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Ann Thorac Surg 1998;66:557-558
© 1998 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
b Division of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
c Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
Accepted for publication February 26, 1998.
Address reprint requests to Dr Sundt, Division of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Suite 3108 Queeny Tower, St. Louis, MO 63110
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Abstract |
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Introduction |
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A 60-year-old man presented with symptoms of increasing fatigability and chest fluttering. Past medical history was significant for non–insulin-dependent diabetes mellitus and a left hemispheric stroke 2 years before the present admission with minimal residual deficit.
His laboratory values and renal function were within normal limits. Serum creatine kinase enzyme levels were consistent with an acute myocardial infarction. He was found to have severe three-vessel disease with severely impaired left ventricular function on cardiac catheterization. Duplex examination demonstrated 80% to 99% stenosis of his carotid arteries bilaterally. Neuroangiography via a right femoral artery puncture demonstrated a 99% stenosis of his left internal carotid artery and an 80% stenosis of his right internal carotid artery. Given the severity of his coronary artery disease and carotid disease, combined coronary artery bypass grafting and carotid endarterectomy were planned.
After an uneventful operative course, the patient was successfully weaned from CPB without inotropic support. Before the patient’s transfer to the postoperative intensive care unit, hemodynamic instability developed and required volume and vasopressors to support his blood pressure. Chest tube output had been minimal, and the transesophageal echocardiographic probe that had been previously removed was reinserted. Transesophageal echocardiographic examination demonstrated good ventricular function but reduced left ventricular area consistent with hypovolemia. Further transesophageal echocardiographic examination demonstrated a large fluid collection thought to be located in the left pleural space. The sternotomy was reopened so we could look for loculated fluid collection and exclude intrathoracic bleeding. On mediastinal exploration, no significant blood was noted in the pericardium or the pleural space. During exploration, the heart fibrillated and open cardiac massage was initiated. Electrical defibrillation was unsuccessful, and the patient was emergently placed on CPB.
Hemodynamic instability persisted and the patient continued to require a significant amount of volume. His body habitus was such that the abdominal girth could not be evaluated with accuracy. To evaluate the possibility of an intraabdominal source of blood loss we made a small incision in the subxiphoid diaphragm to explore the abdomen. After blunt peritoneal dissection, an immediate rush of blood was noted. Emergency exploratory laparotomy was performed with the working diagnosis of a ruptured abdominal aortic aneurysm. Manual compression of the infradiaphragmatic aorta was performed and the abdominal cavity was explored. At this time, a bleeding vessel was found in the mesentery of the distal small bowel with a sizable hematoma in the mesentery. There was no evidence of a retroperitoneal hematoma. After this bleeding was controlled, the patient was weaned off of cardiopulmonary bypass and the chest was closed. A segmental small bowel resection was then performed. The patient remained hemodynamically stable and he was transferred to the intensive care unit. The patient emerged from anesthesia without evidence of neurologic deficit. The remainder of the patient’s postoperative recovery was uncomplicated, and he was discharged from the hospital on postoperative day 10.
Pathologic evaluation of the resected small bowel segment demonstrated hemorrhagic mesentery with no vascular abnormalities. There was evidence of submucosal hemorrhage but no evidence of ischemia or necrotic changes.
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In these studies, more than 23,202 cases were retrospectively reviewed and 172 intraabdominal complications were noted, for an incidence of 0.7% [1–4]. Most of the complications are associated with mesenteric ischemia and low flow states either during CPB or in the perioperative period. Only one of these complications was an intraabdominal hemorrhage. This was discovered on exploration to be a bleeding ovarian tumor.
In the present case, we were presented with refractory hypotension despite increasing vasopressor support and volume replacement after having easily weaned the patient off of CPB. The differential diagnosis included acute myocardial dysfunction and acute blood loss. Transesophageal echocardiography demonstrated good myocardial function and hypovolemia. The absence of a large intrathoracic fluid collection caused us to entertain the possibility of localized tamponade, although the Swan-Ganz catheter pressure measurements did not support this diagnosis. Our differential diagnosis also included a ruptured abdominal aortic aneurysm, retroperitoneal bleeding from the right femoral artery puncture, or other acute intraabdominal blood loss. To rapidly evaluate the abdominal cavity without performing an exploratory laparotomy, we created a window into the abdomen through the diaphragm from the chest incision.
The exact cause of the bleeding vessel in the current case is unclear. Although the neuroangiogram performed the day before carotid endarterectomy and coronary artery bypass grafting was reportedly performed without complication, it is conceivable that while attempting the arterial puncture, the needle may have traversed the peritoneum and lacerated the small bowel mesenteric artery. This bleeding may have not become evident until full systemic heparinization was instituted for CPB. When faced with an unexplained volume requirement after CPB, a high level of suspicion should prompt the consideration of an intraabdominal source of bleeding. In this case, a small peritoneal window through the diaphragm allowed us to rapidly and accurately diagnose a life-threatening intraabdominal bleed.
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