Ann Thorac Surg CASE REPORT SEKINE ET AL 1123 1995;60:1123-6 CORONARY GRAFT OBSTRUCTION

Fig 3. The cut surface of the stented segment showed a huge throm- bosed.false lumen communicatin X with a pr ima~ lumen (small as- terisk). The entrance (arrow) h~ the false lumen (large asterisk) was lapxest at the proximal ha!f qfi the dishd sc,\~ment qf the stent.

C o m m e n t

Conventional PTCA in patients with prior bypass graft- ing who have stenosis of the vein graft generally pro- duces satisfactory initial angiographic success [1, 2]. However, the rate of recurrence in vein graft lesions is much higher than that in native coronary arteries [2, 3]. Stenting of vein grafts seems likelv to have a high early success rate with fewer subacute thrombotic events than in native artery; its restenosis rate is 25% to 28% with use of the Palmaz-Schatz stent [4, 5] in contrast to 46% with vein graft PTCA [1]. These facts make us support the choice of stenting to manage the vein graft stenosis. In patients with aged vein grafts, however, the development of intimal hyperplasia in the anastomosed site or athero- sclerosis throughout the body would have progressed to a relativelv severe extent ]6]. Stent deployment in such a case will easily cause dissection of the target wall and result in subadventitial hematoma. Even though the target lesion is dilated without dissection, the wall stress amplified by elastic recoil against permanent "mandato- ry" expansion of the stent might lead to tearing of the target wall. Certainly, primary intervention has a lower morbidity and mortality rate as compared with coronary reoperation. We emphasize that stenting of the aged vein graft after failed primary PTCA may cause a dilating complication as in this case, and when acute occlusion is due to parietal dissection, elastic recoil, and thrombosis after vein graft PTCA, a bridge procedure to semielective CABG, such as a perfusion balloon, should be consid- ered. Even when bailout stenting gives angiographic success, the contour and size of the vein graft around the stented site should be examined perindically by echocar- diography or tomography.

R e f e r e n c e s

1. Dorros G, Johnson WD, Tector A.!, Schmahl TM, Kalush SL, Janke L. Percutaneous transluminal coronary angioplasty in

patients with prior coronary artery bypass grafting. J Thorac Cardiovasc Surg 1984;87:17-26.

2. Cooper I, Ineson N, Demirtas E, Coltart J, Jenkins S, Webb- Peploe M. Role of angioplasty in patients with previous coronary: artery bypass surgery. Cathet Cardiovasc Diagn 1989;16:81-6.

3. Platko WP, Hollman J, Whitlow PL, Franco I. Percutaneous transluminal angioplasty of saphenous vein graft stenosis: brag-term follow-up. J Am Coil Cardiol 1989;14:1645-50.

4. Leon MB, Kent KM, Bairn DS, et al. Comparison of stent implantation in native coronaries and saphenous vein grafts [Abstract]. J Am Coil Cardiol 1992;19:263A.

5. Pomerantz RM, Kuntz RE, Carrozza JP, et al. Acute and long-term outcome of narrowed saphenous vein grafts treated by endoluminal stenting and directional atherectomy. Am J CardioI 1992;70:161-7.

6. Fuster V, Chesebro JJ. Aortocoronary artery vein-graft dis- ease: experimental and clinical approach for the understand- ing of the role of platelets and platelet inhibitors. Circulation 1985;72(Suppl 5):65-70.

Dacron Coronary Graft Obstruction After Composite Graft Replacement of Aortic Root Satoshi Sekine, MD, Tadaaki Abe, MD, Keiji Seki, MD, Yoshiki Shibata, MD, Itsuro Yamagishi, MD, and

Makoto Kamada, MD

Department of Cardiovascular Surgery, Akita University School of Medicine, Akita, Japan

Obstruction of the left coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts, lntimal proliferation caused by the turbulent blood f low at this site may be the cause of the obstruction, which is considered a possible cause of late cardiac events such as sudden death and global myocardial infarction. We describe a case of tight steno- sis at the left coronary ostial anastomosis in a 38-year-old woman with Marfan's syndrome who had undergone a composite graft replacement that employed separate Dacron coronary grafts.

