery.

It has been mentioned earlier that usage of IMA to LAD is important for long term survival and a life free of angina. A patent and functioning LIMA does not prevent recullence of angina altogether as the ischaeinia could be in the territory of RCA or circumilex coronary artery. Coronary angiogram to show suitability for re grafting and thallium scan to show reversible iscllaemia in that telitory should be done before re intcrvenlion.

Re operation is a complicated procedure and carries higher risk as compared to primary surgery. The patients are older and may have co existing disease like diabetes. There is likelihood of progression of native coronary artery disease along with disease of conduits and probably poor LV function. At the time of surgery, athero-embolism from partially patent vein grafts is a grave danger.

There will be adhesion in the pericardium causing excessive bleeding. In case of patent LIMA to LAD, there is danger to that pedicle on release of adhesions. The heal may be dependant 011 this single graft.

The indications for re operation are generally the same as for primary operation. As the risk is higher; the operation should be reserved for ignore symptomatic patients with large area of myocardium at risk. Patient should have at least one good target vessel of more than 1.5 mm with more than 75 per cent proximal narrowing before advising surgery. Thallium 201 myocardial perfusion scan will help in arriving at a decision in these patients.

The surgeon has to study carefully the previous operation notes and diagrams of coronary arteriography and the vessels grafted. A lateral view chest X-ray and CT scan will help in deciding on the relationship of R.V and aorta to the under surface of the sternum.