Eur J Cardiothorac Surg 2004;25:902-904
© 2004 Elsevier Science NL
Early type A dissection with the aortic connector device
Kenji Okada*,
Taijiro Sueda,
Kazumasa Orihashi,
Katsuhiko Imai
Department of Cardiovascular Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
Received 7 December 2003;
accepted 9 February 2004.
* Corresponding author. Tel.: +81-82-257-5216; fax: +81-82-257-5219
e-mail: kokada{at}hiroshima-u.ac.jp
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Abstract
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A 75-year-old woman who had suffered type B dissection had coronary artery bypass grafting surgery using a mechanical aortic connector. Four days after the operation, she had a sudden syncope. CT demonstrated type A dissection, and an emergency operation was done, and postoperative course was uneventful. This case demonstrates that this connector should be used carefully in patients with a history of type B dissection.
Key Words: Dissection • Connector • Off-pump coronary artery bypass grafting
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1. Introduction
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The Symmetry Bypass System Aortic Connector (St Jude Medical, Inc.) is a novel device for the construction of sutureless proximal anastomoses [1]. The connector allows attachment of saphenous vein grafts to the aorta without requiring aortic clamping. However, complications due to this system have been reported [2,3]. We report a case of type A dissection after deployment of this device.
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2. Clinical summary
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A 75-year-old woman had severe back and abdominal pain. The helical computed tomography (CT) demonstrated a type B dissection with an entry 1 cm distal to the origin of the left subclavian artery. The true lumen became gradually smaller in diameter and was interrupted just above the celiac artery (CA). The CA and the superior mesenteric artery (SMA) were occluded. She was diagnosed with visceral ischemia due to type B dissection. Emergent bypass graftings for the CA and the SMA using the right gastroepiploic artery (GEA) saphenous vein (SV) and the left radial artery (RA) were performed. The postoperative course was uneventful.
Four months later, she had chest pain and was readmitted to our hospital. Coronary angiography demonstrated significant stenosis on the left anterior descending artery (LAD) and the circumflex artery (CX). Coronary artery bypass grafting (CABG) was planned. The RA graft had already been used, and the right internal mammary artery (IMA) seemed to be too short to reach the posterolateral artery (PL). We planned bypass grafting of the left IMA to the LAD and an SV graft to the PL. Because this patient had type B dissection, we decided not to clamp the ascending aorta. Consequently, the procedures were performed on a beating heart without cardiopulmonary bypass (CPB) using the symmetry bypass system aortic connector. After median sternotomy the left IMA was skeletonized for optimal length. Hand-sewn anastomosis was performed to the LAD using the left IMA. The vein graft was prepared, fitted into the sutureless connector system, and proximal anastomosis was performed. There was no leakage at the anastomosis site and no additional hemostatic sutures were required. Sequentially, anastomoses to the PL were completed. During the operation, no abnormal findings were recognized, even by transesophageal echography. The postoperative course was uneventful.
Four days after the operation, she had a sudden syncope. CT demonstrated type A dissection (Fig. 1)
, and an emergency operation was done. After reopening the heart, slight bleeding was found at the proximal site of the SVG on the ascending aorta and moderate bloody cardiac effusion was recognized. However, neither dislocation nor migration of the connector was found. CPB was established with right atrial vein drainage and through a right axillary arterial cannula via a conduit. After a left ventricular vent was placed into the right superior pulmonary vein, perfusion cooling was initiated to a rectal temperature of 25 °C. During cooling, the ascending aorta was clamped and the aortic root was opened. However, any tears were not found, only the aortic connector was found in the aortic root. Reforcing proximal anastomomic site, and when the rectal temperature reached 25 °C, circulatory arrest was obtained. Under selective cerebral perfusion, direct visual inspection of the aortic arch revealed that there were no abnormal findings or tears. Replacement of the ascending aorta with a 22 mm diameter prosthesis was then performed. After completion of the proximal anastomosis, all clamps on the ascending aorta and the cervical vessels were removed, and systemic rewarming perfusion was reestablished through the right axillary artery. The body was rewarmed and the heart began to pulsate spontaneously. Weaning off CPB was uneventful. The postoperative course was uneventful. The postoperative CT demonstrated that the false lumen at the aortic arch had disappeared (Fig. 2)
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Fig. 1. Preoperative CT: (a) the innominate and left common carotid artery was dissected. (b) The density of the false lumens differed markedly between the aortic arch (*) and the descending aorta (**). (c) Different density area was recognized in the false lumen (*,**) of the ascending aorta (the false lumen was divided into two by the aortic connector) (*** the true lumen). (d) Dissected the ascending aorta (* the aortic connector).
