Ann Thorac Surg 2003;76:621-622
© 2003 The Society of Thoracic Surgeons
Case report
Concomitant transabdominal MIDCAB and abdominal aortic aneurysm repair
Hidehito Sakaguchi, MDa*,
Shigeki Taniguchi, MDa,
Tetsuji Kawata, MDa,
Nobuoki Tabayashi, MDa,
Takashi Ueda, MDa
a Department of Surgery III, Nara Medical University, Kashihara, Nara, Japan
Accepted for publication January 23, 2003.
* Address reprint requests to Dr Sakaguchi, Department of Surgery III, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
e-mail: sakahide{at}naramed-u.ac.jp
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Abstract
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We present 2 patients who underwent transabdominal minimally invasive direct coronary artery bypass with the right gastroepiploic artery combined with abdominal aortic aneurysm repair. The surgical procedures, both performed through a median laparotomy, proved safe and of limited invasiveness. The one-stage surgical intervention prevented catastrophic complications, such as acute myocardial infarction or rupture of abdominal aortic aneurysm. We believe that concomitant transabdominal minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair should be considered as a single combined surgical strategy in selected patients.
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Introduction
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The transabdominal approach to coronary artery revascularization does not require osteotomy, and therefore, is considered a minimally invasive procedure in patients who need to undergo combined abdominal aortic aneurysm repair. Few reports are available on the efficacy of concomitant transabdominal minimally invasive direct coronary artery bypass (MIDCAB) and abdominal aortic aneurysm (AAA) repair [1]. We report satisfactory results with this surgical approach in 2 patients.
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Case reports
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Patient 1
A 78-year-old woman was referred to us with the diagnosis of an infrarenal AAA of 5 cm in diameter without any symptoms. Preoperative coronary angiography revealed a significant stenosis in the right coronary artery. However, it appeared that a percutaneous coronary intervention would be difficult to perform because of a type C lesion (American College of Cardiology and American Heart Association stenosis morphology classification). She had an obstructive pulmonary disorder (forced expiratory volume in 1 second, 66%) and mild renal dysfunction (serum creatinine, 1.5 mg/dL). These organ dysfunctions and her advanced age encouraged us to perform concomitant transabdominal MIDCAB and AAA repair. After an upper median laparotomy, the costal arch was retracted toward the patient’s head, which increased the operative exposure anteriorly and cranially. The right gastroepiploic artery was harvested using an ultrasonic scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, OH). The adhesion between the diaphragm and the left lobe of the liver was dissected, followed by a T-shaped incision into the tendon of the diaphragm (6 cm of horizontal incision and 3 cm of vertical incision). A drape was sutured around the inferior edge of the incised diaphragm, which prevented the intestines and the omentum from encroaching on the operative field (Fig 1).
The anterior edge of the incised diaphragm was also retracted anteriorly and superiorly. The right posterior descending coronary artery was identified and was stabilized by using an Octopus III Flexible Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) attached to the USS Mini-CABG ring base of Thoralift (United States Surgical, Norwalk, CT) set in the abdominal retractor. The right gastroepiploic artery was grafted on the right posterior descending coronary artery with an end-to-side anastomosis using a 7-0 polypropylene suture (Ethicon, Inc, Somerville, NJ). The diaphragm was approximated after confirmation of hemostasis at the anastomotic site. The median laparotomy was extended to the pubic symphysis. The AAA was repaired with a bifurcated knitted vascular graft (Boston Scientific, San Jose, CA). The postoperative course was uneventful.
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Fig 1. Intraoperative photograph (upper) and line-drawing diagram (lower) are shown. Arrowheads indicate the incised diaphragm and the inferior wall of the heart exposed through the diaphragm. (CABG = coronary artery bypass grafting; RCA = right coronary artery; RGEA = right gastroepiploic artery.)
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Patient 2
A 72-year-old man was referred to us with the diagnosis of an infrarenal AAA of 5 cm in diameter without any symptoms. Preoperative workup revealed severe right coronary artery disease (CAD) and no other organ dysfunction. Transabdominal MIDCAB and AAA repair were performed simultaneously using the same technique as described in patient 1. His postoperative course was also uneventful.
