Ann Thorac Surg 2004;77:2186-2188
© 2004 The Society of Thoracic Surgeons
Case report
Off-pump coronary artery bypass in patients with Takayasu's disease
Atsushi Yamaguchi, MD, PhDa*,
Hidehito Endo, MDa,
Hideo Adachi, MD, PhDa,
Koji Kawahito, MD, PhDa,
Takashi Ino, MD, PhDa
a Department of Cardiovascular Surgery, Omiya Medical Center, Jichi Medical School, Saitama, Japan
Accepted for publication June 13, 2003.
* Address reprint requests to Dr Yamaguchi, 1-847, Amanuma, Omiya-ku, Saitama, 330-8503, Japan
e-mail: yamaatsu{at}omiya.jichi.ac.jp
 |
Abstract
|
|---|
We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease in which severe angina was successfully relieved by off-pump coronary artery bypass grafting. In one case, visceral arteries such as the right gastroepiploic artery, the superior mesenteric artery, and the splenic artery were used as proximal blood sources of saphenous vein grafts. In another case, an aortic connector system was employed for proximal anastomoses of saphenous vein grafts. The use of off-pump coronary artery bypass grafting techniques should be considered in surgical coronary revascularization in patients with Takayasu's disease, thus leading to wide-spreading indication for the surgery.
|
Introduction
|
|---|
Takayasu's disease affects the aorta and its major branches, including coronary arteries, some of which may require coronary artery bypass grafting [1]. However, calcification of the aorta affected by Takayasu's disease often makes proximal anastomosis of a vein graft very difficult. In addition, because the major branches of the aortic arch are also frequently affected by it, the internal mammary arteries are unsuitable for use in coronary artery bypass. The disease very often makes impossible the use of a cardiopulmonary bypass system because of no sites for an arterial cannula. We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease who were successfully relieved by off-pump coronary artery bypass grafting (OPCAB).
|
Case reports
|
|---|
Patient 1
A 60-year-old woman with severe chest pain was diagnosed as having Takayasu's disease upon finding a significant difference in blood pressure between upper and lower extremities (70/50 vs 180/90 mm Hg). The computed tomography and magnetic resonance image (MRI) of the great vessels showed heavy calcification of the entire thoracic aorta with occlusion of both subclavian arteries and stenosis of the right carotid (Fig 1).
The coronary angiogram (CAG) revealed a significant lesion with 99% stenosis in the left main coronary artery and 75% ostial stenosis of the right coronary artery. Intraoperative examination revealed that entire wall of the ascending aorta had severe calcification considered to be unsuitable for arterial cannulation or aortic clamping. Two saphenous vein grafts were anastomosed to the splenic artery and the superior mesenteric artery (SMA) for proximal sources. The distal ends of the vein grafts then were anastomosed to the left anterior descending artery and posterolateral branch using the OPCAB technique (Fig 2) using a cardiac tissue stabilizer (Axius off-pump system, Guidant Co, Indianapolis, IN).
Thereafter, the right gastroepiploic artery was anastomosed to the posterior descending branch of the right coronary artery.
View larger version (79K):
[in this window]
[in a new window]
|
Fig 1. (Top) The computed tomography reveals heavy calcification of the entire thoracic aorta. (Bottom) The MRI of the aortic arch and its branch vessels shows occlusion of both subclavian arteries and stenoses of the right carotid.
|
|
View larger version (153K):
[in this window]
[in a new window]
|
Fig 2. The postoperative coronary angiogram shows a functioning saphenous vein bypass from the splenic artery to the left anterior descending artery (left upper), a bypass from the superior mesenteric artery to the posterolateral branch (right upper), and bypasses from the aorta to the left anterior descending artery (left lower) and the obtuse marginal artery (right lower). (LAD = left anterior descending artery; OM = obtuse marginal branch; PL = posterolateral branch; SVG = saphenous vein graft.)
|
|
Patient 2
A 60-year-old woman with chest pain was diagnosed as having Takayasu's disease upon finding a significant difference in blood pressure between upper and lower extremities (110/80 vs 200/90 mm Hg). The MRI showed occlusion of the major branch vessels of the aortic arch. The CAG revealed a significant lesion with 75% stenosis in the left main coronary artery. At the operation, the wall of the ascending aorta was evaluated using an epiaortic echography. Only 30 x 20 mm of a small area in the aorta was free from calcification and considered to be suitable for employing the aortic connector system (Symmetry aortic connector system, St. Jude Medical Anastomotic Technology Group, Minneapolis, MN). Two saphenous vein grafts were attached to the ascending aorta using the connectors. The distal ends of the vein grafts then were anastomosed to the left anterior descending artery and the obtuse marginal branch by the OPCAB technique (Fig 2).