(Ann Thorac Surg 1995;60:1123-6)

C omposite graft replacement of the ascending aorta and aortic valve [1] has become the standard sur-

gical technique for the t reatment of aortic regurgitation associated with ascending aortic aneurysm. The use of a small Dacron tube in coronary reimplantation, intro- duced by Cabrol and colleagues ]2] in 1978, contributed to a sound anastomosis without tension and prevent ion of late pseudoaneurysm. Although the long-term results of composite graft replacement with Dacron coronary grafts have been reported as satisfactory [2-4], some cases of life-threatening complications related to coro- nary reconstruction were reported [5, 6]. This report

\ccepted for publication April 24, 1995.

Address reprint requests to Dr Sekine, Akita University School of Med- icine, 1-1-1 Hondo, Akita 010, Japan.

© 1995 by The Societx i~t Thornci~ ",ur~e~n~ 0003-4975/95/$9.50 SSDI 0003-4975(95)00693-F

1124 CASE R E P O R T S E K I N t t I , \[ A n n 1-horac S u r g C O R O N A R Y G R A F T O B S I R L ( I ION 1995;60:1123-6

A

Fig 1. C4) Di£,ital subtraction an gio~,,raphi! t~H the 28th postoperative day. Note the normal am~stomosL, ( a r r m x ~ I~ct~,cen the h'.O coronary ,graft and thv lqO main corollary ortcm/. ¢lq) A r r o w ~]low> the stem> sis off anastomosis between Hlt, [)a( rcl~l Xll{~t d~ld the ostium q( the h'ft coronary arh'ry.

presents a rare late complication of a tight stenosis at the junction of coronary graft and left coronary orifice, which required urgent coronary revascularization.

A 38-year-old woman with Marfan's >vndrome had an- nuloaort ic ectasia and chronic type B aortic dissection, and she underwent composite graft rep lacement of the ascending aorta and aortic valve at Akita University

f tospital in February 1994. Short segments of 8-mm Gelseal (Vascutek Ltd, lnchinnan, Scotland) in terposed grafts were used for coronary re implanta t ion with the technique descr ibed by Piehler and Pluth [3], and they were anas tomosed to both coronary ostia with continu- ous 4-0 po lypropylene suture. After the composi te graft consisting of a 23-mm St. Jude Medical valve (St. Jude Medical Inc, St. Paul, MN) and a 24-mm Gelseal graft was seated to the aortic annulus, small but tons of the graft were excised above the prosthet ic valve, and coronary grafts were anas tomosed to the composi te graft in an end- to-s ide fashion with cont inuous 4-0 po lypropylene suture. Aneurysmal wall above the sinuses of Valsalva was resected, and the inclus ion/wrap technique was not used. Retrograde blood cardioplegia was used for the myocardial protection.

The postoperat ive course was uneventful. Angiogra- phy per formed on the 28th postoperat ive day revealed both the coronary artery grafts patent, and no anasto- motic stenosis or p seudoaneurysm at any site (Fig 1A). The patient was discharged home receiving warfarin, t i c lop id ine (200 mg /day ) , and m e t o p r o l o l t a r t r a t e (120 mg/day).

She was healthy until November 1994, when she was readmit ted to this hospital for a late evaluat ion of surgi- cally treated aortic root and chronic type B aortic dissec- tion. Aortogram of the ascending aorta showed all anas- tomoses intact, and no pseudoaneurysm was observed. However, selective dye injection into the left coronary graft revealed a tight stenosis at the distal anastomotic site (Fig 1B). The left anterior descending ar tery and circumflex coronary artery were intact. There was no stenosis between the right coronary graft and right cor- onary artery. Coronary ar ter iogram showed that the circumflex artery was hypoplast ic with right coronary arte W predominance . Left ventr icular function was main- tained normal. Chronic type B aortic dissection extended from just below the origin of the left subclavian ar tery to throughout the abdominal aorta. Because the coronary obstruction represen ted a severe left main t runk stenosis, urgent coronary, bypass grafting was indicated. Wai t ing for the operat ion, the pat ient had a first angina with ischemic electrocardiographic changes on the precordial leads.

