Asian Cardiovasc Thorac Ann 2007;15:159-161
© 2007 Asia Publishing EXchange Ltd
Composite Y-Graft for Syphilitic Ostial Stenosis in Left Main Coronary Artery
Keita Tanaka, MD,
Makoto Takeda, MD,
Kazuhiro Nagayama, MD
Division of Cardiovascular Surgery, Teikyo University School of Medicine Ichihara Hospital, Ichihara City, Japan
For reprint information contact: Keita Tanaka, MD Tel: 81 3 3588 1111 Fax: 81 3 3582 7068 Email: kyky-tanaka{at}mvc.biglobe.ne.jp, Division of Cardiovascular Surgery, Cardiovascular Center, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo 105-8470, Japan.
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ABSTRACT
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Coronary ostial stenosis is one of the cardiac manifestations of tertiary syphilis and should be perceived as a disorder of the aorta. A 45-year-old man with no coronary risk factors except smoking developed severe isolated ostial stenosis in the left main coronary artery. He underwent emergency bypass surgery using the bilateral internal thoracic arteries as a composite Y-graft, and recovered uneventfully.
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INTRODUCTION
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Tertiary syphilis has been virtually eradicated since the widespread introduction of penicillin. Recently, however, syphilis has reappeared in developed countries, probably because of drug abuse and sexual promiscuity. The cardiovascular manifestations of syphilis comprise asymptomatic aortitis, aortic regurgitation, coronary ostial stenosis, aortic aneurysm, and gummatous myocarditis. For treatment of syphilitic coronary ostial stenosis, many surgeons carry out coronary artery bypass grafting (CABG) in preference to a reconstructive procedure on the ostium, such as endarterectomy.
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CASE REPORT
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A 45-year-old man was admitted to our hospital with unstable angina pectoris. He had a history of smoking but no other coronary risk factors. He had been divorced 10 years previously, and had been sexually active with several women. Physical examination revealed no fever or musculoskeletal deformities, and there was no difference in blood pressure between the two arms. Results of a neurological study were normal. An electrocardiogram showed horizontal ST-segment depression in leads V4 through V6 with inverted T waves in aVL. Emergency coronary angiography indicated severe ostial stenosis of the left main coronary artery (Figure 1
), but no other lesions were evident. Left main angioplasty was considered risky. Due to persistent ST changes despite full medication, emergency off-pump CABG using the bilateral in situ internal thoracic arteries (ITA) was planned. Transesophageal echocardiography after general anesthesia demonstrated mild aortic regurgitation and mild dilatation of the ascending aorta. As use of a surgical retractor for harvesting the ITA induced hypotension and exacerbated the ST depression, it was decided to perform on-pump CABG. The ascending aortic wall was found to be not only edematous and discolored, but also thickened and sticky, so it was suspected that some form of inflammatory aortic disease had been involved in the etiology of the coronary ostial stenosis.
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Figure 1. Coronary angiography showed isolated severe ostial stenosis of the left main coronary artery (white arrow).
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Considering the further possibility of aortic valve or root replacement, it was decided to use a graft that did not pass over the ascending aorta. In addition, the length of the in situ right ITA, which was harvested by the skeletonization technique, was insufficient to reach the obtuse marginal branch via the transverse sinus. Therefore, the patient underwent CABG to the left anterior descending artery and the obtuse marginal branch using the bilateral ITA as a composite Y-graft (Figure 2). As his left ITA was small in diameter, his free right ITA was anastomosed to the left anterior descending artery. The graft flows determined by transit time flow measurement were 201 mL·min–1 in the pedicled left ITA and 86 mL·min–1 in the free right ITA. Hypoperfusion syndrome did not occur, and the postoperative course was uneventful.
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Figure 2. Postoperative coronary angiography demonstrated good patency of the Y-graft. Free RITA was anastomosed to the LAD, and in situ LITA was used for the OM.
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A postoperative electrocardiogram showed no ischemic changes, and cardiac enzyme levels were normal. A pathological study of the remnants of the distal ends of both ITA demonstrated no inflammatory changes. Using a blood sample obtained at the time of admission, the Treponema pallidum hemagglutination assay and the fluorescent treponemal antibody absorption test gave values of 5120 fold and 1280 fold, respectively, while human immunodeficiency virus antibody and C-reactive protein were negative. Therefore, it was considered likely that the coronary artery ostial stenosis had resulted from syphilitic aortitis without evidence of neurosyphilis. Postoperatively, oral benzylpenicillin benzathine was administered to counteract any ongoing Treponema infection, and the patient recovered uneventfully.
