Ann Thorac Surg 2004;77:1451-1454
© 2004 The Society of Thoracic Surgeons
Case report
Successful off-pump coronary artery bypass for Behcet's disease
Min-Ho Song, MD, PhDa*,
Takashi Watanabe, MD, PhDa,
Hajime Nakamura, MD, PhDa
a Division of Cardiovascular Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Song, Division of Cardiovascular Surgery, Shizuoka Saiseikai General Hospital, 1-1-1 Oshika, Shizuoka-shi, Shizuoka 422-8527, Japan
e-mail: songmhmd{at}attglobal.net
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Abstract
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A 66-year-old woman with a 30-year history of Behcet's disease was referred for coronary surgery because of restenosed stent and crescendo angina. We succeeded in operating on her by off-pump coronary bypass with bilateral internal mammary arteries, which were anastomosed to the left anterior descending artery and diagonal artery. The grafts were patent postoperatively and she became free from angina. Coronary surgery for Behcet's disease is extremely rare and this experience prompted us to report this case.
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Introduction
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Off-pump coronary artery bypass (OPCAB) is recognized as a safe and established alternative for conventional on-pump coronary artery bypass grafting. We recently cared for a woman with a 30-year history of Behcet's disease and performed OPCAB using bilateral internal mammary arteries. For fear of trouble of aorta of this Behcet's patient, we stick to the principle of aorta-non-touch and avioded proximal anastomosis.
Behcet's disease is known to have very uncommon involvement of coronary artery and few successful coronary surgeries have been reported. This experience prompted us to report this case.
A 66-year-old woman was referred for coronary surgery because of stenosed stent at left anterior descending artery (LAD) and crescendo angina. She has been on steroid regimen for 30 years because of Behcet's disease. Her Behcet's disease was diagnosed based on oral aphtha and erythematous nodule. Her coronary artery angiogram revealed 90% stenosis of LAD stent and 90% stenosis of the first diagonal artery. Other coronary arteries were free from lesion. The systemic computed tomography (CT) scan indicated no thrombosis at pulmonary artery and no aneurysm at arterial systems. Her laboratory data were unremarkable except for elevated C-reactive protein (2.8 mg/dL) and erythrocyte sedimentation rate (66 mm per hour). Because she had instent stenosis of stent at LAD and diagonal, and she continued to suffer from rest angina and dyspnea, surgical coronary revascularization was performed urgently.
After induction of general anesthesia, a midline sternotomy was done and bilateral mammary arteries were harvested by ultrasonic scalpel. They were skletonized. They appeared to be normal and their diameters were 13 mm and 17 mm, respectively, which were anticipated by preoperative multidetector CT scan. They were, however, very prone to dissect even by slight touch by coronary pickups. Their free flow were 46 mL/min and 52 mL/min. We decided to use both internal mammary arteries (IMA) for revascularization. Opening the pericardium, the ascending aorta was very short and seemed to be fragile. We decided to operate on the beating heart of the patient. Two deep pericardial traction sutures were put to expose the LAD and the diagonal. The Octopus II (Medtronic, Inc, Minneapolis, MN) adequately stabilized the targets. First the LAD was bypassed using the right IMA, and then the diagonal was bypassed using the left IMA. The coronary arteries was very thin and easy to detach. After ascertaining no leakage, the surgery was completed.
She recovered without complications. Cefazoline, 2 g per day, was given until the postoperative day 7. One-week after the surgery her steroid (predonisolone 20 mg per day) was resumed to control activity of Behcet's disease because there was no sign of infection at that time. No other immunosuppressive agents were added because her Behcet phenotype was only the vascular type and her inflammatory activity had been well controlled by predonisolone alone. One-month after the surgery
a coronary angiogram was performed, which revealed patent grafts and no anastomotic complication (Figs 1, 2, and 3).
The pathology of her mammary artery was consistent with vasculitis. She has been free from angina since the surgery.
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Fig 1. Postoperative multidetector computed tomography revealed patent bilateral mammary arteries without anastomotic complication. The arrows indicate the sites of anastomosis.
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Fig 2. Postoperative coronary angiogram illustrates patent right internal mammary artery graft to left anterior descending artery.
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Fig 3. Postoperative coronary angiogram demonstrates patent left internal mammary artery graft to the first diagonal artery.
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Comment
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Behcet disease is a systemic, generalized, chronic, inflammatory disease characterized by oral aphtha, genital ulcers, and ocular lesions. Cardiac involvement is seen in 5% to 10% of Behcet disease [1] and it may present as coronary arteritis, myocardial infarction, conduction disturbance, or aortic regurgitaion [2, 3]. Coronary aneurysms are more frequent than the stenotic lesions and coronary artery disease in Behcet disease is extremely uncommon. Coronary occlusion may be caused by fibrous intimal thickening secondary to the local vasculitis. Anastomotic pseudoaneurysm is a common complication and it is crucial to avoid it when treating Behcet coronary disease. Also, graft occlusion is not uncommon in case of vein grafts [4]. To avoid the aortic manipulation, OPCAB is a decent surgical modality nowadays and this report is the first successful report of OPCAB for Behcet disease [5]. In this patient, instent stenosis at stented coronary and active Behcet disease warranted off-pump, beating, aorta-non-touch, in situ grafting. Technically, because the Behcet mammary and coronary artery were very easy to dissect and detach, even though steroid was given preoperatively, fine handling and swift stiching were thought to be important to complete the bypass. We used 8–0 Prolene (Ethicon, Sommerville, NJ) for the stiches and put the sutures in with a single parachute without intraluminal shunt. Though the postoperative coronary angiogram revealed no anastomotic lesions, meticulous outpatient follow-up is important for detection of late aneurysmal formation because the puncture site itself can be a source for pseudoaneyrysm formation. We are now following-up her by periodical latest multidetector CT scan, which is less invasive, does not require a puncture to the artery, and is more informative than angiogram and magnetic resonace imaging. Also, activity of the inflammation should be monitored and steroid dose shall be tailored according to it in order to attain good long-term result of Behcet coronary surgery.
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References
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- Hirose H., Takagi M., Noguchi M., et al. Coronary revascularization and abdominal aortic aneurysm repair in a patient with Behcet's disease. J Cardiovasc Surg 1998;39:751-755.[Medline]
- Ando M., Kosakai Y., Okita Y., Nakano K., Kitamura S. Surgical treatment of Behcet's disease involving aortic regurgitaion. Ann Thorac Surg 1999;68:2136-2140.[Abstract/Free Full Text]
- Schiff S., Moffatt R. Acute myocardial infarction and recurrent ventricular arrhythmias in Behcet's syndrome. Am Heart J 1982;103:438-440.[Medline]
- Suzuki A., Amano J., Tanaka H., Sakamoto T., Sunamori M. Surgical consideration of aortitis involving the aortic root. Circulation 1989;80(Suppl I):I-222-232.[Medline]
- Ipek G., Omeroglu S.N., Mansuroglu D., Kirali K., Uzun K., Sismanoglu M. Coronary artery bypass grafting in a 26-year-old man with total occlusion of the left main coronary artery related to Behcet disease. J Thorac Cardiovasc Surg 2001;122:1247-1249.[Free Full Text]
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Abstract
Introduction