In p lanning the operat ive procedures, we considered the left internal thoracic artery or the right gastroepiploic ar tew, one of the terminal branches of the celiac t runk arising from a pseudolumen, unsui table as a bypass conduit because they would be obstructed in the ex- pected operat ion on the descending thoracic aorta. Also, right internal thoracic ar tery- lef t anter ior descending artery bypass would result in hypoperfus ion with cata- strophic consequences at the presence of severe left main trunk stenosis [7]. Thus, single aor tocoronary bypass (composite graft to the left anterior descending artery) using a saphenous vein graft was indicated.

The pat ient underwent operat ion on November 24, 1994. The proximal end of the saphenous vein graft was anas tomosed to the thickened and rigid lateral wall of the composite graft with the help of a cuff ta i lored with a strip of equine per icard ium (Xenomedica; Baxter Heal th-

Ann Thorac Surg CASE REPORT SEKINE ET AL 1125 1995;60:1123-6 CORONARY GRAFT OBSTRUCTION

Fig 2. Postoperative angiography demonstrates the patent saphenous vein grt~ft and satisfacto~ fillins~ of the h'ft coronary system.

care Corp, Irvine, CA). The distal end of the saphenous vein graft was directly anastomosed to the left anterior descending coronary artery. The patient was weaned from cardiopulmonary bypass easily, and her postoper- ative course was uneventful. Postoperative angiography showed a patent saphenous vein graft, satisfacto o" filling of the left coronary system (Fig 2), and total occlusion of the left Dacron corona O' graft. She was discharged from the hospital on the 53 postoperative day, and has been well 3 months after operation.

C o m m e n t

Composite graft replacement of the ascending aorta and aortic valve, first described by Bentall and De Bono [1] in 1968, has become the standard technique for the surgical repair of aortic root disease including annuloaortic ecta- sia. The Cabrol operation is an alternative, using a small Dacron tube to reimplant the corona D' arteries, in which excessive tension exerted on coronary anastomoses and a late pseudoaneurysm can be avoided. The procedure employed in this case was the modification of Cabrol operation described by Piehler and Pluth [3]; separate coronary grafts were used for coronary reattachment. The long-term results of composite graft replacement with small coronary grafts have been reported to be satisfactory [4], and Cabrol and colleagues [2] reported no anstomotic complications of the Dacron coronary graft in a late follow-up. However, sudden death and global myocardial infarction have been the main cause of late cardiac death after the composite graft replacement [3, 4], and some similar cases with anastomotic stenosis of a coronary graft after the Cabrol operation were reported, in which urgent coronaw artery bypass was required [5, 6].

Size discrepancy between the 8-mm Dacron coronary grafts and native coronary arteries might cause turbulent flow at the coronary orifices. Ostial intimal hyperplasia resulting from this turbulent flow might be the reason for late anastomotic stenosis of coronary graft in this patient, in whom intimal i n j u ~ bv direct coronary perfusion

cannula insertion could be avoided. Although this is an exceptional complication after composite graft replace- ment using coronary, graft reimplantation, anastomotic stenosis between the coronary graft and coronary ostium is considered a possible cause of late cardiac events such as sudden death and fatal myocardial infarction. Recent advances in transesophageal echocardiography provide direct visualization and assessment of the left main coronary artery [8]. We suggest that a new noninvasive method such as t ransesophageal echocardiography should be added to the routine computed tomography and magnetic resonance imaging for follow-up after composite graft replacement using small coronary grafts, to facilitate in due time the diagnosis of left main coro- nary stenosis.

