Ann Thorac Surg 2003;76:926-927
© 2003 The Society of Thoracic Surgeons
Case report
Combined off-pump coronary revascularization: ascending aorta to carotid bypass
Shelly C. Lall, BSa,
Jeffery M. Rhodes, MDa,
William H. Risher, MDb*
a University of Rochester School of Medicine and Dentistry, Division of Vascular Surgery, Rochester, New York, USA
b St. Luke’s Regional Heart Center, Bethlehem, Pennsylvania, USA
Accepted for publication February 14, 2003.
* Address reprint requests to Dr Risher, St. Luke’s Regional Heart Center, 801 Ostrum Street, Bethlehem, PA 18015, USA
e-mail: risherw{at}slhn.org
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Abstract
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A 76-year-old man with symptomatic cerebral vascular disease and coronary artery disease was treated with simultaneous off-pump bypass and cerebral revascularization. With the emergence of off-pump coronary artery operation as a viable option for coronary revascularization we believe that this procedure will become our method of choice for combined cerebral and coronary artery disease.
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Introduction
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Combined coronary revascularization and ascending aorta to carotid artery bypass is traditionally done using full cardiopulmonary bypass. We present a novel approach using off-pump coronary artery revascularization and carotid artery operation.
A 76-year-old white male with noninsulin-dependent diabetes and tobacco abuse presented with a 5-week history of bilateral eye weakness and blurred vision. He was found to have right retinal embolization on ophthalmologic examination. Five days before admission, the patient experienced left lower extremity weakness, slurred speech, and left facial weakness, all of which improved except for mild left facial weakness. Evaluation included carotid duplex scan, which showed 50% to 79% right internal carotid artery stenosis, 50% to 79% left internal carotid artery stenosis, and possible great vessel disease with right subclavian occlusion and left subclavian stenosis. Angiography was obtained showing high-grade ulcerated innominate plaque of greater than 90% at its origin, right subclavian occlusion, 70% right external carotid artery stenosis, left subclavian artery stenosis, and greater than 60% bilateral internal carotid artery stenosis. It was thought that the innominate lesion was symptomtatic and that an aorta-to-carotid bypass should be performed. The patient denied chest pain, history of myocardial infarcts, and symptoms of congestive heart failure. He had multiple cardiac risk factors, including diabetes, tobacco abuse, and strong family history. A persantine thallium test revealed inferior ischemia. A cardiac catherization showed an ejection fraction of 50% and a normal left main coronary artery. The left anterior descending artery had an 80% lesion; a large ramus marginalis had a 90% lesion; the left circumflex system was small and nondiseased; and the right coronary artery was completely occluded. Severe calcification of the arch and plaque in the ascending aorta were seen on transesophageal echocardiography. We planned surgical intervention including bypass of the symptomatic innominate lesion and coronary revascularization.
The patient underwent off-pump three-vessel coronary artery bypass grafting (saphenous vein graft to left anterior descending artery, saphenous vein graft to ramus marginalis, and saphenous vein graft to right coronary artery), ascending aorta to right carotid bypass, and carotid endarterectomy. The patient was given heparin, with activated clotting times kept above 300 seconds. Coronary revascularization was performed first using the octopus retractor system (Medtronic Inc, Minneapolis, MN) to afford stabilization. Intracoronary shunts (Medtronic Inc) were used for distal anastomoses. Proximal anastomoses were performed using a single partial occlusion clamp on the ascending aorta, placed with the guidance of epiaortic ultrasound to avoid the ascending plaque seen on transesophageal echocardiography. There were no electrocardiogram changes after removal of air from the graft and removal of the partial occlusion clamp. The patient had been monitored throughout the procedure with continuous electroencephalography. The right carotid bifurcation was exposed through a separate right neck incision. A partial occlusion clamp was placed on the ascending aorta while an 8-mm Dacron graft was sewn in place. This graft was tunneled over the brachiocephalic vein and under the strap muscles. An endarterectomy was then performed using a longitudinal arteriotomy extending from the common carotid artery and up the internal carotid artery. The proximal common carotid artery was oversewn. The 8-mm Dacron graft was sewn end to end to the endarterectomized bifurcation. Intraoperative duplex scan confirmed a technically adequate reconstruction. There were no electroencephalographic changes during any portion of the procedure. Heparin was reversed with protamine. The patient was transferred to the intensive care unit in stable condition, discharged to a subacute rehabilitation facility, and subsequently lost to follow-up.
