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J Thorac Cardiovasc Surg 1995;109:178-179
© 1995 Mosby, Inc.

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Use of an intraluminal shunt to repair a coronary bypass graft injury during resternotomy

Zurich, Switzerland

From the Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland.

In recent years, there has been an increase in the number of patients who are subjected to second cardiac procedures for correction of congenital heart defects, valve problems, and repeat coronary artery revascularization. Catastrophic hemorrhage is a rare complication that may occur while the sternum is being reopened. The most frequent causes include tears of the right ventricle and lesions of previous coronary bypass grafts; less common are bleeding from ascending aortic aneurysms or tears in the right atrium.

In 1985, a 66-year old patient had undergone an aortic valve replacement with a Capentier-Edwards bioprosthesis (Baxter Healthcare Corp, Edwards Div., Santa Ana, Calif.) and a saphenous vein graft to the circumflex artery with jump anastomoses to an intermediate branch, the first diagonal branch, and the left anterior descending artery. Postoperative recovery was uneventful, and the patient felt well until 1992. At this time, the patient reported having exertional dyspnea and increasing weariness. A cardiologic examination was performed and transthoracic echocardiography demonstrated degeneration of the bioprosthesis, resulting in moderate aortic stenosis (mean systolic gradient 45 mm Hg, peak-to-peak gradient 70 mm Hg, and a valve opening area of 0.8 cm² ). Left ventricular function was severely depressed with an ejection fraction of 0.26. At coronary angiography, each coronary–saphenous vein anastomosis was patent but some atherosclerotic changes were described in the proximal part of the graft.

A median sternotomy was performed with the oscillating saw; during preparation and mobilization of the sternal borders, the aneurysmal proximal part of the saphenous vein bypass graft, which was completely adherent to the sternum, was damaged. Because of the important myocardial area supplied by the graft, it could not have been occluded either with clamps or with Fogarty catheters. Therefore we elected to insert a small intraluminal silicone shunt, which is usually used during carotid endarterectomy to preserve homolateral cerebral perfusion, as a bridge between the proximal and distal vein graft segments and secured it with tourniquets (Fig. 1). With this technical assistance, the bleeding could be easily controlled and no electrocardiographic changes or hemodynamic alterations appeared.

View larger version (68K): [in this window] [in a new window]   Fig. 1. Insertion of a silicone stent, secured with tourniquets, between the vein graft segments.

View larger version (64K): [in this window] [in a new window]   Fig. 2. A short vein graft was used to repair the lesion and exclude the aneurysmal segment.

Various methods have been proposed in the past for sternal reentry. Femoral artery cannulation can be used when the right ventricle seems to be adherent to the sternum, when there is strong suspicion that the internal mammary artery or a venous bypass graft is crossing the midline, when the chest has been reconstructed by muscle flaps, and when an ascending aortic aneurysm is present. ^2,3

When progressive coronary artery disease necessitates a second operation with a new graft to the anterior and posterolateral walls of the left ventricle, thoractomy may allow excellent exposure of the left anterior descending branch and obtuse marginal branches. Proximal anastomoses are then performed to the descending aorta. ⁴

In the case presented here, the use of an intraluminal shunt allowed us to control the bleeding and maintain a sufficient perfusion to prevent myocardial ischemia; furthermore, it allowed controlled, unhurried institution of cardiopulmonary bypass. This elegant method, preventing bleeding and myocardial ischemia, prompted us to review the literature, and we found only one similar description. ⁵

Footnotes

J THORAC CARDIOVASC SURG 1995;109:178-9

References

1. Lytle BW, Loop FD. Coronary reoperations. Surg Clin North Am 1988;68:559-80.[Medline]
   
2. Mahfood S, Higgins TL, Loop FD. Management of complications related to coronary artery bypass surgery. In: Waldhausen J, Orringer M, eds. Complications in cardiothoracic surgery, St Louis: Mosby, 1991:265-80.
   
3. Loop FD. Catastrophic hemorrhage during sternal reentry. Ann Thorac Surg 1984;37:271-3.[Medline]
   
4. Burlingame MW, Bonchek LI, Vazales BE. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508-11.[Abstract]
   
5. Robison RJ, Brown JW, Deschner WP, King RD. Intraluminal shunting of operatively severely injured aortocoronary saphenous vein grafts. Ann Thorac Surg 1986;42:475-6.[Abstract]
   

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