Ann Thorac Surg 2005;80:1096-1098
© 2005 The Society of Thoracic Surgeons
Case report
Combined Myocardial and Mesenteric Surgical Revascularization
Michel Kindo, MD,
Arnaud Mommerot, MD,
Guillaume Maxant, MD,
Georges Giron, MD,
Mario Arguello, MD,
Bernard Eisenmann, MD
*
Department of Cardiovascular Surgery, Hôpital Civil, Strasbourg, France
Accepted for publication March 15, 2004.
* Address reprint requests to Dr Eisenmann, 1 Place de l’Hôpital, BP 426, 67091 Strasbourg, Cedex, France (Email: bernard.eisenmann{at}chru-strasbourg.fr).
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Abstract
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Chronic mesenteric ischemia is a rare disorder that is frequently associated with coronary artery disease. Myocardial ischemia is a leading cause of morbidity and mortality after revascularization of the splanchnic arteries. The optimal treatment of concomitant chronic mesenteric ischemia and myocardial ischemia is unknown. We report a case of this condition in a 57-year-old man who required revascularization of both the left anterior descending coronary and superior mesenteric arteries with venous grafts anastomosed to the ascending aorta. The patient remains asymptomatic after a 3-year follow-up. This good result argues for one-stage combined myocardial and mesenteric revascularization in selected symptomatic patients.
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Introduction
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Arteriosclerosis is a multifocal disease that in some cases affects both the coronary and mesenteric arteries. The incidence of this combined presentation is not well established. However, it is known that the incidence of mesenteric ischemia after cardiac operations is low but its mortality rate high [1, 2], that chronic mesenteric ischemia (CMI) is often associated with coronary artery disease (CAD) [3], and that myocardial ischemia is the leading cause of morbidity and mortality after surgical mesenteric revascularization [4]. No specific recommendations have yet been established for the treatment of concomitant CMI and myocardial ischemia. We report a case of severe CMI associated with symptomatic CAD in which the anatomic distribution of arteriosclerotic lesions necessitated revascularization of the left anterior descending coronary artery (LAD) and superior mesenteric artery (SMA) with venous grafts anastomosed to the ascending aorta.
A 57-year-old man was referred to Hôpital Civil for treatment of CMI. Thirteen years before, he had undergone coronary artery bypass grafting (CABG) of the left internal mammary artery to the LAD. In the 6 months before referral to us, the patient had complained of postprandial abdominal pain and weight loss.
Color Doppler ultrasonography revealed diffuse calcification of the abdominal aorta, significant stenotic lesions in the inferior mesenteric and celiac arteries, short occlusion of the SMA origin with continuous flow below, and occlusions of left subclavian and both iliac arteries. These observations were confirmed by computed tomography (CT) and angiography. In particular, CT revealed dense calcifications of the abdominal aorta (Fig 1A) that appeared to extend to the descending thoracic aorta and both iliac arteries. Holter electrocardiography revealed symptomatic ischemic episodes. Coronary angiography revealed significant stenotic lesions in the circumflex and right coronary arteries that were not amenable to revascularization because of the diffuse nature of the involvement in tiny vessels, significant stenosis of the proximal portion of the LAD, and occlusion of the previously placed left internal mammary artery graft. Ventriculography revealed an impaired left ventricular ejection fraction of 40%.
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Fig 1. (A) Preoperative computed tomography revealed dense calcifications of the distal descending thoracic aorta and abdominal aorta with a short occlusion of the superior mesenteric artery origin. (B) Patent venous graft from the ascending thoracic aorta to the superior mesenteric artery, as visualized by magnetic resonance imaging.
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The LAD and SMA were revascularized in a combined procedure. First, a median sternotomy was made, while right saphenous vein grafts were harvested simultaneously. Cardiopulmonary bypass was initiated with moderate hypothermia. A reverse saphenous vein graft was attached to the LAD. Then, after the aortic cross-clamp was released and the heart resumed beating, a proximal anastomosis to the ascending aorta was performed. The midline incision was extended down to the umbilicus. Abdominal exploration confirmed the presence of dense aortic calcifications extending to the distal descending thoracic aorta and both iliac arteries. Next, the SMA was dissected at the mesenteric root. A proximal anastomosis of the venous graft to the ascending aorta was performed. The venous graft was placed on the anterior face of the heart and passed through the diaphragm. Next, the left triangular ligament was sectioned, allowing the left lobe of the liver to recline backwards, and the venous graft was placed on the liver’s anterior face. The graft was then passed through the transverse mesocolon. Finally, a distal anastomosis to the middle portion of the SMA was performed.
