Asian Cardiovasc Thorac Ann 2005;13:187-189
© 2005 Asia Publishing EXchange Ltd
Myocardial Ischemia after Cabrol Operation
Gürkan Çetin, MD,
Ahmet Özkara, MD,
Emin Tireli, MD,
Özge Köner, MD1,
Kaya Süzer, MD
Department of Cardiovascular Surgery
1 Department of Anesthesiology and Reanimation,Istanbul University Institute of Cardiology, Istanbul, Turkey
For reprint information contact: Ahmet Özkara, MD Tel: 90 212 459 2083 Fax: 90 212 459 2069 Email: aozkara{at}superonline.com, Toprakkale sok Gülsoy Apt No: 8/16 Etiler 34337 Istanbul, Turkey.
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ABSTRACT
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A 33-year-old woman who had undergone a Cabrol-type aortic root replacement for acute aortic dissection during labor 27 months ago was admitted with chest pain. Electron-beam tomography and coronary angiography showed stenosis at the level of the anastomosis. Urgent coronary revascularization was performed using bilateral internal mammary artery grafts. Although graft occlusion after the Cabrol procedure is an infrequent complication, it should be considered during follow-up.
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INTRODUCTION
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The Cabrol technique for reconstruction of the ascending aorta and aortic root carries potential risks of various complications such as kinking and occlusion of the limbs of the coronary perfusion graft.1 Although it is unclear whether the incidence of coronary stenosis differs between the Cabrol operation and the Carrel patch technique, coronary graft occlusion after the Cabrol operation has been reported in 4% of patients.2–3 We report a life-threatening late complication of a Cabrol-type ascending aorta reconstruction: stenosis of the coronary tube graft, which led to the development of acute myocardial ischemia.
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CASE REPORT
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A 31-year-old woman in the 38th gestational week had chest pain and hypotension during early labor. Immediately after a transesophageal echocardiographic examination that showed severe aortic insufficiency with 6 cm of annular dilatation, ascending aortic diameter of 8 cm, and an intimal flap, the patient was transferred to the operating room. After performing a cesarean section, the femoral artery and right atrium were cannulated and extracorporeal circulation was established. On cooling the patient to 18°C, total circulatory arrest was initiated. The diameter of the ascending aorta was approximately 9 cm, and dissection was observed in the proximal section. The aortic arch was intact.
After distal anastomosis with a composite 27 mm Dacron graft (St. Jude Medical, Inc., St. Paul, MN, USA), rewarming was started. Due to severe annular dilatation (6 cm), low-lying coronary ostia, and continuation of the dissection into the coronary ostia, the Cabrol procedure was chosen. A 10-mm interposition tube graft was looped between the coronary ostia and attached to the posterolateral part of the composite valve conduit by side-to-side anastomosis. The postoperative course was uneventful. From the first postoperative day, a regimen of anticoagulation treatment with warfarin sodium was started. The target international normalized ratio was 2.5 to 3. Antiplatelet therapy was also initiated.
The patient was readmitted with persistent chest pain and unstable angina pectoris after 2 complaint-free years. An electron-beam tomographic examination showed severe narrowing at the level of the anastomosis of the left coronary ostium with the coronary perfusion graft, and the right coronary artery was not visualized (Figure 1
). Coronary angiography confirmed the diagnosis of a lesion in the left coronary artery system and also revealed a totally occluded right coronary artery with retrograde filling (Figure 2). Due to uncontrollable chest pain and persisting electrocardiographic changes, an urgent conventional coronary bypass graft operation was performed using a left internal mammary artery graft to the left anterior descending coronary artery, right internal mammary artery to the right coronary artery, and a saphenous vein graft to the obtuse marginal branch of the circumflex artery. No kinking of the coronary perfusion graft was observed. The postoperative period was uneventful and the patient was discharged without any problems.
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Figure 1. Electron-beam tomographic sagittal view of the tube graft, showing stenosis at the anastomosis site.
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DISCUSSION
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Various surgical treatment modalities have been devised for ascending aortic pathologies and annuloaortic ectasia. Bentall and De Bono4 reported total replacement of the aortic root with a valved conduit and end-to-side reimplantation of the coronary ostia in 1968. Difficulty in hemostasis and pseudoaneurysm formation at the coronary ostia and distal anastomosis suture line were the major complications related to this technique.5–6 For these reasons, some modifications of the original technique have been recommended; most important are the coronary button (Carrel patch) and Cabrol techniques.1 We did not favor the button technique because of the large annulus and fragile dissected low-lying coronary ostia. We preferred the Cabrol technique as there is minimal tension on the coronary anastomosis and it was the best choice for dealing with such fragile, very acutely dissected, remote coronary ostial walls. Obtaining hemostasis is also easier because all the bleeding sites can be easily visualized, and there is a lower incidence of false aneurysm formation at the coronary ostia. For these reasons, this technique is generally preferred in redo cases, extensively calcified aneurysmal aortas, and in cases of low coronary ostia where mobilization and/or approximation of coronary ostial buttons to the ascending aortic graft is difficult or impossible.
The main problem with the Cabrol technique is kinking or occlusion of the coronary artery tube graft.2 There is little information regarding occlusion of the coronary perfusion graft with this technique.7–8 Technical problems, re-dissection, thrombus, and myointimal hyperplasia may be possible causes of occlusion of the coronary perfusion graft. Unfortunately, a definitive answer is seldom possible, as in our case. Although some modifications to prevent stenosis at the level of the coronary anastomosis have been reported, the problem still remains.8 Gelsomino and colleagues3 found only one occlusion of the left limb of a coronary perfusion graft in 41 patients during 87 months of follow-up. In our case, there was critical stenosis at the level of the anastomosis of the left coronary ostium with the graft, and in addition, the right limb of the graft was totally occluded, thus coronary revascularization was performed. In such cases where the open button technique is not feasible, a Cabrol-type repair may be the technique of choice. This experience illustrates that although not very frequent, there is the possibility of stenosis or occlusion of one or both limbs of the coronary perfusion graft, and this complication should be considered during the follow-up of such patients.
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REFERENCES
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- Cabrol C, Pavie A, Gandjbakhch I, Villemot JP, Guiraudon G, Laughlin L, et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg 1981;81:309–15.[Abstract]
- Jault F, Nataf P, Rama A, Fontanel M, Vaissier E, Pavie A, et al. Chronic disease of the ascending aorta. Surgical treatment and long-term results. J Thorac Cardiovasc Surg 1994;108:747–54.[Abstract/Free Full Text]
- Gelsomino S, Frassani R, Da Col P, Morocutti G, Masullo G, Spedicato L, et al. A long-term experience with the Cabrol root replacement technique for the management of ascending aortic aneurysms and dissections. Ann Thorac Surg 2003;75:126–31.[Abstract/Free Full Text]
- Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338–9.[Abstract/Free Full Text]
- Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427–39.[Abstract]
- Aoyagi S, Kosuga K, Akashi H, Oryoji A, Oishi K. Aortic root replacement with a composite graft: results of 69 operations in 66 patients. Ann Thorac Surg 1994;58:1469–75.[Abstract]
- Mestres CA, Betriu A, Pomar JL. Occlusion of the coronary perfusion graft: an exceptional complication after reconstruction of the ascending aorta with the Cabrol technique. J Thorac Cardiovasc Surg 1989;98:302–3.[Medline]
- Yokoyama M. A new coronary tube for Cabrol’s technique. J Thorac Cardiovasc Surg 1988;95:738–9.
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ABSTRACT
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