In both patients, the postoperative CAG showed all the grafts functioning 2 weeks after the operation (Fig 2). There were no postoperative cerebrovascular events or any other complications.
|
Comment
|
|---|
Abdominal visceral arteries including the SMA, splenic artery [2], and gastroduodenal artery [3] have been rarely reported to be used in reoperation or minimally invasive surgery, though long-term data have not been demonstrated. Employing OPCAB techniques made it easy to achieve coronary revascularization when the proximal source of the vein grafts was placed on the visceral arteries. However, the risk of late stenosis in the abdominal visceral arteries may occur during the late postoperative period as a result of exacerbation of the inflammatory processes affecting the abdominal aorta.
The aortic connector, which is employed for proximal anastomosis of a vein graft, is considered to have advantages especially in patients with the porcelain aorta. The use of the aortic connector may reduce postoperative cerebrovascular events [4], as the vein graft can be attached on the ascending aorta without aortic clamping. On the other hand, Eckstein and associates [4] reported an intraoperative device failure, defined as leaking, that was due to using the aortic cutter at an angle different from 90 degrees, leading to a small intimal flap. The ascending aorta must be evaluated carefully using an epiaortic echography so that proximal anastomosis is placed in an area with the least potential for embolization or an intimal flap. Furthermore, the risk of graft stenosis around the connector may occur during the late postoperative period as a result of exacerbation of the inflammatory processes affecting the aorta [5]. Adequate follow-up is necessary, because early patency of vein grafts that were anastomosed using the aortic connectors in patients with regular atherosclerotic disease has just been reported [6].
The use of saphenous vein grafts combined with OPCAB techniques should be considered in surgical coronary revascularization for patients with Takayasu's disease, thus leading to wide-spreading indication for coronary surgery.
|
References
|
|---|
- Aufderheide A.C., Henke B.W., Parker E.H. Granulomatous coronary arteritis (Takayasu's disease). Arch Pathol Lab Med 1981;105:647-649.[Medline]
- Baumgartner F.J., Gheissari A., Panagiotides G.P., Capouya E.R., Declusin R.J., Yokoyama T. Off-pump obtuse marginal grafting with local stabilization: thoracotomy approach in reoperations. Ann Thorac Surg 1999;68:946-948.[Abstract/Free Full Text]
- Minakawa M., Takahashi K., Kondo N., Hatakeyama M., Kuga T., Oikawa S. Minimally invasive direct coronary artery bypass performed via diaphragmatic approach. Kyobu Geka 2001;54:288-292.[Medline]
- Eckstein F.S., Bonilla L.F., Englberger L., et al. Minimizing aortic manipulation during OPCAB using the symmetry aortic connector system for proximal vein graft anstomoses. Ann Thorac Surg 2001;72(Suppl):995-998.
- Cipriano P.R., Silverman J.F., Perlroth M.G., Griepp R.B., Wexler L. Coronary arterial narrowing in Takayasu's aortitis. Am J Cardiol 1977;39:744-750.[Medline]
- Wiklund L., Bugge M., Berglin E. Angiographic results after the use of a sutureless aortic connector for proximal vein graft anastomoses. Ann Thorac Surg 2002;73:1993-1994.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
A. Korach, P. Menon, and O. M. Shapira
Patch Aortoplasty for Proximal Anastomosis of Coronary Artery Bypass Grafts in Patients With Complex Aortic Pathology
Ann. Thorac. Surg.,
March 1, 2008;
85(3):
1108 - 1109.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Iino, S. Tomita, K. Higashidani, T. Ujiie, S. Arai, and G. Watanabe
Successful Coronary Revascularization Using the PAS-Port System in a Patient With Takayasu's Arteritis and Behcet's Disease
Ann. Thorac. Surg.,
November 1, 2006;
82(5):
1889 - 1891.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Takahashi, K. Daitoku, M. Minakawa, N. Kondo, K. Naito, and S. Oikawa
Coronary artery bypass grafting using an abdominal artery as an inflow.
Ann. Thorac. Surg.,
July 1, 2006;
82(1):
69 - 73.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
