Ann Thorac Surg 1999;67:831-832
© 1999 The Society of Thoracic Surgeons
Case Reports
Anastomosis to the wrong vessel during off-pump bypass surgery via mini-thoracotomy
Christof Schmid, MDa,
Tonny D.T. Tjan, MDa,
Karl J. Henrichs, MDb,
Dietrich Boppert, MDb,
Hans H. Scheld, MDa
a Department of Cardiothoracic Surgery, Westfaelische Wilhelms-Universitaet, Muenster, Germany
b Department of Cardiology, County Hospital, Luedenscheid, Germany
Accepted for publication August 12, 1998.
Address reprint requests to Dr Schmid, Klinik für Thorax-, Herz- & Gefaesschirurgie, Albert-Schweitzer-Str. 33, 48149 Muenster, Germany
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Abstract
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Recently, minimally invasive coronary artery bypass graft operation has been established as a new treatment strategy for cardiac surgeons. We report on a patient who underwent off-pump coronary artery bypass graft operation through a mini-thoracotomy to the wrong coronary artery (first diagonal) with consecutive successful percutaneous transluminal coronary angioplasty of the vessel involved (left anterior descending coronary artery) to demonstrate a special risk that is associated with this kind of operation.
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Introduction
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During the past few months, many cardiac surgeons began to perform bypass grafting of the left internal mammary artery to the left anterior descending coronary artery (LAD) on the beating heart. However, there are many pros and cons for the new surgical techniques, and the learning curves are quite variable [1]. We illustrate an extraordinary complication that may occur during off-pump mini-thoracotomy coronary artery bypass grafting procedures.
A 42-year-old male obese patient, experiencing recurrent anginal pain caused by singular proximal stenosis of the LAD, was referred to our institution for minimally invasive coronary artery bypass graft operation (Fig 1). A small anterolateral thoracotomy was performed, and the presumed LAD identified in a thick layer of epicardial fat. The pedicle was prepared from the fifth to the second intercostal space under direct vision. Heparin (10,000 IU) was administered, polypropylene sutures were looped around the small coronary artery proximal and distal to the anastomotic site, and the vessel was occluded with tourniquets. The heart rate was slowed to about 65 beats per minute using short-acting ß-blocking agents (Breviblock) because a mechanical stabilizer was not available at our institution at that time. The anastomosis was achieved with a polypropylene 7-0 suture (occlusion time, 10 minutes). After immediate extubation and an uneventful postoperative recovery, the patient was referred to a county hospital for rehabilitation 4 days afterward.
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Fig 1. Preoperative angiogram demonstrating proximal stenosis of the left anterior descending coronary artery.
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Three weeks later, with increasing physical exercise, he redeveloped anginal pain. Control coronary angiography revealed that the left internal mammary artery had been anastomosed to the first diagonal branch, and the LAD was still unprovided (Fig 2). Percutaneous transluminal coronary angioplasty with additional stent placement was performed successfully, and the patient has remained free of symptoms since then (Fig 3).
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Fig 3. Postoperative angiogram after percutaneous transluminal coronary angioplasty and placement of a stent into the left anterior descending coronary artery.
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Comment
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The case demonstrates a pitfall of minimally invasive coronary artery bypass graft operation when using a mini-thoracotomy approach. The identification of the correct vessel can be rather difficult or sometimes even impossible through the small incision, especially when the patient is obese and the coronary artery has an intramural course. Therefore, the risk of operating on a wrong vessel is certainly fundamental. Nevertheless, the mistake may occur more often during the learning curve. Generally, we ask for magnetic resonance tomography before operation, which nicely depicts the course of the LAD within the epicardial fat [2]. Thus, an intramural course can be detected in advance and an open procedure scheduled if necessary. However, magnetic resonance imaging cannot prevent the surgeon from anastomosing the wrong vessel.
Intraoperative and postoperative angiography to control graft patency are desirable strategies [3]. However, intraoperative imaging is not possible in many institutions, including our own. Moreover, postoperative angiography is an additional expense and adds a slight risk to the patient. Nevertheless, it may help to identify inadequate bypass procedures and allow percutaneous transluminal coronary angioplasty to alleviate recurrent angina [4]. Therefore, we routinely evaluate all our patients by angiography within 6 months after operation.
In conclusion, minimally invasive coronary artery bypass graft operation certainly provides an important new tool for the cardiac surgeon. However, it entails specific difficulties and risks because patients may undergo perfect surgery to the wrong vessel.
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References
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Shennib H., Mack M.J., Lee A.G.L. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110-115.[Abstract/Free Full Text]
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Scheld H.H., Schmid C. Cardiac surgery without the use of cardiopulmonary bypass: the challenges. Curr Opin Anaesthesiol 1998;11:5-8.
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Emery R.W., Emery A.M., Flavin T.F., Nissen M.D., Mooney M.R., Arom K.V. Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging. Ann Thorac Surg 1996;62:591-593.[Abstract/Free Full Text]
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Angelini G.D., Wilde P., Salerno T., Bosco G., Calafiore A. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularization. Lancet 1996;347:757-758.[Medline]
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Abstract
Introduction
