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Eur J Cardiothorac Surg 2003;23:137-138
© 2003 Elsevier Science NL

Letter to the Editor

Bilateral harvesting of internal thoracic artery for coronary bypass: augmenting the risk for postoperative airway obstruction?

Aristotle D. Protopapas*

Barts Hospital, London, UK

Received 20 August 2002; received in revised form 20 August 2002; accepted 17 October 2002.

* 37 The Farthings, Kingston-upon-Thames KT2 7PT, UK. Tel.: +44-79-5689-7683; fax: +44-20-8546-2901
e-mail: aresprotopapas{at}yahoo.co.uk

Key Words: Complication • Coronary bypass • Internal mammary artery • Internal thoracic artery • Outcome • Vocal cord paralysis

You published two interesting papers on iatrogenic vocal cord dysfunction, recently by Hamdan et al. [1] and previously by Shafei et al. [2]. In the era of total arterial coronary revascularisation, another relevant pathological mechanism springs to mind:

It is known that trauma to the recurrent laryngeal nerve (RLN) compromises the posterior cricoarytenoid muscle (abductor of the ipsilateral vocal cord) and thus paralyses the latter structure in adduction. Unilateral vocal cord paralysis may manifest as hoarseness or other deficit in phonation. Bilateral paralysis causes life-threatening acute airway obstruction, estimated to 1.9% in all-comers to cardiac surgery by Shafei et al. [2].

It is of particular interest to the coronary surgeon that the RLN may be injured during the harvesting of internal thoracic (mammary) artery (ITA) [3], where it ‘hooks’ around the subclavian artery (SA).

Most of us are increasingly using bilateral ITAs [4], the right ITA being often mobilised up to its origin from the SA [5]. Bilateral dissection exposes both right and left RLNs to concurrent intraoperative injury.

Will this evolution in cardiothoracic practice increase the incidence of bilateral vocal cord paralysis in coronary surgery? Does the risk warrant further prospective evaluation with a view to medico legal implications and informed consent?

In any case, we would consider prudent to keep this potential disaster mechanism in mind, in addition to the scenarios meticulously enumerated by Hamdan et al.[1].

References

  1. Latif Hamdan A., Moukarbel R.V., Farhat F., Obeid M. Vocal cord paralysis after open-heart surgery. Eur J Cardiothorac Surg 2002;21:671-674.[Abstract/Free Full Text]
  2. Shafei H., el-Kholy A., Azmy S., Ebrahim M., al-Ebrahim K. Vocal cord dysfunction after cardiac surgery: an overlooked complication. Eur J Cardiothorac Surg 1997;11:564-566.[Abstract]
  3. Phillips T.G., Green G.E. Left recurrent laryngeal nerve injury following internal mammary artery bypass. Ann Thorac Surg 1987;43:440.[Abstract]
  4. Lytle B.W., Blackstone E., Loop F.D., Houghtaling P.L., Arnold J.H., Akhrass R., McCarthy P.M., Cosgrove D.M. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
  5. Buche M., Schroeder E., Chenu P., Gurne O., Marchandise B., Pompilio G., Eucher P., Louagie Y., Dion R., Schoevaerdts J.C. Revascularisation of the circumflex artery with the pedicled right internal thoracic artery: Clinical functional and angiographic midterm results. J Thorac Cardiovasc Surg 1995;110:1338-1343.[Abstract/Free Full Text]



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I. Dimarakis and A. D. Protopapas
Vocal cord palsy as a complication of adult cardiac surgery: surgical correlations and analysis
Eur. J. Cardiothorac. Surg., October 1, 2004; 26(4): 773 - 775.
[Abstract] [Full Text] [PDF]

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