The postoperative course was uneventful. After a 3-year follow-up, the patient remains asymptomatic. Magnetic resonance imaging and angiography have confirmed the patency of the venous graft from the ascending thoracic aorta to the SMA (Fig 1B).
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Comment
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CMI is rare, but its incidence is probably underestimated secondary to misdiagnosis. Surgical treatment of symptomatic CMI has a low operative mortality rate and produces good long-term relief of symptoms [3, 4]. Surgical techniques vary but none is clearly superior [3, 4]. Percutaneous transluminal angioplasty has produced results similar to those of surgery but with a higher incidence of symptom recurrence [5].
An estimated one third of patients who undergo surgical revascularization of the splanchnic circulation also have CAD, and myocardial ischemia is the most common cause of morbidity and mortality during their follow-up [3, 4]. However, the optimal treatment of concomitant CMI and CAD remains unclear. Though the incidence of mesenteric ischemia during on-pump CABG is low (0.6% to 3.7%), the associated mortality is high (13.9% to 100%) [1, 2]. Moreover, according to Musleh and colleagues [2], on-pump and off-pump CABG both pose the same risk of mesenteric complications. According to Eagle and colleagues, vascular surgery poses a greater risk of complications for patients with known CAD than it does for patients who have undergone a prior CABG, especially those with three-vessel CAD and low left ventricular ejection fraction [6].
In the present case, we performed a combined on-pump revascularization procedure to avoid destabilizing either the myocardial or mesenteric perfusions. Others had already demonstrated that one-stage combined surgery can be safely done, with acceptable morbidity and mortality, in the presence of concomitant CAD and either peripheral vascular disease or abdominal aorta aneurysm [7, 8]. One previously reported case of combined myocardial and mesenteric revascularization had a favorable immediate outcome [8]. However, the SMA graft in that case was prosthetic and the inflow was from the infrarenal aorta. In contrast, we used a venous graft instead of a prosthetic graft because of the length and tortuosity of the pathway from the ascending aorta to the SMA, and we used the ascending aorta for inflow to the SMA because of the diffuse extent of arteriosclerosis from the descending thoracic aorta to the iliac arteries. We also protected the cardiac and peripheral circulations from hemodynamic fluctuations after partial aortic clamping and unclamping by maintaining cardiopulmonary bypass support throughout the mesenteric revascularization procedure.
Outcome after mesenteric revascularization depends on the diffuse extent of arteriosclerosis, especially to the myocardial circulation. In the present case, our unique combination of mesenteric and myocardial revascularization in a one-stage procedure was dictated by the anatomic distribution of the arteriosclerotic lesions. Our excellent results argue for combined surgical revascularization in patients who exhibit symptoms of myocardial and mesenteric ischemia.
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References
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- Venkateswaran RV, Charman SC, Goddard M, Large SR. Lethal mesenteric ischaemia after cardiopulmonary bypassa common complication?. Eur J Cardiothorac Surg 2002;22:534-538.[Abstract/Free Full Text]
- Musleh GS, Patel NC, Grayson AD, et al. Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications Eur J Cardiothorac Surg 2003;23:170-174.[Abstract/Free Full Text]
- Mateo RB, O’Hara PJ, Hertzer NR, Mascha EJ, Beven EG, Krajewski LP. Elective surgical treatment of symptomatic chronic mesenteric occlusive diseaseearly results and late outcomes. J Vasc Surg 1999;29:821-831.[Medline]
- Park WM, Cherry Jr KJ, Chua HK, et al. Current results of open revascularization for chronic mesenteric ischemiaa standard for comparison. J Vasc Surg 2002;35:853-859.[Medline]
- Kasirajan K, O’Hara PJ, Gray BH, et al. Chronic mesenteric ischemiaopen surgery versus percutaneous angioplasty and stenting. J Vasc Surg 2001;33:63-71.[Medline]
- Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersch BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study Circulation 1997;96:1882-1887.[Abstract/Free Full Text]
- Mohr FW, Falk V, Autschbach R, et al. One-stage surgery of coronary arteries, and abdominal aorta in patients with impaired left ventricular function Circulation 1995;91:379-385.[Abstract/Free Full Text]
- Guler M, Balkanay M, Tataroglu C, Guzelmeric F, Isik O, Yakut C. Simultaneous surgical intervention to coronary artery disease, peripheral arterial disease and superior mesenteric artery stenosis J Cardiovasc Surg (Torino) 1999;40:587-590.[Medline]
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Abstract
Introduction
