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J Thorac Cardiovasc Surg 2005;130:938-940
© 2005 The American Association for Thoracic Surgery

Brief Communication

Intractable postoperative internal thoracic artery spasm managed with angiographic intraluminal papaverine

Sir Charles Gairdner Hospital (SCGH, Perth, Australia), Department of Cardiothoracic Surgery, Perth, Australia.

Received for publication March 21, 2005; accepted for publication April 5, 2005.

^_* Address for reprints: Lucas H. A. Sanders FCS(SA), MD, Sir Charles Gairdner Hospital (SCGH, Perth, Australia), Department of Cardiothoracic Surgery, Hospital Ave, Nedlands, Perth, WA6007, Australia (Email: lucmedi{at}hotmail.com).

Spasm of the left internal thoracic artery (LITA) and native coronary artery in the immediate postoperative period represents a life-threatening complication. Successful treatment with papaverine injected intraluminally by angiographic catheterization has not previously been reported. We present such a case.

Clinical Summary

An 84-year-old woman underwent sequential grafting of the first diagonal and left anterior descending coronary artery (LAD) with a pedicled, nonskeletonized left internal thoracic artery (LITA). The procedure was performed without the aid of cardiopulmonary bypass with an Octopus IV Tissue Stabilizer (Medtronic, Inc, Minneapolis, Minn). Preoperative angiography revealed sequential 50% and 70% LAD and 90% first diagonal stenoses. The right coronary artery was blocked with a small distal vessel to an inferior infarct, well collateralized from the left. Left ventricular function was mildly impaired because of inferior akinesia. Interestingly, left ventriculography revealed hypercontractility in its midportion, resulting in a double-chamber–like image. The patient's history included hypertension, hypercholesterolemia, and peptic ulcer disease. She had stopped smoking 10 years previously. Medications included atenolol, pantoprazole, isosorbide mononitrate, indapamide, ramipril, lercanidipine, pravastatin, nicorandil and clopidogrel (discontinued 3 days before the operation).

At surgery the mid-LAD portion was intramuscular. After dissection, both the distal LITA and LAD were noted to be in spasm. Papaverine was applied topically (20 mL of 3:1 normal saline solution sprayed with a 26-gauge needle) and intraluminally (20-gauge cannula), resulting in good blood flow from the LITA. The LITA was wrapped in a papaverine-soaked gauze until it was prepared for anastomosis. The operation was performed without incident, and hemodynamics and electrocardiogram were initially normal.

Ventricular fibrillation developed 15 minutes after the patient's arrival in the intensive care unit. After 60 minutes, the patient was stabilized with high doses of epinephrine to maintain arterial blood pressure. Electrocardiography showed signs of inferior ischemia. The patient was transferred to the angiography suite.

Emergency coronary and LITA angiography revealed severe spasm in the LITA segment between the anastomoses to the diagonal and to the LAD (Figure 1). Glyceryl trinitrate injected intraluminally into the LITA had no effect. In contrast, direct angiographic catheter injection of papaverine (3 mg/mL normal saline solution) into the LITA lumen resulted in relief of spasm and significant dilatation of the LITA (Figure 2) as well as the native coronary arteries both distal and proximal to the LITA anastomoses. Epinephrine requirement could be reduced immediately. Amlodipine was commenced. The postoperative course was complicated by atrial fibrillation, pleural effusion, confusion, and hallucinations. The patient was discharged home, in sinus rhythm, 11 days postoperatively with a regimen of amlodipine and amiodarone. Five weeks postoperatively, she appeared well and without angina.

View larger version (157K): [in this window] [in a new window]   Figure 1. Pretreatment angiography shows areas of spasm in the LITA.

View larger version (161K): [in this window] [in a new window]   Figure 2. Posttreatment angiography shows relief of LITA spasm and dilatation of native coronary arteries.

Reports of spasm of the LITA and native coronary artery in the immediate postoperative period are marked by an intractable and lethal course. ^1-3 Severe LITA spasm presents with acute hemodynamic collapse, anatomic segmental ST-segment elevation, and ventricular fibrillation.

The mechanism of perioperative vascular spasm is multifactorial. Previous reports have implicated local manipulation, ¹ -adrenergic activity, ¹ high blood pH, ¹ low body temperature, ¹ increased platelet release of vasoconstrictive factors, ¹ increased vasopressin levels, ¹ histamine release, ¹ local increased potassium levels, ¹ possible rebound vasoconstriction after abrupt withdrawal of calcium-channel blockade, ¹ low PaCO ₂, ⁴ smoking, ⁴ and use of the distal section of LITA. ⁵ Measures that aid in the prevention of postoperative spasm are continued intraoperative use of calcium-channel blockers ⁴ and intraoperative local application of vasodilators (nitroglycerin ⁴ and papaverine).

Management of postoperative LITA or native coronary artery spasm is challenging. Causative factors should be corrected where possible. The experience with our case led us to believe that a high arterial blood pressure must be maintained for LITA and coronary perfusion. Which inotropic or vasoconstrictive agent is best suited has not been determined. Epinephrine was used successfully in our case. In the event of acute refractory hemodynamic collapse in the immediate postoperative period, Sarabu and colleagues ¹ have recommended immediate reopening. Spasm can then be treated with topical papaverine and additional grafting. Sarabu and colleagues ¹ and Paterson and associates ² have suggested infusion of intraluminal vasodilators for postoperative vasospasm (LITA and native coronary spasm). Our patient was successfully treated with papaverine injected intraluminally through angiographic catheterization. This has not been reported before. In our search of the English literature, only one case report of internal thoracic artery spasm refractory to angiographic intraluminal injection with nitroglycerin was found. ³ In our case, intraluminal nitroglycerin was ineffective in relieving the LITA spasm. Papaverine inhibits oxidative phosphorylation but may cause vasodilatation by inhibiting phosphodiesterase, which prevents breakdown of cyclic nucleotides. Angiographic intraluminal papaverine prevents the complications of surgical delay, reoperation, graft manipulation, external graft injection of vasodilators, repeated use of cardiopulmonary bypass, and additional grafting.

References

1. Sarabu MR, McClung JA, Fass A, Reed GE. Early postoperative spasm in left internal mammary artery bypass grafts. Ann Thorac Surg. 1987;44:199-200.[Abstract]
   
2. Paterson HS, Jones MW, Baird DK, Hughes CF. Lethal postoperative coronary artery spasm. Ann Thorac Surg. 1998;65:1571-1573.[Abstract/Free Full Text]
   
3. Kitamura H, Nakayama K, Kitano T. A case of refractory spasm of multiple coronary arteries and left internal thoracic artery graft following off-pump CABG. Kyobu Geka. 2001;54:1103-1106.[Medline]
   
4. Yoshida S, Sakuma K, Yokoyama H, Oda K. [Coronary vasospasm during off-pump coronary artery bypass grafting: report of two cases] Japanese. Kyobu Geka. 2003;56:585-588.[Medline]
   
5. He GW. Contractility of the human internal mammary artery at the distal section increases toward the end. Emphasis on not using the end of the internal mammary artery for grafting. J Thorac Cardiovasc Surg. 1993;106:406-411.[Abstract]
   

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