Simultaneous

c,seMedicalJournal2005;118(8):699—701?699?

    ;Casereport

    ;Simultaneouscoronaryarterybypassgrafting,replacementofthe

    ;innominatearteryandsubtotalthyroidectomyina61year—old

    ;patient:acase—report

    ;JensLitmathe,MuhammedKurt,KlausGrabitz,Wolfram|r.KnoefelandEmmeranGams

    ;Keywords:concomitantoperation?ischemicheartdisease?innominatearteryretrosternalgoiter

    ;Themanagementofpatientswithcoexisting ;_diseaseswhoundergocardiacsurgeryisa

    ;subiecltocontroversiaIdiscussionsastheoperative ;mortalityisthoughttobeincreasedbysimultaneous ;procedures.Traditionally.thesurgicalprocedures ;havebeenstagedwiththecardiacsurgery

    ;performedfirstfollowedbythevisceraIoperationat ;aIaterdate.However.especiallyincasesof ;malignantdiseasefe.g.pulmonaryorabdominaI) ;thecurativetreatmentisdelayedandtheadditionaI ;costsoftwosettingshavetobeconsidered.. ;AIthoughencouragingresultshavebeenreported ;concernlnflsimultaneouspulmonarytUmor ;resection.carotidendarterectomyorabdominaI ;aneurysmrepair.2-5detailedknowledgeconcerning ;furthercoexistingnon-cardiacdiseasesrequiring ;surgicaItherapyisstilIIacking.Insomeextremely ;rarecasespatientssu仟erfrOmmorethaniustone

    ;coexistingdiseaseofdifferentorigins:thecurrent ;reportfocusesona61?-year?-oldfemalepatient ;sufferingfr0mischemicheartdisease.occlusionof ;theinnOminalearteryandaretrosternaIgoiterasan ;incidentaIfinding.Shewastreatedina

    ;simultaneousprocedurewiththreeoperationsinonly ;onesetting.Theperioperativefeaturesofthis ;speciaIcasearereflectedinthefollowingcourse. ;CASEREPORT

    ;Thepatientwasadmittedtoourinstitutionafter ;cardiaccatherizationthatwascarriedoutdueto ;anginouscomplaintsaccordingtoCCSIeveIII一?.

    ;Additionallyshereportedondysnoeaaccordingto ;NYHAII.AsknownfrOmtheanmnesisshealready

    ;sufferedfr0mmyocardiaIinfarctionoftheanterior ;walIfiveyearsago.NutritionaIstatuswasobese. ;furthercoexistingdiseaseswereknown,suchas ;renaIarterystenosisonbothsideswhichwere ;alreadyperCutaneOuSIVd_latedandstentedin1998 ;ontherightside.RenaIfunctionwaschronically ;impairedwithaserum-creatinineof16mg/L. ;however.withoutIOSSofdiuresis.Besidesthat,a ;formernicotineabuse,hyperlipidemiaandperipheral ;vasculardiseasedegreellaaccordingtoFontaine’s

    ;classificationofbothIegswereknown.

    ;Furthermore,thepatienthadalreadyundergone ;thrombendarterectomyoftherightinternaIcarotid ;arteryfICA)fouryearsago.Currently,she ;reportedontransientischemicattacksfTIA)leading ;toangiographyofthesuparaaorticbranches.Inthe ;frameofthisexaminationacompleteocclusionof ;theinnominatearteyandamoderatestenosisofthe ;IeftICAcouldensuredfFig.).

    ;Cardiaccatherizationhadalreadybeenperformed ;priortoadmissioninourhospitaIandshowedatriple ;vessel-diseasewithoutthepossibilityofinter- ;ventionaItreatment.Leftventricularfunctionwas ;assessedtobeimpairedwithanejection-fraction ;fEF)of33%.

    ;Routineevaluationoflaboratoryanalysisshowedno ;distinctpathologicchanges;thyroidmetabolismwas ;consideredtobenormal,justwithaslightly ;suppressedthyroid-stimulatinghormone(TSH),but ;DepartmentofThoracicandCardiovasculatSurgery,Heinrich—

    ;Heine—UniversityHospital,D-40225Duesseldorf,Germany ;(LitmatheJ.KurtMandGamsE)

    ;DepartmentofVascularSurgeryandKidneyTransplantation, ;Heinrich—Heine—UniversityHospita1.D225Duesseldorf. ;Germany(GrabitzK)

    ;DepartmentofVisceralandGeneralSurgery.Heinrich—Heine—

    ;UniversityHospital,D_40225Duesseldorf,Germany(KnoefelwT)

    ;Correspondenceto:Dr.JensLitmathe,DepartmentofThoracicand

    ;CardiovascularSurgery,Heinrich—Heine—UniversityHospital, ;Moorenstrasse5.D-40225Duesseldorf,Germany(Tel:49—211—

    ;8l18331.Fax:49-2l1—8l18333.1itmathe@med.uni—

    ;duesseldorf.de)

    ;

    ;Chin72(205:t18l8J:699—70,

    ;Fig.Completeocclusiorloftheinnominateartery ;(arrow】.preoperativeangiography

    ;withnOrmalperipheralhormones

    ;X-rayofthechestshowedagloballyenlarged ;cardiacsilhouette,signsofmoderatepulmonal’

    ;venouscongestionbutnoclueformediastinal ;pathologies.

