Denny John T, Mungekar Sagar, Landgraf Benjamin R, McRae Valerie A, Ibrar Sajjad, Kiss Geza K, Bonitz Joyce, Cohen Shaul, Tse James T
Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
SAGE Open Med Case Rep. 2018 Mar 28;6:2050313X18767228. doi: 10.1177/2050313X18767228. eCollection 2018.
Left internal mammary artery grafting is commonly used in elective coronary artery bypass graft surgery. We report a near-fatal case with graft kinking upon sternal closure due to distended, emphysematous lungs impinging on the mammary graft. After the sternum was closed, the patient suffered a severe hemodynamic deterioration. Surgical examination revealed kinking of his left internal mammary artery upon sternal closure due to distended, emphysematous lungs impinging on the mammary graft. Using an off-bypass technique, the kink in the mammary graft to the left anterior descending artery was removed by moving the origin of the left internal mammary artery to a hooded graft of a saphenous vein graft instead. In this position, the graft no longer was impinged upon by the distended emphysematous lungs. Subsequently, the patient's sternum was closed without hemodynamic impingement. Although chronic obstructive pulmonary disease is well described to increase complications in coronary artery bypass graft surgery, it has not been previously associated with the kinking of a left internal mammary artery. This report highlights another contribution that chronic obstructive pulmonary disease can make to increased morbidity following coronary artery bypass graft surgery and alerts readers to watch for this complication in susceptible patients.
左乳内动脉移植常用于择期冠状动脉旁路移植手术。我们报告了一例近乎致命的病例，患者在胸骨关闭时移植血管发生扭结，原因是膨胀的肺气肿肺压迫了乳房移植血管。胸骨关闭后，患者出现严重的血流动力学恶化。手术检查发现，由于膨胀的肺气肿肺压迫乳房移植血管，患者左乳内动脉在胸骨关闭时发生扭结。采用非体外循环技术，将左乳内动脉的起始端移至大隐静脉移植血管的带帽移植处，从而消除了至左前降支动脉的乳房移植血管的扭结。在此位置，移植血管不再受到膨胀的肺气肿肺的压迫。随后，患者的胸骨顺利关闭，未出现血流动力学影响。虽然慢性阻塞性肺疾病被充分描述为会增加冠状动脉旁路移植手术的并发症，但此前它与左乳内动脉扭结并无关联。本报告强调了慢性阻塞性肺疾病对冠状动脉旁路移植手术后发病率增加的另一贡献，并提醒读者在易感患者中留意这种并发症。
