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J Thorac Cardiovasc Surg 2003;125:958-960
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Cardiovascular Surgery Department, University Hospital CHU Caen, France.
Received for publication July 25, 2002. Accepted for publication Aug 15, 2002. Address for reprints: Gérard Babatasi, MD, PhD, Cardiovascular Surgery Department, University Hospital, Avenue Côte de Nacre, CHU Caen, 14033 Caen cedex, France (E-mail: babatasi-g{at}chu-caen.fr).
Coronary artery disease (CAD) and low ejection fraction are the most important risk factors for morbidity and mortality in patients undergoing abdominal aneurysm repair. Prior revascularization techniques have helped to decrease the risk of cardiac-related adverse events. There is, however, a subgroup of patients having both severe CAD and an acutely expanding or ruptured aneurysm that represent a therapeutic challenge.
Clinical summary
The patient was a 62-year-old man with increasing abdominal pain with posterior radiation. Computed tomographic scanning demonstrated an 8.9-cm aneurysm and a perianeurysmal hematoma (Figure 1). The patient had a history of angina. Electrocardiography (ECG) demonstrated signs of myocardial ischemia. The hemoglobin level was 11.7 g initially and decreased to 9.4 g in 3 hours. Coronary angiography (Figure 1
) demonstrated left main coronary artery stenosis (>75%). Ejection fraction was impaired (45%). Although median sternotomy was first performed, the left internal thoracic artery (LITA) and radial artery were harvested simultaneously. No vein graft was available. Heparin (200 IU/kg) was administered. Heart exposure and stabilization was achieved by using the Cohn immobilizer (Genzyme Corporation, Cambridge, Mass). The LITA was first implanted to the left anterior descending artery. The circumflex artery was exposed in the atrioventricular groove, and the anastomosis was performed with the radial artery. The radial artery was implanted in the LITA (T graft and end to side) to limit the potential risk of embolic catastrophe associated with crossclamping the severely diseased aorta. The chest was closed, and laparotomy was then performed. An extensive hematoma was detected on the retroperitoneal area. A standard graft inclusion technique with a collagen-coated Dacron bifurcated (18/9) graft (Hemashield, Meadox Medicals, Inc, Oakland, NJ) was performed. The length of the total procedure was 5 hours. Transfusions included 4 units of blood, 400 mL of fresh plasma, and 1 unit of platelets. ECG results returned to normal levels immediately after the cardiac procedure. The patient was extubated the day after the procedure. The patient was symptom free without any medication at 1 year of follow-up.
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Surgical mortality from abdominal aortic aneurysm (AAA) repair has decreased over the past 20 years because of improvements in anesthetic technique, better intraoperative hemodynamic control caused by careful intensive monitoring, improved postoperative care, and also improvement in medical therapy (including coronary artery bypass grafting [CABG] or angioplasty). CAD is one of the leading causes of perioperative mortality. 1 In a subset of patients with severe CAD, it was shown that coronary revascularization clearly reduces the risk of perioperative myocardial infarction at subsequent AAA repair. 2 Operative mortality in this subgroup is between 12% and 25%. 3 Treatment options available are combined CABG and AAA repair or staged repair of the AAA after CABG. The major drawback of the staged procedure is postoperative rupture of the AAA after CABG. An increase in systemic elastase activity after nonvascular surgery was demonstrated 3 and probably might contribute to the leakage or rupture of the AAA after any surgical treatment. Increased elastase levels detected in on-pump patients (>10-fold) linked to the acute lung injury increase the risk for rupture of the AAA in patients recovering from CABG. Most surgical teams have clearly demonstrated the multiple advantages of combined strategy by decreasing the duration of anesthesia, lessening postoperative complications, reducing the cost, and alleviating the distress of a second procedure. 1 A high incidence (29%) of perioperative cardiac complications has been reported in that population. 1 Because of contraindication as a result of acute rupture of the abdominal aneurysm with the potential hemorrhagic risk of antiplatelet drugs, stent angioplasty was not planned in our patient. The combined operation is currently almost exclusively performed with continuing cardiopulmonary bypass during aortic surgery. Recent reports have shown a decrease in morbidity in the off-pump CABG group, particularly in elderly and high-risk populations. 4,5 Avoiding cardiopulmonary bypass in patients with acute rupture of the AAA had several advantages, such as minimal inflammatory response, better myocardial protection, reduced risk of stroke because of underperfusion, reduction of emboli from aortic crossclamping, and reduction of bleeding-related complications. A few teams 6 have gained experience in the use of endovascular grafts for ruptured aortoiliac aneurysms. Use of endovascular grafts required preoperative management, including hypotensive hemostasis by minimizing fluid resuscitation. Our patient had myocardial ischemia on ECG and left main stenosis on angiography with a low ejection fraction, and therefore we did not plan endovascular grafting.
Standard open repair allowed the evacuation of the huge hematoma in the retroperitoneal space that was responsible for compartment syndrome leading to ischemic colitis.
Our experience is limited to one successful case, and no definitive conclusions can be reached concerning the choice of 1-stage surgery combining off-pump CABG and open repair of the ruptured aneurysm.
References
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