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Ann Thorac Surg 1999;68:1537-1539
© 1999 The Society of Thoracic Surgeons
a Department of Surgery III, Nara Medical University, Nara, Japan
Address reprint requests to Dr Kameda, Department of Surgery III, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
e-mail: ykameda{at}naramed-u.ac.jp
Presented at Evolving Techniques and Technologies in Minimally Invasive Cardiac Surgery, San Antonio, TX, Jan 22–23, 1999
Abstract
Background. For simultaneously combined coronary artery bypass surgery with infrarenal abdominal aortic aneurysm (AAA) repair, a relatively high operative mortality and morbidity have been reported.
Methods. From February 1998 to December 1998, simultaneous minimally invasive direct coronary artery bypass combined with the AAA repair was performed for 4 patients (3 males, 1 female; mean age, 74 ± 7 years). Three were high-risk patients: 2 were over 75 years of age, 2 had respiratory insufficiency, and 1 had severe renal impairment.
Results. There were no mortalities. The endotracheal tube was removed within approximately 12 hours, and the postoperative courses were uneventful. During 4 ± 4 months of follow-up, there was neither angina recurrence nor other morbidity.
Conclusions. Minimally invasive direct coronary artery bypass combined with AAA repair was safe even for high-risk patients.
Since its introduction in 1995, minimally invasive direct coronary artery bypass (MIDCAB) technique has gained acceptance worldwide. This alternative technique has advantages not only for low-risk patients but also for high-risk patients [1, 2]. In this report, we described our experience with MIDCAB combined with infrarenal abdominal aortic aneurysm (AAA) repair in 4 patients, 3 of which were at high-risk.
Case reports
Patient one
A 71-year-old man suffered from increasing severe lumbago and was bedridden. Abdominal computed tomography (CT) scan demonstrated a 9-cm infrarenal AAA and a 4-cm right common iliac artery aneurysm. Electrocardiogram (ECG) showed old myocardial infarction of the anteroseptal wall, and coronary angiogram demonstrated total occlusion of the proximal left anterior descending artery (LAD). His respiratory function was impaired 1(% volume capacity: 64%; forced expiratory volume1%: 61%), and the mediastinum was shifted to the left due to left tuberculous pyothorax at 30 years of age. Because of adhesions in his thoracic space, the left internal thoracic artery (LITA) was directly harvested via L-shaped partial sternotomy from the suprasternal notch to the left fifth intercostal space. His heart was translocated to the left and unaccessible from the median incision. Therefore we made a 7-cm minithoracotomy slightly lateral to the mid-clavicular line to make anastomosis of the LITA to the LAD. Bifurcated graft replacement of the aorta was concomitantly performed through a median laparotomy. The endotracheal tube was extubated 14 hours postoperatively. His postoperative course was uneventful, and he could walk by himself on discharge.
Patient two
A 66-year-old man suffered from angina pectoris. Coronary angiogram showed a total occlusion of the proximal LAD, and abdominal aortogram revealed a 3-cm bilateral common iliac artery aneurysms. Percutaneous transluminal angioplasty (PTCA) was tried for the LAD, but it was unsuccessful. He strongly requested simultaneous correction of the coronary artery disease and iliac aneurysms. Therefore, we planned simultaneous MIDCAB and bifurcated-graft replacement. We harvested LITA by the thoracoscopic technique. Then, we made anastomosis of the LITA to the LAD via a 6-cm left anterior thoracotomy. Concomitantly, we performed bifurcated-graft replacement through a median laparotomy. The endotracheal tube was removed 12 hours after operation. The patient had a satisfactory postoperative course.
Patient three
An 84-year-old woman had received medication for angina pectoris for 7 years. She felt a pulsating abdominal mass, and abdominal CT scan revealed a 6-cm infrarenal AAA and 2.5-cm bilateral common iliac artery aneurysms. Coronary angiogram demonstrated a 90% stenosis of the proximal LAD for which PTCA could not be performed, for anatomical reasons. We simultaneously performed MIDCAB and bifurcated graft replacement. In MIDCAB, LITA was harvested via a thoracoscopic approach, and the anastomosis of the LITA to the LAD was directly made via a 7-cm, left anterior small thoracotomy. We concomitantly performed AAA repair with bifurcated graft. The endotracheal tube was removed 10 hours after operation. The patient had a satisfactory postoperative course.
