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11 April 2024: Articles  Azerbaijan

Type A Aortic Dissection After Coronary Artery Bypass Grafting

Unusual setting of medical care, Rare disease

Vusal Hajiyev ORCID logo1AE*, Murad Qubadov1B, Leyla Maharramova1B, Gulnaz Dadashova2D, Asiman Hasanov1D

DOI: 10.12659/AJCR.942673

Am J Case Rep 2024; 25:e942673

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Abstract

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BACKGROUND: Aortic dissection is rare after coronary artery bypass grafting (CABG). It is a potentially fatal complication of cardiac surgery. Reoperation may pose problems with thoracotomy, adhesiolysis, and myocardial protection. No standard treatment guidelines exist for chronic aortic dissection after CABG. We present a case of chronic type A aortic dissection after cardiac surgery, which was successfully treated.

CASE REPORT: A 65-year-old female patient presented with a medical background of hypertension, type 2 diabetes mellitus, and hyperlipidemia.No connective tissue disorders were diagnosed. The aortic valve was tricuspid. Three years ago, she had undergone coronary artery bypass grafting involving four branches at a different medical facility. She was complaining of chest pain weeks after bypass surgery, which gradually increased. Aortic dissection was observed in the latest contrast-enhanced CT scan. Beginning from just above the sinotubular junction and reaching below the brachiocephalic trunk.  Two grafts from the saphenous vein were patent, and one was lying just below the sternum. Cardiopulmonary support was initiated by cannulating the right femoral artery and vein. An opening in the ascending aorta exposed an intimal tear near the proximal anastomosis of the two great saphenous vein grafts. Antegrad Del-Nido cardioplegia was given through native ostia and functional bypass grafts. Proximal and then distal anastomosis of graft prosthesis was performed. A new venous graft was anastomosed to the apical part of the left anterior descending artery (LAD). This saphenous vein and the buttons of the two previous vein grafts were anastomosed to the prosthesis. The patient was successfully liberated from the heart-lung machine and exhibited favorable cardiac function in the postoperative period.

CONCLUSIONS: We can conclude that initial peripheral cannulation with a half dose of heparin provides a relatively bloodless and secure re-entry sternotomy. Del-Nido cardioplegia is easy to implement, safe, and gives surgeons enough time without interruptions to perform complex procedures fluently.  

Keywords: Aneurysm, Dissecting, Coronary Artery Bypass, Coronary Artery Disease, Reoperation

Introduction

Aortic dissection is rare after coronary artery bypass grafting. It is a potentially fatal complication of cardiac surgery. Aortic surgery for aortic dissection after previous coronary artery bypass grafting is a challenging procedure. Reoperation may pose problems with thoracotomy, adhesiolysis, and myocardial protection. No standard treatment guidelines exist for chronic aortic dissection after CABG. Some authors suggest surgical treatment in non-stable and medical treatment for stable patients without progression [1,2]. We report the outcome of ascending aortic reoperation after previous CABG and evaluate our management of patent grafts and methods for obtaining myocardial protection.

Case Report

SURGERY:

Cardiopulmonary support was initiated by cannulating the femoral artery and vein on the right side. The cannulation of the right axillary artery was abandoned because of trauma on the right shoulder. Half a dose of heparin was given. At the same time, vena saphena was harvested for LAD bypass. A repeat median sternotomy was conducted. Substernal adhesions were carefully dissected, with particular attention given to the bypass grafts and the enlarged aorta. After completing the dissection, another half dose of heparin was administered, and cardiopulmonary bypass was started. The temperature was lowered to 28°C. The right atrium was additionally cannulated because femoral venous drainage was not sufficient. Dissection was continued in the apical direction. A sequential venous graft from a previous surgery made the secure dissection of adhesions possible only in the apical direction from the graft. Only the distal part of LAD was possible to identify. The LITA graft remained untouched to prevent additional injury. A cut in the ascending aorta exposed an intimal tear near the proximal anastomosis of the 2 great saphenous vein grafts. The false lumen exhibited partial thrombosis. The vein grafts remained patent, and the aortic wall was resected island-like. Antegrade del Nido cardioplegia was given through native ostia and functional bypass grafts. The ascending aorta was clamped immediately before the origin of the right brachiocephalic artery. Teflon felt strips were utilized to create a proximal aortic stump. Subsequently, both proximal and distal anastomoses were executed using a 30-mm Polythese®ICT prosthesis. The second cardioplegia was given through a cardioplegia cannula inserted in the prosthesis. The venous graft was anastomosed to the apical LAD saphenous vein, and the buttons of the 2 previous vein grafts were anastomosed to the artificial graft. Even after mobilization, the vein graft to RCA was too short, so it was elongated with a new saphenous vein graft in an end-to-end fashion. After all anastomoses were completed, the aorta was declamped. Weaning from the heart-lung machine was uneventful. The circulatory arrest time was 119 min and the total bypass time was 207 min. The postoperative course was uneventful, the patient was extubated on postoperative day (POD) 1, and she left the intensive care unit on POD 2. No significant complications were observed, and she was discharged on POD 9.

