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Temporary Axillo-Femoral Bypass for Abdominal Aortic Aneurysm Repair

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Temporary Axillo-Femoral Bypass for Abdominal Aortic Aneurysm Repair Case Temporary Axillo-femoral Bypass for Abdominal Report Aortic Aneurysm Repair in High Risk Patients Shinji Kanemitsu, MD,1 Takatsugu Shimono, MD,2 Koji Onoda, MD,2 and Hideto Shimpo, MD2 Abdominal aortic aneurysm (AAA) is sometimes associated with coronary artery and valvular disease. We report the successful treatment of a 76-year-old woman diagnosed with an infrarenal AAA, associated with severe mitral regurgitation and double-vessel coronary artery disease. First, AAA repair, using temporary axillo-femoral bypasses on both sides was done. Second, after 77 days, we simultaneously undertook coronary artery bypass grafting (CABG) and mi- tral valve repair. This staged operation achieved an excellent result. This rarely used abdominal aortic surgical procedure contributed to minimizing variations in afterload, an important con- sideration in high risk cardiac patients. (Ann Thorac Cardiovasc Surg 2006; 12: 71–3) Key words: abdominal aortic aneurysm, mitral regurgitation, axillo-femoral bypass Introduction Case Report Patients with abdominal aortic aneurysm (AAA) may A 76-year-old woman presented with a palpable pulsa- have significant coronary artery and valvular disease, tile abdominal mass. Physical examination at presenta- which increases the risk of perioperative myocardial is- tion revealed a normotensive healthy female. Other than chemia and death.1) Patients with AAA and abnormal a systolic ejection heart murmur at apex (Levine III/IV) left ventricular ejection fraction are more likely to suf- and palpable AAA, no other significant findings were fer an adverse cardiac event, exceeding 60% in patients present. A chest X-ray film showed a cardiothoracic ratio whose left ventricular ejection fraction was less than (CTR) of 59%, vascular redistribution and mild heart fail- 35%.2) Even with good preoperative medical manage- ure. Computed tomography showed a nonruptured ment, optimal fluid-loading and pharmaceutical after- infrarenal AAA, 72 mm in maximum diameter (Fig. 1). load reducers, some patients retain a high risk for life- Echocardiography revealed severe dilation of the left ven- threatening cardiac events. tricular dimension, severe mitral regurgitation, and ante- Temporary shunting has been shown to offer hemody- rior leaflet prolapse of the mitral valve. An electrocardio- namic stability with lowered blood pressure and cardiac gram showed sinus rhythm and left ventricular hypertro- afterload, resulting in less cardiac workload and decreased phy. Coronary angiography revealed double-vessel coro- myocardial oxygen demands.3) nary artery disease involving a 75% stenosis of the left anterior descending artery (LAD) and a 90% stenosis of the circumflex coronary artery (Cx). Left ventricular an- giography revealed severe mitral regurgitation and glo- From 1Department of Thoracic and Cardiovascular Surgery, Anjo bally depressed left ventricular function. We thought that Kosei Hospital, Anjo, and 2Department of Thoracic and Cardio- vascular Surgery, Mie University School of Medicine, Tsu, Japan there was a possibility of rupture at the early stage be- cause this AAA was large, and surgical treatment was Received January 17, 2005; accepted for publication August 30, immediately necessary. Endovascular surgery with a stent 2005. graft was considered, but the degree of artery meander Address reprint requests to Shinji Kanemitsu, MD: Department of Thoracic and Cardiovascular Surgery, Anjo Kosei Hospital, 28 was a contraindication. Therefore, we thought AAA re- Higashihirokute, Anjo-cho, Anjo, Aichi 446-8602, Japan. pair to be undertaken prior to cardiac surgery. Ann Thorac Cardiovasc Surg Vol. 12, No. 1 (2006) 71 Kanemitsu et al. Fig. 1. Computed tomography showing an infrarenal AAA, 72 Fig. 2. Operative findings. Temporary bilateral axillo-femoral mm in maximum diameter. bypass grafts during AAA repair. Preoperatively, a Swan-Ganz catheter and arterial line mitral valve repair simultaneously followed by AAA re- were inserted. Upon induction, the pulmonary artery (PA) pair at an interval of 77 days. The excellent result was pressure was 46/8 mmHg and artery pressure 100/48 obtained with this staged operation. We suggest that this mmHg. Cardiac output was 5.4 L/min. This patient re- procedure, rarely used in abdominal aortic surgery, may ceived heparin systemically during the operation as well contribute to minimizing variations in afterload in high as the AAA repair without a temporary bypass. The bi- risk cardiac patients. lateral temporary axilla-femoral bypass was created with a woven Dacron graft, 8 mm diameter (Hemashield; Bos- Discussion ton Scientific Corp., Boston, Mass, USA). The grafts lay outside the