References

1. gentall H, De Bono A. A technique for complete replacement of ascending aorta. Thorax 1968;23:338-9.

2. Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replace- ment of the ascending aorta with reimplantation of coronary arteries: new surgical approach. J Thorac Cardiovasc Surg 1981 ;81:309 -15.

3. Piehler JM, Pluth JR. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondis- placed coronary ostia. Ann Thorac Surg 1982;33:406-9.

4. Svensson LG, Crawford ES, Hess KR, Coselli JS, Sail HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427-39.

5. Mestres CA, Betriu A, Pomar JL. Occlusion of the coronary perfusion graft: an exceptional complication after reconstruc- tion of the ascending aorta with the Cabrol technique. J Thorac Cardiovasc Surg 1989;98:302-3.

6. Murakami T, Yanagi H, Nagao T, Nawa K, Senoo Y, Teramoto S. A-C bypass operation after Cabrol procedure: a case report. I Jpn Assoc Thorac Surg 1986;34:118-22.

7. Jones EL, Lattouf OM, Weintraub SW. Catastrophic conse- quences of internal mammary artery, hypoperfusion. J Thorac Cardiovasc Surg 1989;98:902-7.

8. Yoshida K, Yoshikawa J, Hozumi T, et al. Detection of left main coronary artery stenosis by transesophageal color Doppler and two-dimensional echocardiography. Circulation 1990;81:1271 6.

I N V I T E D C O M M E N T A R Y

This is an illustrative observation of main coronary artery stenosis development in an 8-ram graft to the left main ostial button in a threateningly short period of 8 months. The angiographic comparison of the incriminated anas- tomosis directly after the operation with the situation 8 months later, in this case in a 38-year-old woman, may invite one to reconsider the use of the "small" fabric graft as a main coronary artery replacement if the alternative of direct implantat ion is feasible.

Obviously an end-to-side anastomosis of a ostium button to the straight aortic graft is hydrodynamical ly not the same as an end- to-end anastomosis of a coronary a r t e ~ with an 8-ram graft.

In fact, it is not only the turbulent flow that may cause the injury at the anastomotic site. We have to consider that the grafts are, in contrast to the arteries, not compli- ant (elastic) in their cross-sectional area but in their length. The coronary arteries are embedded in the sur-

1126 CASE REPORT RIBEI E I : \L Ann Thorac Surg CARCINOMA AND CONGENITAl I L N G M:\I FORMATION 1995;60:1126-8

rounding tissue, and as the main coronary flow is dia- stolic and their cross-sectional area is almost ideally down-sized in the length, they withstand the systolic hydrodynamic pressure peak without injury.

Especially in the initial postoperative period, the "small" 8-mm fabric graft has no support surrounding it except the original support of the coronary artery just distal from the main ostial button. The systolic pressure peak, "hammer ing" against the button, at that very moment unable to drain the flow, enhances this move- ment of the dissected artery with, as demonstrated in the patient reported by Sekine and associates, a near-fatal result.

However the same theoretical hydrodynamic consid- erations raise the following question: if a graft inclusion is indicated, how can one prevent such an injury, which may result in obstruction? The above-ment ioned consid- erations suggest use of as short a graft as possible and, as much as possible, immobilization of the anastomosis. The turbulent flow caused by the anastomotic discongru- ency, for example from 8 mm down to 3 mm, may benefit from "taper ing" the anastomosis by oblique end-to-end anastomosis, partially sacrificing the traditional button to preserve some laminar flow.

Even these suggestions seem speculative. 1 believe a computer-calculated model of these hydrodynamic pre- mises may help to correct some old aspects and open the mind to new considerations.

