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Intraluminal Shunting of Operatively Severed Aortocoronary Saphenous Vein Grafts
Intraluminal Shunting of Operatively Severed Aortocoronary Saphenous Vein Grafts Robert J. Robison, M.D., John W. Brown, M.D., William P. Deschner, M.D., and Robert D. King, M.D. ABSTRACT Restoration of myocardial perfusion using plastic shunts in severed aortocoronary bypass grafts is described. Reoperative aortocoronary bypass grafting is common, comprising up to 10% of current surgical series [l].Saphenous vein grafts are at risk for injury during sternal division or the dissection of dense adhesions. Severance of patent grafts may be associated with ischemic complications if they supply major areas of myocardium. In this report, we describe our experience with 2 patients who sustained operative injury to critical grafts. These injuries were managed by placing indwelling shunts into the severed graft ends. Myocardial perfusion was restored, and the operations proceeded uneventfully without subsequent evidence of perioperative myocardial injury.
Patient 1 Patient 1 had undergone aortocoronary bypass 10 years previously. Recurrent symptoms prompted cardiac catheterization, which demonstrated total occlusion of a circumflex graft, 90% narrowing of a second circumflex graft, and unobstructed flow through a left anterior descending artery graft. During the course of adhesion dissection, the left anterior descending artery graft was transected. This injury caused ischemic electrocardiographic changes and hemodynamic instability. Following systemic heparinization, graft flow was restored by placement of a Javid shunt (Bard Javid carotid bypass shunt; Bard, Bard Implants Division, C.R. Bard, PO Box M, Billerica, MA 01821), usually used for carotid endarterectomy, into the distal segment of vein and a pursestring suture in the aortic root (Fig 1). The patient’s cardiovascular status stabilized, the electrocardiogram returned to normal, and the remaining portion of the procedure proceeded without difficulty. Postoperative studies showed no evidence of myocardial injury.
Patient 2 Patient 2 had undergone two aortocoronary bypass operations using saphenous vein 12 and 7 years before this
Fig 1 . (Patient 1) Restoration of myocardial perfusion by Javid shunt.
presentation. Recurrent angina subsequently developed, and cardiac catheterization demonstrated occlusion of his right coronary and left anterior descending artery grafts and partial occlusion of a sequential graft that supplied three circumflex artery branches. On sternal division, the sequential graft, which was densely adhered to the upper posterior sternum, was severed. The bleeding ends were clamped, heparin was given intravenously, and a plastic intraluminal shunt (Sundt internal carotid endarterectomy shunt; American HeyerSchulte, Division of American Hospital Supply Corporation, Goleta, CA 93317) was passed into the severed ends (Fig 2). The operation proceeded without further difficulty. Postoperatively, there was no evidence of myocardial injury.
Comment From the Cardiothoracic Section, Department of Surgery, Indiana UNversity School of Medicine, Indianapolis, IN. Accepted for publication Jan 31, 1986. Address reprint requests to Dr. Robison, Department of Surgery, Emerson Hall 212, 515 Barnhill Dr, Indianapolis, IN 46223.
475 Ann Thorac Surg 42:475-476, Oct 1986
Major injury to critical saphenous vein grafts during reoperative aortocoronary bypass can be catastrophic. Plastic shunts are an integral part of carotid artery surgery, either on a routine basis or when inadequate cerebral perfusion is demonstrated [Z].We have used
476 The Annals of Thoracic Surgery Vol 42 No 4 October 1986
these shunts in 2 patients following injury to critical saphenous vein grafts. The technique was effective in restoring and maintaining coronary perfusion during reoperative dissection. A special thanks to Susan Noeller for her secretarial expertise and to John Nixon for his medical illustrations.
References 1. Loop FD, Cosgrove DM, Lytle BW, et al: An 11 year evolution of coronary arterial surgery (1967-1978). Ann Surg 190444, 1979 2. Thompson JE, Talkington CM: Carotid endarterectomy. Ann Surg 184:1, 1976
A
B Fig 2 . (Patient 2 ) (A) Sundt shunt restoring myocardial blood jow. (8) lntraoperative photograph.
Patient 1 Patient 1 had undergone aortocoronary bypass 10 years previously. Recurrent symptoms prompted cardiac catheterization, which demonstrated total occlusion of a circumflex graft, 90% narrowing of a second circumflex graft, and unobstructed flow through a left anterior descending artery graft. During the course of adhesion dissection, the left anterior descending artery graft was transected. This injury caused ischemic electrocardiographic changes and hemodynamic instability. Following systemic heparinization, graft flow was restored by placement of a Javid shunt (Bard Javid carotid bypass shunt; Bard, Bard Implants Division, C.R. Bard, PO Box M, Billerica, MA 01821), usually used for carotid endarterectomy, into the distal segment of vein and a pursestring suture in the aortic root (Fig 1). The patient’s cardiovascular status stabilized, the electrocardiogram returned to normal, and the remaining portion of the procedure proceeded without difficulty. Postoperative studies showed no evidence of myocardial injury.
Patient 2 Patient 2 had undergone two aortocoronary bypass operations using saphenous vein 12 and 7 years before this
Fig 1 . (Patient 1) Restoration of myocardial perfusion by Javid shunt.
presentation. Recurrent angina subsequently developed, and cardiac catheterization demonstrated occlusion of his right coronary and left anterior descending artery grafts and partial occlusion of a sequential graft that supplied three circumflex artery branches. On sternal division, the sequential graft, which was densely adhered to the upper posterior sternum, was severed. The bleeding ends were clamped, heparin was given intravenously, and a plastic intraluminal shunt (Sundt internal carotid endarterectomy shunt; American HeyerSchulte, Division of American Hospital Supply Corporation, Goleta, CA 93317) was passed into the severed ends (Fig 2). The operation proceeded without further difficulty. Postoperatively, there was no evidence of myocardial injury.
Comment From the Cardiothoracic Section, Department of Surgery, Indiana UNversity School of Medicine, Indianapolis, IN. Accepted for publication Jan 31, 1986. Address reprint requests to Dr. Robison, Department of Surgery, Emerson Hall 212, 515 Barnhill Dr, Indianapolis, IN 46223.
475 Ann Thorac Surg 42:475-476, Oct 1986
Major injury to critical saphenous vein grafts during reoperative aortocoronary bypass can be catastrophic. Plastic shunts are an integral part of carotid artery surgery, either on a routine basis or when inadequate cerebral perfusion is demonstrated [Z].We have used
476 The Annals of Thoracic Surgery Vol 42 No 4 October 1986
these shunts in 2 patients following injury to critical saphenous vein grafts. The technique was effective in restoring and maintaining coronary perfusion during reoperative dissection. A special thanks to Susan Noeller for her secretarial expertise and to John Nixon for his medical illustrations.
References 1. Loop FD, Cosgrove DM, Lytle BW, et al: An 11 year evolution of coronary arterial surgery (1967-1978). Ann Surg 190444, 1979 2. Thompson JE, Talkington CM: Carotid endarterectomy. Ann Surg 184:1, 1976
A
B Fig 2 . (Patient 2 ) (A) Sundt shunt restoring myocardial blood jow. (8) lntraoperative photograph.