Ann Thorac Surg 1999;67:1497-1499
© 1999 The Society of Thoracic Surgeons
Case Reports
Combined coronary artery bypass grafting and repair of aneurysm of the descending aorta
Tomislav Mihaljevic, MDa,
Martin Tönz, MDa,
Ludwig K. von Segesser, MDa,
Marko I. Turina, MDa
a Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Accepted for publication November 3, 1998.
Address reprint requests to Dr Mihaljevic, Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115
e-mail: tmihaljev1{at}bics.bwh.harvard.edu
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Abstract
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The outcome of patients with thoracic or thoracoabdominal aortic aneurysm is often determined by the concomitant coronary artery disease. Two patients with thoracic and thoracoabdominal aortic aneurysm and concomitant single-vessel coronary artery disease underwent combined myocardial revascularization and repair of aortic aneurysm. The operations were performed through a left thoracotomy and thoracoabdominal incision with distal aortic perfusion using a partial femoro-femoral bypass and selective right lung ventilation. Coronary anastomoses were performed on the beating heart, and the aneurysm was replaced with a woven Dacron tube graft.
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Introduction
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The mortality and morbidity of patients undergoing repair of the descending thoracic aorta can be severely affected by a concurrent coronary artery disease [1, 2]. Our intention to circumvent this problem led to the performance of a combined operation that included myocardial revascularization and the repair of the aneurysm of the descending aorta. We present two cases where the aneurysmal replacement was accompanied with myocardial revascularization.
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Patient 1
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A 68-year-old man was referred for the repair of the descending thoracic aortic aneurysm. The diagnosis of the descending thoracic aneurysm in this asymptomatic patient has been made during the routine preoperative checkup for the operative correction of a cataract. The chest roentgenogram showed an aneurysmatic enlargement of the thoracic aorta. Further diagnostic evaluation with computer tomography confirmed the initial diagnosis, showing a large aneurysm of the entire descending thoracic aorta with a maximal diameter of 7 x 6.5 cm. Coronary arteriography revealed a single-vessel coronary artery disease with high-grade (90%) proximal stenosis of the left anterior descending artery. The left ventriculography showed a normal left ventricular ejection fraction with a slightly hypokinetic anterolateral portion of the myocardial wall.
At the operation, the patient was placed in the right lateral decubital position, which allowed access to the left femoral vein and artery. A partial femoro-femoral bypass was instituted with heparin-coated perfusion equipment with low systemic heparinization (100 IU/kg, Liquemin; Roche, Basel, Switzerland) with use of an inlet pressure servocontrolled roller pump (Stöckert, Munich, Germany). After the cannulation of the femoral vein and artery, the chest was entered through a large left lateral thoracotomy through the fifth intercostal space. This approach allowed an excellent exposure of the left side of the heart and the aneurysm of the descending thoracic aorta. The partial femoro-femoral bypass was instituted, and the patient was progressively cooled to 30°C. During this time, the left internal mammary artery was harvested in its entire length. The pericardium was opened ventral to the phrenic nerve, allowing the exposure of the diseased left anterior descending artery. The anastomosis was performed on the beating heart using 7-0 prolene continuous suture. Bleeding was controlled with a small bulldog clamp placed proximal and distal to the arteriotomy. After the myocardial revascularization was completed, the thoracic aorta was cross-clamped proximal and distal to the aneurysm, and the aneurysm incised longitudinally. The intraluminal thrombus was evacuated and the ateromatous debris removed. A woven graft (26 mm) was anastomosed using 2-0 polypropylene suture (Fig 1). The remaining portion of the aneurysm was tailored and placed over the Dacron graft. After declamping, the patient was weaned from the femoro-femoral bypass. The remainder of the operation was performed in the usual manner. The operation time was 140 min, femoro-femoral bypass time was 54 min, and the cross-clamping time of the descending aorta was 17 min.
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Fig 1. Intraoperative view through the left lateral thoracotomy showing the anastomosis between the left internal mammary artery and left anterior descending artery. The woven Dacron graft is partially covered by lung.
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The postoperative course was uneventful; there was no evidence of neurologic deficits. The postoperative control angiography revealed the patent left internal thoracic artery graft. The patient was discharged from the hospital 10 days after the operation.
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Patient 2
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A 66-year-old woman was referred for the repair of a thoracoabdominal aortic aneurysm. The diagnosis was made during the preoperative checkup for the operation on an ovarian cyst. Computed tomography of the chest and abdomen revealed a large aneurysm with a maximal diameter of 6.5 cm. The preoperative coronary arteriography showed a significant (95%) stenosis of the posterior descending artery.
