Ann Thorac Surg 1999;68:1418-1420
© 1999 The Society of Thoracic Surgeons
Case Reports
Stent-grafting to descending thoracic aorta during coronary artery bypass grafting
Kazuhiro Kochi, MDa,
Taijiro Sueda, MDa,
Hidenori Shibamura, MDa,
Kazumasa Orihashi, MDa,
Yuichiro Matsuura, MDa
a First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
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Abstract
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We report on 2 patients who underwent successful concomitant operation of coronary artery bypass grafting and stent grafting to descending thoracic aortic aneurysms. The device was inserted through a small linear incision on the anterior wall of the aortic arch. Intraoperative stent grafting to descending thoracic aortic aneurysms is an alternative therapeutic option for patients who require concomitant coronary artery bypass grafting and descending aortic replacement.
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Introduction
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To reduce the invasiveness of concomitant operations of coronary artery bypass grafting (CABG) and descending thoracic aortic replacement, we used an intraoperative stent grafting method. We report on 2 patients who underwent successful stent grafting to descending thoracic aortic aneurysms during CABG.
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Case reports
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Patient 1
A 61-year-old man underwent an emergency operation for a ruptured thoracoabdominal aortic aneurysm. Postoperative angiography showed the diameter of the proximal descending aorta to be 5.5 cm and severe triple vessel disease. A second operation was performed on July 24, 1997. After median sternotomy, the left internal thoracic artery and the cervical vessels were dissected. Cardiopulmonary bypass was established using right atrial drainage and ascending aortic return. Then cardiac arrest was achieved. Usual CABG was performed at first during the period of systemic cooling. After hypothermic arrest at the temperature of 25°C, a linear oblique incision on the anterior wall of the aortic arch, 3 cm in diameter, was made. Selective cerebral perfusion through the cervical arteries was initiated. The stent graft was composed of the triple tandem-type Gianturco stent (William Cook Europe A/S, Bjaever-Skov, Denmark) and Dacron graft (Intervascular Medicals, Intervascular Inc, Clearwater, FL). The stent was inserted in the distal part of the graft with crimp ironed out and was attached to the graft using a series of interrupted 5-0 polypropylene sutures. The stent graft was inserted through the proximal incision site using a 30F flexible catheter sheath. The stent graft was deployed to the distal part of the aneurysm under transesophageal echocardiographic guidance. After withdrawing the sheath and the graft, a 20F Foley balloon was inserted into the graft and inflated to confirm that the stent graft was fully opened and not twisted or kinked. The proximal site of the graft was circumferentially fixed to the proximal descending aorta through the incision site using interrupted 4-0 polypropylene sutures with care not to injure the cervical arteries. Finally, the incision line was closed. His postoperative course was uneventful (Fig 1). No graft-related complications including thromboembolism, occlusion of the graft, and blood leakage from the proxymal or distal anastomotic site were recognized for 20 months.
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Fig 1. (Patient 1) (A) A 30F sheath containing the device is inserted through the linear incision site on the aortic arch. (B) The sheath and the graft are withdrawn. (C) The proximal site of the graft is circumferentially sutured to the proximal descending thoracic aorta. (D) Closure of the incision line is made.
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Patient 2
A 74-year-old woman was referred for chronic Stanford type B dissection, severe triple vessel disease, and abdominal aortic aneurysm. Angiography showed that the descending aorta was enlarged to 5.5 cm, that poor thrombogenesis was present in the false lumen, and that the entry was located beneath the left subclavian artery (Fig 2). On June 10, 1998, she underwent CABG and stent grafting to the descending thoracic aorta to close the entry using the same method as in Patient 1. Postoperative angiography showed thrombogenesis in the false lumen. Her postoperative course was uneventful and no graft-related complications have been recognized for 9 months (Fig 2).
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Fig 2. (Patient 2) (A) Aortogram shows a dissecting aneurysm 5.5 cm in size. (B) Postoperative aortogram shows that the false lumen is occluded by the implanted stent graft.
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Comment
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Concomitant operation of descending thoracic aortic replacement and CABG has been clearly described in recent reports [1, 2]. The problems associated with this conventional method include an additional left thoracotomy to median sternotomy, direct lung compression, and phrenic and recurrent nerve injury, thereby increasing the number of postoperative pulmonary complications. Furthermore, the number of high-risk patients, especially those with coronary artery disease, octogenarians, neurologic and respiratory dysfunction, is increasing [3, 4]. Then, we used an intraoperative stent grafting method using only median sternotomy. Moreover, in both patients we decided to approach through the aortic arch because of the abdominal aortic lesions, which would be a contraindication for the usual stent grafting method through the femoral artery.
Kato and colleagues [5] described the technique of stent grafting for thoracic aortic aneurysms involving the distal aortic arch. In their method, the device was inserted through the transected aortic arch. The proximal side of the deployed graft was fixed to the transected arch. Compared with their method, stent grafting through a small linear incision on the aortic arch has advantages that include reduction of operative time, blood loss, and the length of the suture line. However, because the possibility of intraoperative thromboembolism and long-term prognosis are unknown, more experience is necessary before we can be confident that this less invasive method is efficacious.
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References
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Takamoto S., Matsuda T., Harada M., Shimamura Y. Distal aortic arch aneurysmectomy and coronary revascularization through a left thoracotomy. Ann Thorac Surg 1993;55:151-152.[Abstract/Free Full Text]
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Mukohara N., Asada T., Higami T., Obo H., Gan K., Ogawa K. Graft replacement of a thoracic aneurysm and coronary artery bypass grafting using retrograde cerebral perfusion through left thoracotomy-a case report. Nippon Kyobu Geka Gakkai Zasshi 1996;44:74-77.[Medline]
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Fann J.I., Dake M.D., Semba C.P., Liddell R.P., Pfeffer T.A., Miller D.C. Endovascular stent-grafting after arch aneurysm repair using the "elephant trunk.". Ann Thorac Surg 1995;60:1102-1105.[Abstract/Free Full Text]
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Dake M.D., Miller D.C., Semba C.P., Mitchell R.S., Walker P.J., Liddell R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734.[Medline]
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Kato M., Ohnishi K., Kaneko M., et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94:II188-II193.
Accepted for publication March 30, 1999.
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Abstract
Introduction