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Comment
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This patient had evidence of embolic events originating from the greater than 90% plaque in the innominate artery at the origin. Furthermore, there was moderate stenosis of the right internal carotid artery. Thus, we decided to bypass the plaque at the origin of the innominate artery as well as perform a right internal carotid endarterectomy. Because the right subclavian artery was occluded, a subclavian-to-carotid bypass was not anoption. Because the patient’s right upper extremity was asymptomatic, we elected not to revascularize that vessel. The ascending aorta was our best option for inflow to the carotid endarterectomy site, thus requiring a median sternotomy. Because the chest would be open for innominate bypass, we planned simultaneous off-pump coronary artery bypass (OP-CAB). Carotid endarterectomy is usually performed first when using cardiopulmonary bypass. However, OP-CAB allowed coronary revascularization with electroencephalographic monitoring, followed by carotid revascularization. The left internal thoracic artery was not used for left anterior descending artery revascularization because there was narrowing at the origin of the left subclavian artery; therefore, vein grafts were used.
According to Mackey [1], there are three approaches to the treatment of carotid and coronary artery disease. Mackey rates the degree of coronary and carotid disease separately as critical, severe, or elective. The algorithm recommends that critical or severe carotid disease in conjunction with critical or severe coronary disease be managed by using a synchronous approach. In a patient who has elective coronary operation, any signs of high-grade carotid disease should be dealt with first. If the carotid operation is elective and the patient’s coronary disease is critical, the latter takes precedence. Although somewhat controversial, Mackey advocates that elective carotid (70% to 99% asymptomatic unilateral stenosis) operation in the setting of severe coronary disease should be managed with a synchronous approach. The present patient had critical three-vessel coronary disease and critical, symptomatic innominate disease; thus the synchronous approach was indicated.
A simultaneous approach to carotid and coronary disease without the use of cardiopulmonary bypass has been reported recently. OP-CAB is gaining acceptance as a safe and effective alternative to conventional coronary artery bypass grafting. OP-CAB has been shown to reduce cytokine response and myocardial injury [2]. Interaction of the patient’s blood with the tubing surface causes a systemic inflammatory response. Another reason OP-CAB may benefit selected patients is the regulation of cerebral blood flow [3]. Normally it is tightly regulated by the body; however, while on pump, cerebral blood flow is nonpulsatile and regulated by the pump flow rate. One prospective randomized study reported that OP-CAB resulted in lower operative and nursing costs [4]. Bed occupancy, blood loss, and transfusion requirements are lower with the use of OP-CAB. Other advantages of OP-CAB include avoidance of global myocardial ischemia and preservation of interventricular septal function. Malperfusion, microemboli from the pump, and atheromatous emboli from aortic manipulation are risks associated with cardiopulmonary bypass that can contribute to neuropsychological deficits [5]. The limitations of OP-CAB include number and location of target arteries [6].
In our patient, the target arteries were easily exposed using the octopus tissue stabilizer. This, along with the emerging evidence in support of off-pump coronary artery bypass, guided our decision to perform OP-CAB. In the future, our approach to combined carotid and coronary disease will be off-pump coronary bypass followed by carotid endarterectomy.
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References
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- Mackey W.C. Carotid and coronary disease: staged or simultaneous management?. Semin Vasc Surg 1998;11:36-40.[Medline]
- Wan S., Izzat M.B., Lee T.W., et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg 1999;68:52-57.[Abstract/Free Full Text]
- Taylor K.M. Brain damage during cardiopulmonary bypass. Ann Thorac Surg 1998;65:S20-S26.[Medline]
- Ascione R., Lloyd C.T., Underwood M.J., Lotto A.A., Pitsis A.A., Angelini G.D. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg 1999;68:2237-2242.[Abstract/Free Full Text]
- Jansen E.W., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116(1):60-67.[Abstract/Free Full Text]
- Diegeler A., Martin M., Falk V., et al. Indication and patient selection in minimally invasive and ‘off-pump’ coronary artery bypass grafting. Eur J Cardiothorac Surg 1999;16:S79-S82.[Medline]
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Concomitant Carotid Endarterectomy and Off-Pump Coronary Revascularization
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1883 - 1883.
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Abstract
Introduction