Josef G. Wncent, MD

Herz-Zentn¢m Bodensce CH-8280 Kreuzlingen, Switzerland

Bronchioloalveolar Carcinoma and Congenital Cystic Adenomatoid Malformation Michel E. Ribet, MD, Marie-Christine Copin, MD, Jacques G. Soots, MD, and Bernard H. Gosselin, MD

Unit of Thoracic Surgery, and Department ol Pathology, H6pital Calmette, Universit6 de Lille, Lille Cedex, France

We report on a 42-year-old woman in whom was discov- ered a symptomless peripheral radiologic excavated le- sion of the lung, which actually existed 3 years before. All investigations were negative. A segmentectomy was performed. Histopathologic examination proved a bron- chioloalveolar carcinoma in contact with a type 1 congen- ital cystic malformation of the lung. Such a malformation can be diagnosed late in adult life. The epithelial cells of the malformation might predispose to slow proliferation and malignancy, enhanced by smoking habits.

~Ann Thorac Su; N 1995;60:1126-8)

Accepted tor publicati~n April 22, 1995

Address reprint requests to Dr Ribet, L nil ol lhoracic Surgery, H6pital Calmette, F 59037 Lille Cedex, France.

© 1995 by The Society of 1 h~}ra~i~ ~,ur¢eon~

A 42 year-old woman had been smoking 15 cigarettes a day for 20 years. She had had no previous medical

histo D, before a radiologic abnormali ty of the lung was discovered. A review of former s tandard chest roentgen- ograms, performed during routine industrial medicine controls, showed a similar image going unnot iced 1, 2, and 3 years before (Fig 1). Clinical examination and bronchofibroscopy with cytologic, bacteriologic, and my- cologic studies were all negative. Computed tomographic scans confirmed the presence of a left basal pulmonary excavation surrounded by a zone of solidification (Fig 2). Surgical resection was recommended.

On June 15, 1993, a left anterolateral submammary thoracotomy showed what appeared as a soft lesion in the dorsal part of the lower lobe. A posterobasal classic dissection segmentectomy (S. 10) was performed, with hilar lymphatic dissection. The medias t inum was not explored. The postoperative course was uneventful and the patient left the hospital on the 9th day after operation.

Bacteriologic and fungal cultures of lung tissue re- mained negative. The pathology report described a 7 × 7 x 3-cm specimen, weighing 39 g, with a 2-cm cavity limited by a thick whitish wall on its superficial side and containing mucus. Microscopy showed several carcino- matous focuses, presenting with a tubular architecture and made of mucus-secreting, unistratified or multi- stratified columnar epithelium. Mitoses were few. Some of the tumoral cells formed papillomatous structures within the alveoli, which were either of normal size or dilated (Fig 3). The proliferation was in contact with a cavity lined with unistratified epithelium, ciliated in places. Alveoli were filled with macrophagic cells and edema. Small bronchioles were normal or dilated, with clusters of lymphoid cells in their walls (Fig 4). Pleura and hilar lymph nodes were not invaded. The conclusion was bronchioloalveolar carcinoma in contact with type I con- genital cystic adenomatoid malformation.

We decided to follow up the patient at 6-month inter- vals and to complete the lower lobectomy and mediasti- hal lymph nodes resection in case of recurrence. No further treatment was administered. Twenty-two months later, the patient was in good condition and her chest roentgenogram and computed tomographic scans were normal.

C o m m e n t

Bronchioloalveolar carcinoma, a variety of adenocarci- noma, represents less than 5% of lung carcinomas. It often occurs in young patients and is not affected by sex. The role of inhaled pollutants or toxins seems less evi- dent for bronchioloalveolar carcinorna than it is for the other varieties of bronchial carcinoma. It shows as a solitary nodule, as multiple nodules, or as a diffuse lesion. It is made of cuboidal, columnar, or hob-nai l - shaped cells. There is a mucigenic variety of bronchi- nloalveolar carcinoma. It may be associated with pulmo- nar} scarring or fibrosis [1].

Congenital cystic adenomatoid malformation (CCAM) of the lung is classified, according to Stocker and associ- ates [2], into three types: type 1 (75%), one or several

0003-4975/95/$9.50 SSDI 0003-4975(95)00494-6