Patient four
A 76-year-old man felt a pulsating abdominal mass and suffered from intermittent claudication of the left lower extremity. At 67-years-of-age, he underwent an operation for common bile duct stone. One year ago he had acute myocardial infarction and received direct PTCA with stent for the proximal right coronary artery. A CT scan demonstrated a 5-cm infrarenal AAA, and angiography showed a significant stenosis of the left external iliac artery. Coronary angiogram demonstrated 90% stenosis of LAD and 90% stenosis of the distal branch of the right coronary artery. His respiratory function was impaired 2(forced expiratory volume1%: 57%), and creatinine clearance decreased to 25.7 mL per min. PCTA for LAD had unsatisfactory results. Therefore, we planned simultaneous operation of MIDCAB for LAD and bifurcated-graft replacement. Thoracoscopic LITA harvest was performed, and anastomosis of the LITA to the LAD was made via a 6-cm left anterior small thoracotomy. We concomitantly performed bifurcated-graft replacement through retroperitoneal approach. The endotracheal tube was removed 11 hours after operation. The patient had a satisfactory postoperative course.
Comment
It is well recognized that patients with AAA have a high incidence of coronary artery disease. Coexistent coronary artery disease is the most important cause of both early and late mortality following AAA repair.
It has been demonstrated that coronary revascularization reduces the risk of early and late cardiac events in patients with AAA complicated with coronary artery disease. For these patients, two different surgical strategies were adopted in the past. The most common course is two-stage operation, and the conventional coronary artery bypass surgery is carried out first, followed later by elective AAA repair. In this approach, however, the high incidence of aneurysm rupture after coronary artery bypass surgery has been well documented. The hemodynamic instability, inflammatory response, and perioperative malnutrition, and so on may play a role in hastening aneurysm rupture. It was revealed that 11% to 33% of patients who underwent coronary artery bypass surgery prior to AAA repair died due to aneurysm rupture [3, 4]. Therefore, any coronary patient with AAA 5 cm or greater in diameter should undergo coronary revascularization followed by AAA repair within 2 weeks [4]. Nevertheless, this interval between these two major operations is too short for high-risk patients.
Alternatively, some investigators adopted a one-stage combined procedure of conventional coronary artery bypass surgery and AAA repair. This simultaneous operation reduces the risk of aneurysm rupture, and some patients can not be candidates of staged approach. If the two-stage operation is adopted, patients with severe coronary artery disease and large abdominal aneurysm are exposed to a great risk of aneurysm rupture, and this surgical strategy results in relatively high mortality and morbidity [5], particularly for the elderly patients or those with severe respiratory impairment. The major problem of these conventional surgical approaches is the excessive surgical invasiveness originating from using cardiopulmonary bypass.
A major advantage of MIDCAB is avoidance of the cardiopulmonary bypass. The use of the cardiopulmonary bypass is responsible for deterioration in the renal and respiratory functions, and also the risk of cerebral vascular insufficiency is significantly increased as compared with operations not involving cardiopulmonary bypass [3]. Therefore, MIDCAB decreases mortality and morbidity for elderly patients and those with respiratory insufficiency, who should undergo surgical repair of the AAA, and coronary artery disease, resulting from systemic atherosclerosis probably affecting the cerebral vessels.
We adopted MIDCAB for patients with multivessel disease because the culprit lesions were in LAD. Because the result of the Bypass Angioplasty Revascularization Investigation study revealed that there were no differences in the 5-year survival between coronary artery bypass grafting (CABG) and PTCA groups in spite of the fewer revascularized lesions in the PTCA group, it can be anticipated that a limited but adequate revascularization for the culprit lesions in selected high-risk patients is a reasonable alternative to a risky complete revascularization. In these patients, MIDCAB combines the advantages of revascularization of the culprit lesion with the good long-term results guaranteed by the use of the internal thoracic artery [4, 6].
Although coronary revascularization combined with AAA repair is performed with effort to use conventional techniques, this strategy is maximally invasive for high-risk patients. We obtained good results by applying MIDCAB for coronary revascularization combined with AAA repair in 4 patients. Even for high-risk patients this strategy was safe, and the patients’ discomfort was less, as they endured a single convalescent period owing to a single, minimally invasive operation. Our experience is limited in the patient number, but we believe that this technique can be very useful for those patients if the culprit lesion of the coronary artery is confined to single or nearly single vessel.
References
This article has been cited by other articles:
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  G. Fayad, T. Modine, S. Haulon, C. Decoene, R. Azzaoui, R. Salari, and M. Koussa Infrarenal abdominal aortic aneurysm rupture and severe symptomatic coronary artery disease: Rapid combined transdiaphragmatic off-pump coronary surgery and abdominal aortic aneurysm repair J. Thorac. Cardiovasc. Surg., June 1, 2005; 129(6): 1434 - 1435. [Full Text] [PDF]
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G. Babatasi, M. Massetti, J.-M. Radoux, and A. Khayat Abdominal aneurysm rupture and left main stenosis: Emergency one-stage repair with off-pump coronary surgery J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 958 - 960. [Full Text] [PDF]
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