Discussion

Ascending aortic dissection (AAD) is an uncommon but potentially fatal complication of coronary artery bypass grafting [3]. Causes include aortic clamping, aortic cannulation, and central anastomosis of the vein grafts during previous surgery [4]. In our case, the dissection site was close to the saphenous graft, but the central anastomoses were intact. We assume that aortic clamping could be the reason for dissection, but this was uncertain due to adhesions and the chronic character of the dissection. The surgery was performed in another center, and there was nothing about intraoperative complications or aortic wall pathologies in the documentation. Surgery of chronic type A dissection following CABG becomes more challenging with functional midline crossing bypass grafts. Reoperations after CABG are still associated with high morbidity and mortality rates. To perform complex surgery with optimal results, it has been proposed that a safe and less invasive surgical strategy must be implemented [5]. The operating quickness and a simplified approach, such as the ‘open IMA technique,’ antero-grade cardioplegia, mild-to-moderate hypothermia, and minimal dissection of the mediastinal structures, were proposed [6]. Adequate cardioplegia is vital for appropriate myocardial protection and gives surgeons enough time to perform complex procedures [7]. In this case, we decided to use del Nido cardioplegia to minimize cardioplegia delivery times. Some recent studies have shown good outcomes using del Nido in a complex cardiac procedure in adult patients [8–10].

Our patient was easily weaned from the heart-lung machine and showed good cardiac function postoperatively.

Conclusions

The development of acute aortic dissection after CABG is a rare and potentially lethal complication, and early diagnosis can be life-saving. There are few reports of it in the literature. No standard surgical strategy guidelines exist for late acute aortic dissection after CABG. Reoperation may pose fatal problems with thoracotomy, site preparation, and myocardial protection. Peripheral cannulation with a half dose of heparin administration prevents thrombosis of the cannula and, at the same time, gives the surgeon time for relatively bloodless and secure thoracotomy and dissection of adhesions. It also shortens cardiopulmonary bypass time and complications related to it. If necessary, cardiopulmonary bypass can be started quickly by giving another half dose of heparin. del Nido cardioplegia is easy to implement, is safe, and offers surgeons enough time without interruptions to fluently perform complex procedures.

References:

1.. Zughaib MT, Patel H, Zughaib ME, Successful medical management of an acute ascending aortic dissection after coronary artery bypass graft surgery: Cureus, 2021; 13(8); e17086

2.. Shinfeld A, Raanani E, Late acute aortic dissection after coronary artery bypass: Langenbecks Arch Surg, 2009; 394(2); 345-48

3.. Özçınar E, Çakıcı M, Baran Ç, Results of late-onset type A aortic dissection after previous cardiac surgery: Does prior coronary artery bypass grafting affect survival?: Turk Gogus Kalp Damar Cerrahisi Derg, 2018; 26(1); 1-7

4.. Suzuki H, Kita S, Komagamine M, A case of acute type A aortic dissection after coronary artery bypass grafting: Ann Thorac Cardiovasc Surg, 2023; 29(3); 153-56

5.. Yamauchi T, Miyamoto Y, Takano H, Delayed chronic type A dissection with a functional midline crossing right internal thoracic artery after CABG: A surgical approach to an ascending aorta without dissecting the midline crossing internal thoracic artery: Ann Thorac Cardiovasc Surg, 2004; 10(1); 57-60

6.. Vistarini N, Aubert S, Leprince P, Pavie A, A simplified surgical approach for aortic valve replacement after previous coronary artery bypass grafting: Eur J Cardiothorac Surg, 2009; 36(2); 404-6

7.. Nakajima M, Tsuchiya K, Fukuda S, Aortic operation after previous coronary artery bypass grafting: Management of patent grafts for myocardial protection: Jpn J Thorac Cardiovasc Surg, 2006; 54(4); 155-59

8.. Jiang XL, Gu TY, Liu L, [Safety of del Nido cardioplegia in coronary artery bypass grafting combined with heart valve replacement in adults]: Zhonghua Yi Xue Za Zhi, 2019; 99(48); 3770-74 [in Chinese]

9.. Kim WK, Kim JB, The use of del Nido cardioplegia for multiple cardiac surgery in adults: J Thorac Dis, 2018; 10(Suppl. 33); S3902-S3

10.. Sevuk U, Dursun S, Ar ES, Propensity-matched analysis of del Nido cardioplegia in adults undergoing cardiac surgery with prolonged cross-clamping time: Braz J Cardiovasc Surg, 2022; 37(5); 702-9

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923