The patient was intubated with a double-lumen endotracheal tube that permitted deflation of the left lung. The right lateral decubital position enabled the harvesting of the saphenous vein from the right leg and simultaneous femoro-femoral cannulation, and the institution of the partial bypass. Thoracoabdominal incision through the fifth intercostal space and splitting of the diaphragm enabled an exposure of the whole thoracoabdominal aorta. The pericardium was opened through the inferior incision, which allowed exposure of the diseased posterior descending artery. The end-to-side anastomosis between the coronary artery and the venous graft was performed on the beating heart using continuous 7-0 prolene suture; bleeding was controlled in the same manner as in the first patient. After completion of the coronary artery anastomosis, the aorta was clamped by placing the proximal clamp 5 to 7 cm distal from the origin of the subclavian artery, and the distal clamp at the level of diaphragm. The aneurysm was incised longitudinally and the proximal anastomosis was performed with a 22-mm Dacron graft. After the anastomosis was done, the distal clamp was replaced at the level of the aortic bifurcation. The origins of the celiac, superior mesenteric, and renal arteries were identified and reanastomosed in one oval opening in the graft. The distal graft anastomosis was performed 2 cm above the aortic bifurcation. Large atheromatous plaques made the implantation of the venous graft in the remaining portion of the thoracic aorta between the origin of the subclavian artery and the proximal graft anastomosis impossible, so that the venous graft was implanted directly in the proximal portion of the Dacron graft (Fig 2).
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Fig 2. Schematic presentation of the myocardial revascularization and the replacement of the thoracoabdominal aorta with reinsertion of the visceral arteries (right). Note that the proximal part of the venous graft is implanted directly into the Dacron graft.
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The operation time was 5 hours, femoro-femoral bypass time was 89 min, and descending aortic cross-clamp time was 35 min. The postoperative course was uneventful. There were no signs of perioperative myocardial infarction or neurologic deficits. The patient was transferred to another hospital for further care, in stable condition, 6 days after the operation.
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Comment
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Cardiac complications are the leading cause of death in patients who undergo repair of an aneurysm of the descending thoracic and thoracoabdominal aorta [1]. Similar complications in the repair of an aneurysm of the abdominal aorta as well as in peripheral vascular reconstruction were successfully treated by combined operations, which included myocardial revascularization [3]. However, such a solution has not been described in patients with an aneurysm of thoracic or thoracoabdominal aorta and coronary artery disease. The treatment options that could reduce the morbidity and mortality in such patients include percutaneous transluminal coronary angioplasty or coronary revascularization before elective aortic surgery. Both options are associated with a prolonged hospital stay and high economic costs. The single-stage operation described here offers a therapeutic alternative for this particular population of the patients.
The left thoracotomy, which is the standard approach for the repair of an aneurysm of the descending thoracic aorta, can be also used for coronary artery bypass procedures [4]. This approach also allows harvesting and use of the left internal thoracic artery grafts for the myocardial revascularization, adding the well-documented benefit of its superior long-term patency rate compared with vein grafts. Large thoracoabdominal incision for the repair of the thoracoabdominal aortic aneurysm offers additional benefit of the exposure of both diaphragmatic and lateral heart surfaces, therefore providing access to the left and right coronary artery. Coronary revascularization on the beating heart, as performed in both of our patients, does not require the use of cardioplegia or deep hypothermia. The use of the femoro-femoral bypass and heparin-coated equipment provides the protection of the spinal cord and eliminates the need for systemic heparinization [2, 5].
In summary, we report a case of combined myocardial revascularization and repair of the descending thoracic aortic aneurysm through a single incision. The described operation offers, in our opinion, the optimal surgical treatment for selected patients with aneurysmatic disease of the thoracic and thoracoabdominal aorta and concomitant coronary artery disease.
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References
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Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest 1993;104:1248-1253.[Free Full Text]
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Crawford E.S., Crawford J.L., Safi H.J., et al. Thoracoabdominal aortic aneurysm: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986;3:389-404.[Medline]
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Carrel T., Niederhäuser U., Pasic M., Gallino A., von Segesser L.K., Turina M.I. Simultaneous revascularization for critical coronary and peripheral vascular ischemia. Ann Thorac Surg 1991;52:805-809.[Abstract]
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Von Segesser L.K., Weiss B.M., Garcia E., von Felten A., Turina M.I. Reduction and elimination of systemic heparinization during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1992;103:790-799.[Abstract]
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Abstract
Introduction
