Combined transdiaphragmatic off-pump and minimally invasive coronary artery bypass with right gastroepiploic artery and abdominal aortic aneurysm repair

Background

Abdominal aortic aneurysm (AAA) is commonly associated with coronary artery disease (CAD) [1], which is the most common cause of death after AAA repair [2]. Coronary artery bypass grafting (CABG) before AAA repair decreases postoperative cardiac mortality rates [3] but increases the incidence of postoperative AAA rupture. The combination procedure involving CABG, cardiopulmonary bypass (CPB), and AAA repair can be very invasive. Limited reports are available in the literature on beating heart and AAA repair, including CABG. Here, we report our experience with combined surgical intervention, including AAA repair and transdiaphragmatic minimally invasive CABG of the right gastroepiploic artery (RGEA), in a single surgery.

Case Report

ANESTHESIA:

A lumbar epidural catheter was inserted into the L2–3 inter-vertebral space. After administration of general anesthesia (fentanyl, 20 μg/kg; midazolam, 0.1 mg/kg; and pancuronium. 0.1 mg/kg), an epidural ropivacaine and fentanyl infusion was started with a patient-controlled analgesia device.

SURGERY:

The patient underwent an elective operation for CABG and AAA repair. After the left paramedian incision was made and the peritoneum was opened, we created a passage at the front part of the diaphragm with electrocautery to inspect the RCA and to determine if revascularization was appropriate. After the RGEA was harvested for the transdiaphragmatic exploration of the RCA, the front part of the diaphragm and both arcus costalis were retracted using a sternal retractor (Figure 1A). The RGEA was anastomosed to the RCA on the beating heart using an Octopus4 tissue stabilizer (Medtronic, Inc, Minneapolis, MN, USA) (Figure 1B). Coronary anastomosis was performed in 16 min. After CABG, the aneurysm was excised and circulation was re-established using a collagen-impregnated Dacron graft (20 mm) (Figure 1C).

The total operating time was 4 h. The patient was discharged from the intensive care unit on the second day and from the hospital on the eighth day. No complications were observed during the early or late postoperative period, and CT angiography revealed that the anastomosis was patent in the first month of follow-up (Figure 2).

Discussion

Cardiac complications constitute the principal cause of morbidity and mortality after AAA repair because AAA are frequently associated with clinically significant coexistent CAD. Sprung et al reported that >80% of patients with AAA had angiographically atherosclerotic CAD [4]. The 5-year mortality rate from myocardial infarction in patients with preoperative evidence of heart disease is 4 times higher than that for patients without CAD [3]; therefore, if indicated, cardiac evaluation and coronary revascularization is recommended before AAA repair [5–8].

CAD is generally treated first, followed by AAA repair; however, this procedure may lead to postoperative AAA rupture. There is an increased incidence of AAA rupture after thoracic operations [9], with the primary operation and then postoperative factors playing a role in hastening the rupture. On the other hand, combined intervention for coronary bypass and AAA surgery is safe and certainly cost effective, without any early or late complications [10]. A single surgery avoids repeat anesthesia and avoids having 2 separate convalescence periods. The combined approach is also cost effective because it eliminates the need for a second hospitalization.

Combined CABG on a beating heart and AAA repair may reduce the invasiveness of simultaneous CABG with CPB under cardiac arrest and AAA repair.

The use of a combined operation for coronary revascularization on the transdiaphragmatic beating heart followed by AAA repair has many advantages, such as avoiding sternotomy or thoracotomy and the possible associated risks (patient discomfort, sternal dehiscence, and postoperative sternal bone pain), avoiding large thoracoabdominal exposure, a shortened hospital stay, and reduced hospital costs. In this case, we used RGEA for revascularization; this is an alternative arterial graft for RCA revascularization of patients with AAA and a single CAD.

Conclusions

We conclude that combined CABG on the beating heart and AAA repair using a one-step approach appears to be a safe and effective therapeutic strategy for patients with AAA and CAD. In patients with a single RCA revascularization, the transdiaphragmatic approach may be indicated to avoid a sternotomy. Further follow-up studies of the combined surgical approach are necessary to determine its long-term results.