Intrapleural left axillary artery bypass grafting compromising subsequent left internal thoracic artery harvesting: a case report.

The frozen elephant trunk technique is increasingly used in total arch replacement (TAR) for acute Type A aortic dissection, with left axillary artery bypass commonly employed for left subclavian artery revascularization. We report a case in which an intrapleural left axillary artery Dacron bypass graft led to dense perigraft adhesions that severely compromised subsequent left internal thoracic artery (LITA) harvesting during redo coronary artery bypass grafting. A 45-year-old man underwent valve-sparing aortic root reimplantation, TAR, and left axillary artery bypass. Intraoperative findings revealed dissection extending to the left main trunk ostium, necessitating an arch prosthesis-to-left anterior descending saphenous vein graft, which subsequently failed. Dense intrapleural adhesions surrounding the graft severely impaired LITA harvesting. Complete arterial revascularization was achieved using bilateral internal thoracic arteries and radial artery bridge conduits. This case highlights that intrapleural routing of a left axillary artery bypass graft may compromise future LITA harvesting.