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Comment
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The transabdominal approach is an attractive approach to MIDCAB. It is considered less invasive than an anterior approach or partial sternotomy because no bone is divided [2–4]. Fonger and colleagues [5] described their experience with transabdominal MIDCAB in 117 patients during a 5-year study period; they reported excellent operative results with no perioperative strokes, renal failures, or deaths, and with actuarial and event-free survival at 20 months of 96% and 92%, respectively. Thirty two percent of their patients underwent multiple coronary artery revascularizations with the right and left internal thoracic arteries, right gastroepiploic artery, or radial artery, or a combination thereof. They also suggested that the transabdominal approach had the potential for extending endoscopic or robotic coronary artery surgery in the future. Takahashi and associates [4] reported the advantage of the transdiaphragmatic approach to patients who required reoperative coronary artery bypass grafting without damaging primary patent grafts. Partial contraindications for transabdominal MIDCAB included obesity, previous abdominal operation, or hepatomegaly [3].
Thirty to 40% of patients with AAA are reported to have CAD [6]. At our own institution, between January 1993 and July 2002, out of 231 patients with AAA, 113 (49%) had a severe CAD revealed by coronary angiography. Since we began to undertake MIDCAB or off-pump coronary artery bypass grafting in 1997, our strategy for patients with concomitant CAD and AAA has been a one-stage surgical intervention consisting of MIDCAB or off-pump coronary artery bypass grafting and AAA repair to prevent perioperative life-threatening complications, including acute myocardial infarction and rupture of AAA. In fact, between March 1997 and July 2002, 28 patients underwent simultaneous operations for CAD and AAA with an acceptable operative mortality rate of 3.6% (1 of 28). Initially, we adopted the reversed "J" incision approach to patients with right CAD and AAA. However, this approach was marginal in the exposure of the distal region of the right coronary artery and caused postoperative wound pain. The introduction of transabdominal MIDCAB in 2001 at our institution solved these problems. Epidural anesthesia is used routinely in our patients for the elimination of postoperative wound pain. An incision for transabdominal MIDCAB and AAA repair confined to the abdomen, without the necessity for osteotomy, increases the effectiveness of epidural anesthesia. Moreover, if the patient needs to have further coronary artery bypass grafting for new coronary lesions, a median sternotomy or anterolateral thoracotomy can be carried out safely and easily. We believe that concomitant transabdominal MIDCAB (especially for a lesion of the right coronary artery) and AAA repair should be considered as a single combined surgical strategy in selected patients.
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References
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- Gurbuz A., Kirali K., Tuncer A., Sismanoglu M., Yakut C. Combined transdiaphragmatic MIDCAB with right gastroepiploic artery and abdominal aortic aneurysm repair. Cardiovasc Surg 2000;8:503-506.[Medline]
- Subramanian V.A., Patel N.U. Transabdominal minimally invasive direct coronary artery bypass grafting (MIDCAB). Eur J Cardiothorac Surg 2000;17:485-487.[Abstract/Free Full Text]
- Voutilainen S., Verkkala K., Jarvinen A., et al. Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery. Ann Thorac Surg 1998;65:444-448.[Abstract/Free Full Text]
- Takahashi K., Minakawa M., Kondo N., Oikawa S., Hatakeyama M. Coronary artery bypass surgery by the transdiaphragmatic approach. Ann Thorac Surg 2002;74:700-703.[Abstract/Free Full Text]
- Fonger J.D., Subramanian V.A., Connolly M.W. Limited-access surgical coronary artery revascularization. Semin Thorac Cardiovasc Surg 2002;14:58-69.[Medline]
- Mitchell M.B., Rutherford R.B., Krupski W.C. Infrarenal aortic aneurysms, 4th ed. In: Rutherford R.B., ed. Vascular Surgery. Philadelphia: WB Saunders Co, 1995:1043-1044.
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Abstract
Introduction
