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Combined coronary revascularization and splenectomy
CASE REPORTS
Combined Coronary Revascularization and Splenectomy Ryu Koike, MD, Hisayoshi Suma, MD, Takahiko Oku, MD, Harumitsu Satoh, MD, Yoshihide Sawada, MD, and Atsuro Takeuchi, MD Department of Thoracic Surgery, Osaka Medical College, Osaka, Japan
Idiopathic thrombocytopenic purpura is rarely associated with coronary artery disease. In this report, we describe the successful surgical management of a patient with idiopathic thrombocytopenic purpura and angina pectoriS.
(Ann Thorac Surg 1989;48:8534)
I
diopathic thrombocytopenic purpura is characterized by a decreased number of platelets and excessive posttraumatic bleeding. Rarely is it associated with coronary artery disease. We report the successful surgical management of a patient with idiopathic thrombocytopenic purpura and severe coronary artery disease by splenectomy and coronary artery bypass grafting (CABG). A 37-year-old man was admitted to Kitano Hospital in July 1988 because of severe chest pain and petechiae. Laboratory data included a platelet count of 8,000/mL, a bleeding time of 25 minutes, and normal coagulation factors. The bone marrow contained an increased number of megakaryocytes. Coronary angiography showed 75% stenosis at the proximal portion of the left anterior descending coronary artery, total obstruction of the obtuse marginal branch, and 99% stenosis of the right coronary artery. The patient was transferred to Osaka Medical College for CABG. A midline skin incision was extended to just above the umbilicus, and the left internal mammary artery was taken down. Through a median laparotomy, the spleen was removed without difficulty, and then the right gastroepiploic artery was freed along the greater curvature of the stomach. Because the posterior wall of the left ventricle was already infarcted, we decided to use a bovine internal mammary artery biograft (Bioflow) instead of a saphenous vein graft to avoid a leg wound. Triple CABG (left internal mammary artery-left anterior descending coronary artery, right gastroepiploic arteryright coronary artery, Bioflow-obtuse marginal branch) was done using standard cardiopulmonary bypass with 53 minutes of aortic cross-clamp time (Fig 1). Just after the termination of cardiopulmonary bypass, packed platelets were transfused, and hemostasis was carefully achieved. The platelet count increased to 242,000ImL on the next day, and the thoracic drainage
Fig 1 . Combined triple coronary artery bypass grafting and splenectomy. (GEA = gastroepiploic artery; IMA = internal mammary artery; SA = splenic artery.)
tubes were removed on the fifth postoperative day. During hospitalization, the platelet count remained around 300,000/mL with steroid therapy (Fig 2). The postoperative course was uneventful. When discharged, the patient was free from both angina pectoris and the tendency to bleed.
Accepted for publication June 6, 1989.
Comment
Address reprint requests to Dr Koike, Department of Thoracic Surgery, Osaka Medical College, 2-7 Daigakucho, Takatsukishi, Osaka 569, Japan.
A survey of the literature revealed that a few patients with ischemic heart disease and idiopathic thrombocytopenic
8 1989 by The Society of Thoracic Surgeons
0003-4975/89/$3.50
854
CASE REPORT KOIKE ET AL COMBINED CABG AND SPLENECTOMY
Ann Thorac Surg 1989;48:8534
Fig 2 . Change in plutelet count. (Op. = operution.)
purpura have undergone CABG without concomitant splenectomy [l]. We are aware of only one report of combined splenectomy and mitral valve replacement in a patient with idiopathic thrombocytopenic purpura and mitral regurgitation [2]. To our knowledge, the present report is the first of combined splenectomy and CABG. Medical treatment such as corticosteroids or yglobulin results in a low percentage of patients with sustained clinical remission of idiopathic thrombocytopenic purpura [3]. As an ideal surgical procedure, we performed a one-stage operation involving splenectomy and CABG. The platelet count normalized within a day, and no bleeding tendency was found postoperatively. Because of the young age of the patient and the possible long-term administration of steroids, we used the left internal mammary artery and the right gastroepiploic artery for the area of viable myocardium [4,51.The right gastroepiploic artery is a particularly suitable conduit in patients requiring a laparotomy for splenectomy, for example, as illustrated in the case of OUT patient. Its dissection is safe and easily accomplished without serious invasion. Also, the right gastroepiploic artery can be separated readily without bleeding and is long enough to reach the right coronary artery.
M.4
We thank Dr Mamoru Hiyama, Hiratsuka Gastrointestinal Hospital, for helping with the splenectomy and Dr Takashi Umezawa, Dr Takao Ishimura, and Dr Akira Wakabayashi, Department of Cardiology, Kitano Hospital, for referring this patient to us.
References 1. Iida H, Kitamura N, Yamaguchi A, et al. A-C bypass grafting and ligation of coronary arteriovenous fistula in a patient with idiopathic thrombocytopenic purpura. Nippon Kyobu Geka Gakkai Zasshi 1988;36:2296-3000. 2. Maronas JM, Llamas P, Caffarena JM. Mitral valve replacement and splenectomy in a patient with chronic idiopathic thrombocytopenic purpura. Thorac Cardiovasc Surg 1982; m407-8. 3. Schmidt RE. High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura. Lancet 1981;2:475-6. 4. Jett GK, Aradi JM Jr, Dorsey LMA, et al. Vasoactive drug effects on blood flow in internal mammary artery and saphenous vein grafts. J Thorac Cardiovasc Surg 1987;94:2-11. 5. Homcy CJ, Liberthson RR, Fallon JT, et al. Ischemic heart disease in systemic lupus erythematosus in the young patients: report of six cases. Am J Cardiol 1982;49:478-84.
