Ann Thorac Surg 2005;79:e9-e10
© 2005 The Society of Thoracic Surgeons
Case report
Late Complication of Aortocoronary Venous Bypass Grafting
Gerhard A. Kalweit, MD*,
Hanno Huwer, MD,
Salah El Dsoki,
Helmut Isringhaus, MD
Department of Cardiothoracic Surgery, Voelklingen Heart Centre, Voelklingen/Saar, Germany
Accepted for publication July 19, 2004.
* Address reprint requests to Dr Kalweit, Department of Cardiothoracic Surgery, Voelklingen Heart Centre, D-66333 Voelklingen/Saar, Germany (E-mail: kalweit.vk{at}shg-kliniken.de).
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Abstract
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The problem of symptomatic, diffuse coronary artery disease not amenable to the established methods of medical or revascularizing therapies remains unsolved. Aortocoronary venous bypass grafting is a rare treatment modality bearing considerable risks. We report on a further complication of the method.
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Introduction
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So-called retrovenous or aortocoronary venous revascularization for diffuse coronary arteriosclerosis was mainly a topic under discussion in the 1960s and 1970s of the last century [1]. Following experimental evaluation and clinical application, a number of early and midterm complications were recognized. In rare cases with diffuse coronary sclerosis or coronary arteries not identifiable and not amenable to antegrade perfusion, the method is still occasionally used [2]. We saw a very late complication of the method.
A 64-year-old male with a two-vessel disease had elective coronary bypass surgery in May 1994. He received three saphenous vein bypasses: one to the left anterior descending artery (LAD); one to a first marginal branch; and one to the supply area of a second marginal branch. A diffuse sclerosis of the respective coronary artery was explicitely mentioned but no further irregularities with respect to the distal anastomosis. The quality of all vein grafts was described as "good." The postoperative course was regular and he was discharged after 8 days. Until 2003 he did well except slowly increasing premature dyspnea during special efforts. He assigned this to his age. In May 2003 he experienced a global cardiac decompensation in the course of pneumonia and subsequently underwent cardiologic examination. Coronary arteriography showed an occluded bypass to the first marginal branch, an open and intact graft to the LAD, and surprisingly a dilated vein graft to an aneurysmatically widened posterior vein of the left ventricle (Fig 1). At right heart catheterization pulmonary hypertension with a systolic pressure of 46 mm Hg at rest was confirmed. A left-to-right shunt volume of 34% was oxymetrically calculated. In the catheterization report from 1994 systolic pulmonary artery pressure was 28 mm Hg and there was no evidence for a left-to-right shunt. In the operation report it is not explicitely described if the aortocoronary-vein bypass was made intentionally, but because the diffuse coronary sclerosis in the respective artery is mentioned, this can be assumed.
Regarding the shunt volume, the pulmonary hypertension, the aneurysmatic degeneration of graft and coronary veins and the history of the patient, operative closure of the graft was indicated. No repeat revascularization was planned. The small marginal branches showed a diffuse sclerosis, the LAD-graft was free from degeneration and the right coronary artery had no significant stenosis. A left-sided thoracotomy was performed, the pericardium was opened, and the easily visible, dilated vein graft was occluded with a running suture at its origin from the aorta. The postoperative course was uncomplicated, and the patient could be discharged after 6 days. Six months later he is doing well and his physical capability has markedly improved.
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Comment
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Myocardial ischemia caused by diffuse coronary artery sclerosis that remains symptomatic despite best medical therapy, and is not amenable to interventional or surgical revascularization, remains an unsolved problem. Transmyocardial laser revascularization or the application of angiogenic growth factors as latest adjunctive therapies do not reliably restore a sufficient blood flow to the myocardium.
Retrograde coronary perfusion seemed to be another attractive approach. After experimental evaluation it was proposed for clinical use in two ways: as catheter perfusion through the coronary sinus for emergency treatment of acute ischemia [3]; as venous retroperfusion of ischemic myocardial areas not suitable for antegrade bypass grafting due to diffuse coronary artery sclerosis [1]. The inadvertent creation of aortocoronary venous anastomoses has been repeatedly reported [4], mostly when early or late complications of the procedure were recognized.
In the planned cases unexpected complications are not uncommon, lethal early myocardial hemorrhage being the most serious [5]. Medium-term complications are intimal fibrosis, luminal stenosis or obstruction of the retroperfused veins [6]. Anatomical anomalies of the veins leading to an unexpected distribution of blood may cast additional doubt on its value.
In our case two coincident complications took place. Firstly, a rare aneurysmatic degeneration of the saphenous vein with a diameter of roughly 2 cm over the whole length of the graft developed. Secondly, a concomittent dilatation of the bypassed vein developed, though an arterialisation or a closure of the vein would be more likely [6]. The arteriovenous pressure mismatch led to a shunt volume of 34% with subsequent pulmonary hypertension at rest. This caused congestive heart failure in the course of a pneumonia. No coronary arterial blood supply of the myocardium was seen at angiography of the aortocoronary vein bypass.
In two similar reported cases a moderate elevation of pulmonary blood flow of 23% and 13% was measured but no pulmonary hypertension. The patients were without clinical symptoms [7]. In fact, they were evaluated 5 and 12 months postoperatively and no resembling aneurysmatical degeneration of the vein graft nor the coronary vein was mentioned.
Peculiarities of the venous system [8] or a lacking proximal suture occlusion of the respective vein may have facilitated the direct drainage of bypass blood towards the coronary venous sinus.
In conclusion, we believe that the concept of retrovenous perfusion of the myocardium should be completely abolished. When the known early complications do not occur, one must be aware of late and very late adverse events.
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References
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- Hochberg MS, Austen WG. Selective retrograde coronary venous perfusion Ann Thorac Surg 1980;29:578.[Abstract]
- Kulik A, Borger MA, Scully HE. Aortovenous bypass graft to the posterior left ventricle in absence of an identifiable coronary artery Ann Thorac Surg 2004;78:313-314.[Abstract/Free Full Text]
- Gore JM, Weiner BH, Benotti JR, et al. Preliminary experience with synchronized coronary sinus retroperfusion in humans Circulation 1986;74:381-388.[Abstract/Free Full Text]
- Starling MR, Groves BM, Frost D, Toon R, Arom KV. Aorto-coronary vein fistulaA complication of coronary artery bypass graft surgery. Chest 1981;79:64-68.[Abstract/Free Full Text]
- Tickman RJ, Gravanis MB, Hunter SB. Potential risks in retrovenous revascularization of the myocardium Hum Pathol 1989;20:784-786.[Medline]
- Marco JD, Hahn JW, Barner HB, et al. Coronary venous arterialisation: acute hemodynamic, metabolic and chronic anatomical observations Ann Thorac Surg 1977;23:449-454.[Abstract]
- Marin-Neto JA, Simoes MV, Vicente WV. Acquired aorto-coronary vein fistula after bypass graft surgery: report of two cases with long-term follow-up Int J Cardiol 1991;30:121-124.[Medline]
- von Luedinghausen M. The venous drainage of the human myocardium Adv Anat Embryol Cell Biol 2003;168:1-104.
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Abstract
Introduction
