Ann Thorac Surg 2004;78:316-319
© 2004 The Society of Thoracic Surgeons
Case report
Off-pump reduction aortoplasty and concomitant coronary artery bypass grafting
Sinan Arsan, MDa*
a Department of Cardiovascular Surgery, University of Maltepe, School of Medicine, Istanbul, Turkey
Accepted for publication June 13, 2003.
* Address reprint requests to Dr Arsan, 37 Ada Inci-1 Blok, D.29 Atasehir, 34758 Istanbul, Turkey
e-mail: arsans{at}ixir.com
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Abstract
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This report presents 4 off-pump reduction aortoplasty and concomitant coronary artery bypass grafting (CABG) cases. Severe left ventricular dysfunction, hemodialysis-dependent chronic renal failure, metastatic colon carcinoma, poor nutritional status, difficulties with early mobilization, and ascending aortic dilatation or aneurysm were the critical indications for off-pump reduction aortoplasty and concomitant CABG.
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Introduction
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In cases of ascending aortic aneurysms, the general consensus tends toward performing ascending aortic replacement rather than reinforcing the ascending aorta with external wrapping [1, 2]. An alternative method is reduction aortoplasty with or without external Dacron (DuPont, Wilmington, DE) tube support, as proposed by Robicsek [3].
I have performed 66 such cases with external wrapping. Because of severe cardiac or noncardiac diseases, 4 of these were performed without cardiopulmonary bypass (off pump) in the last 7 years. In this study, I report experiences regarding off-pump reduction aortoplasty and concomitant coronary artery bypass grafting (CABG).
See page 382
Between January 1996 and February 2003, an off-pump reduction aortoplasty and concomitant CABG procedure was performed on 4 patients. Data from the 4 patients were reviewed retrospectively. All patients had marked coronary artery stenosis and ascending aortic aneurysm or dilatation (Fig 1).
The first patient was a 67-year-old woman who had hemodialysis-dependent chronic renal failure, hypertension, obesity, and unstable angina pectoris. In consideration of the patient's hemodialysis-dependent chronic renal failure, age, and obesity, off-pump operation was selected to avoid cardiopulmonary bypass (CPB) and possible postoperative hemorrhage. The second patient was a 74-year-old male heavy smoker who had colon carcinoma, chronic obstructive pulmonary disease, and unstable angina pectoris. The nutritional status of the patient was poor, and off-pump operation was selected for early mobilization of the patient. The third patient was a 55-year-old man who had stable angina pectoris and severe left ventricular dysfunction (the ejection fraction of the left ventricle was 28%). Extracorporeal circulation and aortic cross-clamp might have been dangerous for the patient, and off-pump operation was selected. The fourth patient was a 74-year-old woman. Off-pump operation was selected because the patient's weight was 50 kg and her general condition was not good. Off-pump reduction aortoplasty and concomitant CABG was performed as a completely surgical preference in addition to those indications. Preoperative and operative data of the patients are shown in Table 1.
Median sternotomy was performed in all patients. The pericardium was opened longitudinally, and pericardial traction sutures were inserted. Heparin was given (2 mg/kg). The inferior and superior venae cavae were dissected from surrounding tissue to prevent kinking during cardiac manipulation. Distal coronary anastomosis was performed by simple traction sutures (a tissue stabilizer was not used). One polypropylene suture was used for each distal anastomosis. After distal anastomosis, single proximal anastomosis was performed to the brachiocephalic artery or sinotubular junction of the aorta (if suitable) by using a partial side clamp. If necessary, the other proximal anastomosis was performed to the first anastomosed vein graft (end to side). During side-clamping of the sinotubular junction of the aorta, systolic blood pressure was constantly kept at less than 100 mm Hg. The number of grafts each patient received was determined by the surgeon at the time of operation. Three patients were completely revascularized. Because cardiac manipulation was not tolerated by the second patient, circumflex artery revascularization could not be performed. In this patient, successful percutaneous transluminal balloon angioplasty and stent implantation was performed to the stenotic circumflex artery in the early postoperative period.
External wrapping with an external Dacron tube graft (30 mm) was performed after completion of the off-pump CABG. During external wrapping, systolic blood pressure was constantly kept at less than 90 mm Hg. If necessary, the inferior vena cava was cross-clamped transiently to keep the blood pressure at less than 90 mm Hg, especially during suture tying. The sandwich technique [4] with 5 or 6 U sutures was preferred for reduction aortoplasty. The external tube graft did not affect proximal anastomosis. The wrapping procedure required approximately 13 minutes.
From the first postoperative day onward, all patients started a regimen of lifelong treatment with aspirin, clopidogrel, or both. All patients had a rapid recovery.
The late postoperative course of the first patient was uneventful for cardiac-related problems. Unfortunately, after 4 years, the patient died of intracerebral hemorrhage, probably because of hypertensive crisis. This was confirmed by computerized tomography. The second patient was rehospitalized in the first postoperative month because of a colon operation, and he underwent a successful operation. The remainder of his postoperative course was uneventful. This patient was asymptomatic at 30 months after the operation. The third patient had mild dyspnea symptoms with effort at follow-up 23 months after the operation. The ejection fraction of the left ventricle was 35%, and thallium scintigraphy was normal. Finally, the late postoperative course of the fourth patient was completely uneventful. The patient was asymptomatic at follow-up 6 months after the operation.