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Fig. 2. Postoperative CT: (a) thrombosed false lumen in the innominate and left common carotid artery. (b) Intact ascending aorta. (c) The 3D-CT demonstrating patent grafts: LITA (*), Prosthesis (**), SVG (***).
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3. Comment
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There seemed to be three possible etiological causes of type A dissection in this patient: (I) retrograde dissection of a type B dissection; (II) type A dissection following the appearance of a new tear on the ascending aorta and/or aortic arch; and (III) type A dissection caused by the aortic connector. However, cause (II) can be ruled out easily, because no tears were recognized by intraoperative visual investigation or with a preoperative CT. The probability that cause (I) was responsible is also extremely low, because the density of the false lumens in the preoperative CT differed markedly between the aortic arch and the descending aorta. In other words, there were no continuity of the false lumen between the descending aorta and the ascending aorta in the preoperative CT. Secondly the false lumen at the aortic arch had disappeared in the postoperative CT. Examining all the facts, we can rule out causes (I) and (II). However, the aortic connector was adjacent to both the false lumen and the true lumen in the preoperative CT. Different density area was recognized in the false lumen of the ascending aorta and the false lumen was divided into two by the aortic connector. When the chest was reopened, bleeding was found at the aortic connector. Based on this evidence, we concluded that this connector caused the type A dissection.
Off-pump coronary artery bypass grafting (OPCAB) has received more attention because of recent advances in myocardial stabilization. However, acute ascending aortic dissection following OPCAB occurs more often than following CABG with CPB. Chavanon et al. [4] described that iatrogenic acute aortic dissection occurred in three patients among 308 operated on without CPB. Careful manipulation of the aorta and control of the arterial pressure was required, especially when dealing with atherosclerosis of the aorta, thin dilated aortic walls, cystic medial necrosis, and inherited disorders of connective tissue. A number of the aortic connectors have been used widely in the world to facilitate the creation of an aortosaphenous vein anastomosis for CABG. To our knowledge, type A dissection following the use of the aortic connector device has never been reported. While the frequency of type A dissection caused by the use of this device might be lower than that with standard OPCAB, this connector should be used carefully in patients with a history of type B dissection.
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References
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- Eckstein F.S., Bonilla L.F., Englberger L., Immer F.F., Berg T.A., Schmidli J., Carrel T.P. The St Jude Medical symmetry aortic connector system for proximal vein graft anastomoses in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2002;123(4):777-782.[Abstract/Free Full Text]
- Traverse J.H., Mooney M.R., Pedersen W.R., Madison J.D., Flavin T.F., Kshettry V.R., Henry T.D., Eales F., Joyce L.D., Emery R.W. Clinical, angiographic, and interventional follow-up of patients with aortic-saphenous vein graft connectors. Circulation 2003;108(4):452-456.[Abstract/Free Full Text]
- Carrel T.P., Eckstein F.S., Englberger L., Windecker S., Meier B. Pitfalls and key lessons with the symmetry proximal anastomotic device in coronary artery bypass surgery. Ann Thorac Surg 2003;75(5):1434-1436.[Abstract/Free Full Text]
- Chavanon O., Carrier M., Carrtier R., He'bert Y., Pellerin M., Page P., Perrault L.P. Increased incidenceof acute ascending aortic dissection with off-pump aortocoronary bypass surgery. Ann Thorac Surg 2001;71:117-121.[Abstract/Free Full Text]
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Abstract
1. Introduction