Combined Coronary Revascularization and Splenectomy Ryu Koike, MD, Hisayoshi Suma, MD, Takahiko Oku, MD, Harumitsu Satoh, MD, Yoshihide Sawada, MD, and Atsuro Takeuchi, MD Department of Thoracic Surgery, Osaka Medical College, Osaka, Japan
Idiopathic thrombocytopenic purpura is rarely associated with coronary artery disease. In this report, we describe the successful surgical management of a patient with idiopathic thrombocytopenic purpura and angina pectoriS.
(Ann Thorac Surg 1989;48:8534)
I
diopathic thrombocytopenic purpura is characterized by a decreased number of platelets and excessive posttraumatic bleeding. Rarely is it associated with coronary artery disease. We report the successful surgical management of a patient with idiopathic thrombocytopenic purpura and severe coronary artery disease by splenectomy and coronary artery bypass grafting (CABG). A 37-year-old man was admitted to Kitano Hospital in July 1988 because of severe chest pain and petechiae. Laboratory data included a platelet count of 8,000/mL, a bleeding time of 25 minutes, and normal coagulation factors. The bone marrow contained an increased number of megakaryocytes. Coronary angiography showed 75% stenosis at the proximal portion of the left anterior descending coronary artery, total obstruction of the obtuse marginal branch, and 99% stenosis of the right coronary artery. The patient was transferred to Osaka Medical College for CABG. A midline skin incision was extended to just above the umbilicus, and the left internal mammary artery was taken down. Through a median laparotomy, the spleen was removed without difficulty, and then the right gastroepiploic artery was freed along the greater curvature of the stomach. Because the posterior wall of the left ventricle was already infarcted, we decided to use a bovine internal mammary artery biograft (Bioflow) instead of a saphenous vein graft to avoid a leg wound. Triple CABG (left internal mammary artery-left anterior descending coronary artery, right gastroepiploic arteryright coronary artery, Bioflow-obtuse marginal branch) was done using standard cardiopulmonary bypass with 53 minutes of aortic cross-clamp time (Fig 1). Just after the termination of cardiopulmonary bypass, packed platelets were transfused, and hemostasis was carefully achieved. The platelet count increased to 242,000ImL on the next day, and the thoracic drainage
Fig 1 . Combined triple coronary artery bypass grafting and splenectomy. (GEA = gastroepiploic artery; IMA = internal mammary artery; SA = splenic artery.)
tubes were removed on the fifth postoperative day. During hospitalization, the platelet count remained around 300,000/mL with steroid therapy (Fig 2). The postoperative course was uneventful. When discharged, the patient was free from both angina pectoris and the tendency to bleed.
Accepted for publication June 6, 1989.
Comment
Address reprint requests to Dr Koike, Department of Thoracic Surgery, Osaka Medical College, 2-7 Daigakucho, Takatsukishi, Osaka 569, Japan.
A survey of the literature revealed that a few patients with ischemic heart disease and idiopathic thrombocytopenic
8 1989 by The Society of Thoracic Surgeons
0003-4975/89/$3.50
854
CASE REPORT KOIKE ET AL COMBINED CABG AND SPLENECTOMY
Ann Thorac Surg 1989;48:8534
Fig 2 . Change in plutelet count. (Op. = operution.)
purpura have undergone CABG without concomitant splenectomy [l]. We are aware of only one report of combined splenectomy and mitral valve replacement in a patient with idiopathic thrombocytopenic purpura and mitral regurgitation [2]. To our knowledge, the present report is the first of combined splenectomy and CABG. Medical treatment such as corticosteroids or yglobulin results in a low percentage of patients with sustained clinical remission of idiopathic thrombocytopenic purpura [3]. As an ideal surgical procedure, we performed a one-stage operation involving splenectomy and CABG. The platelet count normalized within a day, and no bleeding tendency was found postoperatively. Because of the young age of the patient and the possible long-term administration of steroids, we used the left internal mammary artery and the right gastroepiploic artery for the area of viable myocardium [4,51.The right gastroepiploic artery is a particularly suitable conduit in patients requiring a laparotomy for splenectomy, for example, as illustrated in the case of OUT patient. Its dissection is safe and easily accomplished without serious invasion. Also, the right gastroepiploic artery can be separated readily without bleeding and is long enough to reach the right coronary artery.
M.4
We thank Dr Mamoru Hiyama, Hiratsuka Gastrointestinal Hospital, for helping with the splenectomy and Dr Takashi Umezawa, Dr Takao Ishimura, and Dr Akira Wakabayashi, Department of Cardiology, Kitano Hospital, for referring this patient to us.
References 1. Iida H, Kitamura N, Yamaguchi A, et al. A-C bypass grafting and ligation of coronary arteriovenous fistula in a patient with idiopathic thrombocytopenic purpura. Nippon Kyobu Geka Gakkai Zasshi 1988;36:2296-3000. 2. Maronas JM, Llamas P, Caffarena JM. Mitral valve replacement and splenectomy in a patient with chronic idiopathic thrombocytopenic purpura. Thorac Cardiovasc Surg 1982; m407-8. 3. Schmidt RE. High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura. Lancet 1981;2:475-6. 4. Jett GK, Aradi JM Jr, Dorsey LMA, et al. Vasoactive drug effects on blood flow in internal mammary artery and saphenous vein grafts. J Thorac Cardiovasc Surg 1987;94:2-11. 5. Homcy CJ, Liberthson RR, Fallon JT, et al. Ischemic heart disease in systemic lupus erythematosus in the young patients: report of six cases. Am J Cardiol 1982;49:478-84.