After operation, control computerized tomography scans were performed on the third and fourth (Fig 2)
patients. Additionally, on the first patient, cerebral and thoracic computerized tomography scans were performed for precise diagnosis of the intracerebral hemorrhage. Only the second patient was followed up with echocardiography. Neither aortoplasty nor cardiac-related problems were encountered in any case.
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Fig 2. Postoperative computerized tomography scan of patient 4. (A) Suture line. (B) Size of the wrapped aorta (26.5 mm). (C) Size of the descending aorta (25 mm). (D) Sternum.
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Comment
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Making a decision how to deal with a dilated ascending aorta during coronary bypass operation is sometimes difficult because of the relatively high mortality and morbidity rates of the replacement therapy, especially in patients with severe cardiac or noncardiac disease in whom prolonged CPB and aortic cross-clamp times cannot be tolerated [5–7]. In this report, I presented such 4 cases treated with off-pump reduction aortoplasty with a Dacron tube graft and concomitant coronary bypass. Off-pump reduction aortoplasty and concomitant coronary bypass was not encountered in the literature. Although there are several surgical techniques for treatment of reduction aortoplasty [1–3, 8], I routinely prefer an external wrapping technique without incision or excision of the diseased aorta (sandwich technique). Bauer and colleagues [9] reported on 1 patient who developed wrap dislocation after 4 years, and Neri and colleagues [10] reported on 2 patients who developed false aneurysm of the ascending aorta after 7 and 11 years. The sandwich technique [4] without incision or excision prevents complications and can easily be performed even on a beating heart (off pump) in selected cases. External tube grafting does not affect proximal anastomosis. If such a situation occurs, especially when the proximal anastomosis is performed to the sinotubular junction of the aorta, either in off-pump or on-pump external wrapping cases, the tube is cut to create a slight apertura in its lower end. When the internal diameter of the aorta is less than 6 cm and there is no calcification, atherosclerotic penetrating ulcers, or suspicion of dissection, I prefer external wrapping with or without CPB instead of replacement therapy.
If the aneurysm is primarily due to an aortic pathology, such as a saccular form of aneurysm; if the internal diameter of the aneurysm is more than 6 cm; or if the aneurysm has calcification, atherosclerotic plaques, or penetrating ulcers, I prefer replacement of the ascending aorta. In cases of Marfan syndrome and dissection, I routinely prefer replacement operation, as do others [1, 5–7, 11].
Older age, poor nutritional status, and difficulties with early mobilization in patients for whom prolonged CPB and aortic cross-clamp times cannot be tolerated are the critical indications for off-pump operations. In these situations, if the patient has coronary disease as well as an ascending aortic aneurysm or dilatation, reduction aortoplasty and concomitant coronary bypass can be performed off pump with the least risk in selected cases. This type of technique is not routine, as indicated by its application, which was necessary only 4 times among 122 ascending aortic aneurysm cases in 7 years. Although those cases can be performed with CPB, this type of surgical procedure is carried out as a completely surgical preference in addition to those indications.
In conclusion, I believe that my small series provides convincing evidence that off-pump reduction aortoplasty and concomitant coronary bypass operation is the procedure of choice in selected high-risk cases for the treatment of borderline ascending aortic aneurysms and coronary artery disease, with low mortality and morbidity rates.
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References
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- Egloff L., Rothlin M., Kugelmeier J., Senning A., Turina M. The ascending aortic aneurysm: replacement or repair?. Ann Thorac Surg 1982;34:117-124.[Abstract]
- Bauer M., Pasic M., Schaffarzyk R., et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve. Ann Thorac Surg 2002;73:720-723.[Abstract/Free Full Text]
- Robicsek F. A new method to treat fusiform aneurysms of the ascending aorta associated with aortic valve disease: an alternative to radical resection. Ann Thorac Surg 1982;32:92-94.
- Arsan S. How to avoid problems with reduction aortoplasty [Letter to the Editor]. Ann Thorac Surg (in press)
- Crawford E.S., Svensson L.G., Coselli J.S., Safi H.J., Hess K.R. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch: factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
- Estrera A.L., Miller C.C., Huynh T.T.T., Porat E.E., Safi H.J. Replacement of the ascending and transverse aortic arch: determinants of long-term survival. Ann Thorac Surg 2002;74:1058-1065.[Abstract/Free Full Text]
- Lytle B.W., Mahfood S.S., Copsgrove D.M., Loop F.D. Replacement of the ascending aorta: early and late results. J Thorac Cardiovasc Surg 1990;99:651-658.[Abstract]
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- Bauer M., Grauhan O., Hetzer R. Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta. Ann Thorac Surg 2003;75:583-584.[Abstract/Free Full Text]
- Neri E., Massetti M., Tanganelli R., et al. It is only a mechanical matter? Histologic modifications of the aorta underlying external banding. J Thorac Cardiovasc Surg 1999;118:1116-1118.[Free Full Text]
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S. Arsan
Reply
Ann. Thorac. Surg.,
July 1, 2005;
80(1):
386 - 386.
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Abstract
Introduction