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DISCUSSION
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Syphilitic ostial stenosis of the coronary artery should be considered a different disease entity from atherosclerotic coronary artery disease, being a disorder of the aorta rather than the coronary artery. Endarteritis obliterans of the vasa vasorum leads to medial necrosis with destruction of elastic tissue. The syphilitic process extends to the ascending aorta, involves the orifices of the coronary arteries, and produces ostial stenosis.1 Extraostial coronary artery syphilis occurs only rarely.2 Thus, it follows that aortocoronary bypass using a saphenous vein graft is unsuitable for the treatment of this disease. Continuous infection of the ascending aorta may induce restenosis at the site of the proximal anastomosis. In fact, Herskowitz and colleagues3 reported an instructive case of syphilitic aortitis in which the proximal site of the anastomosis of a saphenous vein graft was found to be occluded due to the syphilitic process 6 months after bypass surgery. For the same reason, reconstructive ostial surgery such as transaortic endarterectomy or patch plasty is not recommended. Moreover, it is technically difficult to make a smooth round ostium because of calcified proliferation of the intima.
In situ arterial grafts, especially the ITA, can resolve such problems. First, an in situ arterial graft requires no proximal anastomosis to the diseased aorta. Second, unlike Takayasu’s arteritis, syphilitic arteritis usually does not involve the major branches of the aortic arch. The bilateral subclavian or internal thoracic arteries are seldom affected by the syphilitic process. Indeed, the pathological study in this case revealed that both ITA were unaffected by syphilitic arteritis. Therefore, we chose to use the bilateral ITA instead of saphenous vein grafts. It should be noted that the in situ crossover technique should be avoided for CABG in cases of syphilitic aortitis. In this patient, future re-operation was considered very likely because of progression of aortic regurgitation and dilatation of the ascending aorta. Further dilatation of the ascending aorta would gradually compress any graft crossing anterior to the aorta. Joyce and colleagues4 stated that re-operation can be performed with an acceptable risk in patients who have undergone CABG using the bilateral ITA; however, they also reported that two patent ITA grafts were damaged during dissection at re-operation. In contrast, the composite Y-graft technique leaves the ascending aorta free and reduces the risk during repeat sternotomy at re-operation.5 Aortic root replacement does not require complete dissection of the left side of the heart, and the Y-graft can be left free without exposure. Exposure and clamping of the pedicled ITA enables cross clamping of the aorta and arrest of the heart, obviating the need for deep hypothermia and circulatory arrest. Additionally, the Y-graft has adequate flow reserve to supply the entire left coronary system with sufficient blood.5,6
This case highlights the importance of evaluating all patients with isolated ostial stenosis for inflammatory diseases including syphilis. We believe that a composite Y-graft using the bilateral ITA is a safe and reliable alternative for treatment of syphilitic ostial stenosis in the left main coronary artery. However, long-term follow-up of this patient is mandatory as a result of potential future aortic regurgitation and dilatation of the ascending aorta.
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REFERENCES
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- Jackman JD Jr, Radolf JD. Cardiovascular syphilis. Am J Med 1989;87:425–33.[Medline]
- Heggtveit HA. Syphilitic aortitis. A clinicopathologic autopsy study of 100 cases, 1950 to 1960. Circulation 1964;29:346–55.
- Herskowitz A, Cho S, Factor SM. Syphilitic arteritis; involving proximal coronary arteries. N Y State J Med 1980;80:971–4.[Medline]
- Joyce FS, McCarthy PM, Taylor PC, Cosgrove DM 3rd, Lytle BW. Cardiac reoperation in patients with bilateral internal thoracic artery grafts. Ann Thorac Surg 1994;58:80–5.[Abstract]
- Calafiore AM, Contini M, Vitolla G, Di Mauro M, Mazzei V, Teodori G, et al. Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts. J Thorac Cardiovasc Surg 2000;120:990–6.[Abstract/Free Full Text]
- Ochi M, Hatori N, Bessho R, Fujii M, Saji Y, Tanaka S, et al. Adequacy of flow capacity of bilateral internal thoracic artery T graft. Ann Thorac Surg 2001;72:2008–12.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
