Eur J Cardiothorac Surg 2001;19:935-937
© 2001 Elsevier Science NL
Simultaneous coronary arterial bypass surgery using mini-sternotomy and off-pump methods and abdominal aneurysm repair
Yoshiharu Takahara,
Yoshio Sudo,
Keiichi Ishida,
Kaoru Matsuura
Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, 1-21-1 Kanansugi Funabashi, Chiba, 273-8588 Japan
Received 9 January 2001;
received in revised form 22 February 2001;
accepted 15 March 2001.
Corresponding author. Tel.:+81-474-3321; fax:+81-474-7795
e-mail: yosh193{at}attglobal.net
 |
Abstract
|
|---|
A technique of combined minimally invasive coronary artery surgery and abdominal aneurysm repair is described. A mini-sternotomy and off-pump coronary artery bypasses to the left descending branch and right coronary arteries are conducted before abdominal aneurysm repair in a simultaneous operation.
Key Words: Simultaneous coronary artery bypass grafting and abdominal aneurysm repair • Off-pump coronary artery bypass grafting • Mini-sternotomy
|
1. Introduction
|
|---|
Simultaneous coronary artery bypass grafting (CABG) and abdominal aneurysm repair is widely accepted to be characterized by a low mortality rate [1]. However, full median sternotomy and cardiopulmonary bypass are invasive to a patient undergoing such a combined operation, and this invasiveness may result in postoperative morbidity [2,3]. We report the surgical technique of mini-sternotomy and off-pump CABG.
|
2. Patients and methods
|
|---|
Eleven patients who had abdominal aneurysm and coronary artery disease underwent a simultaneous operation using minimally invasive method at our institution between July 1999 and December 2000. There were five cases of single vessel disease, five cases of double vessel disease and one case of triple vessel disease (Table 1). Off-pump CABG to the left anterior descending branch (LAD) and the right coronary artery (RCA) was conducted. Ten of the patients had abdominal aortic aneurysms, and one patient had a left common iliac aneurysm. Concomitant renal arterial reconstruction was conducted in one patient.
2.1. Surgical procedures
A median skin incision was conducted from the left second intercostal space to the xiphoid, and the reversed-J inferior sternotomy was made. We used the left internal mammary artery (LIMA) to the LAD, and the right gastroepiploic artery (RGEA) to the RCA. The LIMA was easily harvested using a mammary retractor. If we could not use the LIMA nor the RGEA, we chose a saphenous vein graft (SVG). The proximal anastomosis of a SVG was conducted on the axillary artery, because the ascending aorta could not be seen in the operative field of vision. The axillary artery was prepared through the infraclavicular incision. We used a tissue stabilization system (Medtronic Octopus 2 or 2+) in the coronary arterial anastomosis. After the coronary arterial revascularization, the skin incision was extended to the lower abdomen, and the abdominal aneurysm repair was conducted as usual. We used the intraoperative whole blood autotransfusion system during the off-pump CABG and abdominal aneurysm repair owing to the decreased need for homologous blood transfusions. Heparin was administered throughout the CABG and aortic grafting, and the active coagulation time was kept from 150 to 180 s.
|
3. Results
|
|---|
No hospital mortality has been reported to date. The mean operative time was 263±82 min. The mean total amount of intra-operative blood loss was 547±269 ml. Nine of the patients did not undergo homologous blood transfusion operations. Two patients suffered from preoperative anemia, and underwent operative homologous blood transfusions. Among the postoperative courses, one patient suffered from pneumonia (Table 2).
|
4. Discussion
|
|---|
One-stage surgery of the coronary artery and the abdominal aorta using cardiopulmonary bypass is a reasonable option. There have, however, been reports of substantial hospital morbidity [2,3]. Some damaging effects of cardiopulmonary bypass have been reported [4]. Abnormal bleeding, cerebral complications and pulmonary dysfunction constitute the primary causes of mortality and morbidity following cardiopulmonary bypass, especially in a combined surgery. Currently, minimally invasive CABG has been introduced into cardiac surgery [5]. We propose the use of off-pump CABG can help protect the patient from the complications of cardiopulmonary bypass. On the other hand, the full median sternotomy and wide laparotomy constitute a source of severe postoperative pain and respiratory failure. Although we need a wide laparotomy for the grafting of an abdominal aneurysm, CABG can be performed using a mini-sternotomy under the off-pump technique. Mini-sternotomy is less traumatic for the thoracic wall [6]. The patients received most of the advantages of a minimally invasive technique in the postoperative period.
Other previous reports noted that the two-staged operation of CABG and abdominal aortic aneurysm repair had a high risk of aneurysm rupture during an interval of more than 2 weeks between the two operations [7,8]. Recently, single and double vessel coronary disease have been found to be good indications of cathether intervention. Thus, if patients have an asymptomatic abdominal aortic aneurysm with the maximum diameter of less than 50 mm, the method of cathether intervention is conducted, and the aneurysm repair is after. If the maximum diameter of the abdominal aortic aneurysm is more than 50 mm, we conduct simultaneous CABG and abdominal aortic aneurysm repair.
Coronary bypasses to the left circumflex branch (LCX) can not performed by this technique. We have two options for the LCX. First, simultaneous CABG to the LAD and the RCA and abdominal aneurysm repair can be conducted using a minimally invasive technique. In the postoperative period, drug therapy or cathether intervention to the LCX is chosen. Second, if the LCX lesions are severe, we conduct the simultaneous operation using full median sternotomy and off-pump or on-pump CABG. In this study, there were four patients who had LCX lesions. All of them had been chosen for the drug control, and had exhibited no chest pain attacks or heart failure.
In conclusion, the method of mini-sternotomy and off-pump CABG is one of useful technique in patients undergoing simultaneous CABG and abdominal aneurysm repair.
|
References
|
|---|
-
Hinkamp T.J., Pifarre R., Bakhos M., Blakeman B. Combined myocardial revascularization and abdominal aortic aneurysm repair. Ann Thorac Surg 1991;51:470-472.[Abstract]
-
Autschbach R., Waither T., Vetteschoss M., Diegeler A., Dalichau H., Morh F.W. Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease-indication and results. Eur J Cardio-thorac Surg 1995;9:678-684.[Abstract]
-
Gade P.V., Ascher E., Cunningham J.N., Kallakuri S., Scheinman M., Scherer H., Robertazzi R., Hingorani A. Combined coronary artery bypass grafting and abdominal aortic aneurysm repair. Am J Surg 1998;176:144-146.[Medline]
-
Kirklin J.K., Westaby S., Blackstone E.H., Kirklin J.W., Chenoweth D.E., Pacifico A.D. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86:845-857.[Abstract]
-
Pfister A.J., Zaki M.S., Garcia L.M., Mispireta L.A., Corso P.J., Qazi A.G., Boyce S.W., Coughlin T.R., Gurny P. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085-1092.[Abstract]
-
Grandjean J.G., Canosa C., Mariani M.A., Boonstra P.W. Reversed-J inferior sternotomy for beating heart coronary surgery. Ann Thorac Surg 1999;67:1505-1506.[Abstract/Free Full Text]
-
Blackboume L.H., Tribble C.G., Langenburg S.E., Mauney M.C., Buchanan S.A., Sinclair K.N., Kron I.L. Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization. Ann Surg 1994;6:693-698.
-
Paty P.S.K., Darling R.C., Chang B.B., Lloyd W.E., Kreienberg P.B., Shah D.M. Repair of large abdominal aortic aneurysm should be performed early after coronary artery bypass surgery. J Vas Surg 2000;31:253-259.
Top
Abstract
1. Introduction