body, traversing the sterile drapes (Fig. 2). The major cause of morbidity and mortality in patients PA pressure rose temporarily immediately after the cross following repair of an AAA is the presence of coronary clamp. After the cross clamp had been applied, PA pres- artery disease.1,4) This patient presented with an asymp- sure was 61/13 mmHg and artery pressure 102/50 mmHg. tomatic aortic aneurysm and nonoperable valvular dis- Cardiac output was 6.9 L/min. Ten minutes after the ease with severe mitral regurgitation. Despite optimal clamp, PA pressure was 42/11 mmHg and artery pres- medical management preoperatively, the patient remained sure 97/43 mmHg. The infrarenal AAA was resected with high risk. a woven Y graft (18×9 mm, Gelweave, Sulzer Vascutek In such a situation, several options in treatment are Ltd., Renfrewshire, Scotland). After declamping, the tem- available. One is undertaking heart surgery first, and the porary axillo-femoral bypass grafts were removed and a second is AAA repair. There is the further option of si- small cuff of graft was left on each vessel. After the aor- multaneous surgery. However, this patient was elderly. tic clamp was released, PA pressure was 35/10 mmHg We concluded that simultaneous surgery was not feasible. and cardiac output 6.2 L. Arterial pressure remained In this case, the maximum diameter of AAA was larger steady at 93/54 mmHg. There were no technical or throm- than 70 mm and we thought that it would rupture in the botic complications on placing or removing the tempo- near future. Therefore, we considered that AAA repair rary grafts. Heart rates were within normal limits when must be undertaken first. the grafts were functional. Though common in thoracic aortic surgery, mechani- The patient was successfully treated with the tempo- cal shunts are rarely used in surgery on the abdominal rary bypass, and her postoperative course was unevent- aorta.5-7) They have been described especially in patients ful, even leaving hospital once in the interim period. We undergoing renal re-implantation and AAA repair.6) did the coronary artery bypass graft (CABG) and the Giulini et al. reported the use of a temporary axillo-femoral 72 Ann Thorac Cardiovasc Surg Vol. 12, No. 1 (2006) Temporary Axillo-femoral Bypass for Abdominal Aortic Aneurysm Repair in High Risk Patients bypass graft for renal transplant protection during aortic bypass grafts can modulate or eliminate the causes and aneurysm repair.8) Neglen7) described the use of a modi- ill effects of declamping hypotention; and can also afford fied blood unit of a hemodialysis machine for temporary technical as well as physiologic advantages. Thus, the bypass in 10 high risk patients undergoing AAA repair. physiologic and mechanical advantages of a temporary With no increase in morbidity and favorable effects on bypass grafting are available to high risk cardiac patients. central hemodynamics and muscle metabolism, Neglen We foresee additional applications of temporary recommended temporary shunting in high risk medically axillofemoral bypass grafts and await opportunities to optimized patients. In this group of patients, aortic clamp- implement them. ing induced severe temporary incomplete ischemia with It would be difficult to obtain an adequate sample size a 300% increase in lactate pyruvate ratio. Also, systemic to conduct a proper trial comparing patients with and vascular resistance, mean arterial pressure and left ven- without temporary extra-anatomical bypass. However, in tricular stroke work increased. Neglen concluded that this extremely high risk patient we felt that the potential extracorporeal bypass improved performance and pre- benefit outweighed any potential risks. We suggest that vented derangements of muscle metabolism. cardiologists be aware of this optional surgical technique Temporary axillo-femoral bypass was used in this pa- for patients with severe cardiac disease who require AAA tient presenting with asymptomatic AAA and poor left repair, and who might not otherwise be deemed surgical ventricular ejection fraction. Whether the usual preop- candidates. erative and operative precautions may have been suffi- cient to result in a favorable outcome in this patient is References unknown. However, no complications occurred due to the use of the temporary bypass. Temporary bypasses, a me- 1. Hertzer NR, Beven EG, Young JR, et al. Coronary ar- tery disease in peripheral vascular patients. A classifi- chanical means of reducing afterload, are believed to be cation of 1000 coronary angiograms and results of sur- indicated in operations on AAA patients associated with gical management. Ann Surg 1984; 199: 223–33. cardiac disease. Early experiences with surgery of the 2. Matley PJ, Immelman EJ, Horak A, Commerford PJ. abdominal aorta disclosed complications of myocardial Equilibrium radionuclide angiocardiography
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