    ;0perativedetails

    ;Uridergeneralanesthesiaamedianstemotomywas ;performed.AftercarefuIpreparationofthe ;mediastinaltissuearetrosterrlaIgoiteraffectingthe ;exposureoftheheartandgreatvesselsbecame ;incidentallyapparent.Thus,anendocrinesurgeon ;wasconsultedwhoperformedasubtota1

    ;thyroidectomyenlargingtheincisiontothejugulum ;andusinganadditionaIKocher’saccess.Histologic

    ;examinationshowedafterwardsamuitinodular ;goiter.

    ;UnderstablehemodynamIcconditionscardiac ;surgeonsharvestedtheIeftinternaIthoracicartery ;(LITA)andlhreevenousgrafts(V.saphena ;magna)Afterapplicationof300IU./’kgbodyweight

    ;heparine.extracorporealcirculation(ECC).usinga ;slightlyatypicalrightsidedaccessattheascending ;aortaforarterialcannulation.wasestablishedand ;coronaryarterybypassgrafting(Ll1_AandIhree ;additionaIvenousgraftswascarriedoutPeffusion ;limewas100minutes.myocardialischemielime39 ;minutesAlterweaningfr0mtheECCwithmoderate ;catecholamine-substitution(0.5mg/hsuprarenine) ;anddec.annulationlhevascularprocedurewas ;carriedout:replacementoflheinnOminaleartery ;waspeormedusinga11mmdacron-Prothesisas ;end—to—endanastomosisbetweentheformer

    ;cannulationareaoflheascendingaortaandlhe ;commoncarotidarterySomato—senseryevoked

    ;potentialsweremonitoredatanytimeoflheentire ;operationFinallypericardialaswelIassternaIand ;woundclosurewerecarriedoulintypicaImanner. ;Thedurationoflheentireoperationwasdetermined ;within433minutes.

    ;PostoperativecourseandfurtherfoIlow—up

    ;ThepatientwasventilatedeIectivelyattheintensive ;careunilf1CU)andextubatedafter36hourswhen

    ;vigilanceandoxygenationweresatisfactory. ;Moderatecatecholamine—substitutionwasnecessary ;untilextubationAtthethirdpostoperativeday ;diuresisimpairedandthepat1entbecameanuric ;despiteintensivefurosemid—stimulationSimuI-

    ;taneouslyretentionparametershadincreased ;(creatinine45mg/L,urea1000mg/L)sothal ;in1errnmenthemodialysishadtobeperformedAtter ;fOUrdaysofdailyhemodialysisdiuresisrecovered ;withasufficientrenaIfunctionThepatientcouldbe ;transferredlothenOnnalwardWoundhealingwas ;uneventfu1andthepatientcouldbedischargedtoa ;rehab…tationcenteratday19aftersurgery

    ;Threemonthsaftertheoperationthepatient ;presentsherselfinasatisfactoryconditionwithan ;improvedloadingcapacity(NYHAI)andwithout ;angJnouscomplaintsAclueforcerebralevents ;couldnotbeobservedThyroidmetabolismhad ;shownhypothyroidismintheearlypostope-rative ;course;itbecame,however,physiologicusinga ;substitutiontherapyconsistingof150gL—

    ;thyroxine

    ;DlSCUSSION

    ;Traditionallycardiologicpatientssufferinqfr0m ;coexistingdiseasesotherthancardiacoriginshave ;beentreatedoperativelylndifferentsettings. ;However.inrecenlyearsmanyattemptshavebeen ;madeinordertoavoidonemoreoperationand ;anesthesiawiththeaimlofulfilltwooperationsin ;onlyonesetting.Theaccompanyingnon?cardiac ;diseasesarevarious:themethodofsimultaneous ;carotidendarterectomycombinedwithopenheart ;surgeryhasbeenreportedbydifferentauthorsand ;hasbecomearoutineprocedurenowadays. ;EvagelOpOu10sandcolleaguesreportonaseries ;ofaltogether313patientswhohaveundergonesuch ;procedureBesidesthaijthasbecomeanaccepted ;COnGapttotreatpatientswithcardiacdiseaseand ;concomitanlpulmonarycancerinthesamesetting ;

    ;ChineseMedicalJournal2005;118(8):699—701?7O1?

    ;asasimultaneousoperation.Dantonand ;colleagues0reportonaseriesof13patientswith ;anacceptableperioperativeriskandlong-term

    ;foIlow-up.Thisisinagreementwithotherauthors, ;someofthemperformsuchcombinedprocedures ;notonlyasopenheartsurgerybutalsoasanoff- ;pumpoperation.AfurtherreviewoftheJiterature ;showssingularilyotheroriginsofcombinedcardiac ;withgeneralorvascularsurgicalprocedures,such ;asrepairofabdominalaneurysm77correctionof ;pectusmalformationsincaseofreplacementofthe ;ascendingaorta..

    ;Toourknowledge,however,wereportforthefirst ;timeonaconcomitantcoronaryarterybypass ;grafting(CABG).replacementoftheinnOminate ;arteryandthyroidectomy.Singularcaseshave ;alreadyshowneithercombinedcentralvascularand ;heartsurgeryorcombinedheartandendocrine ;surgery,especiallyofthethyroidgland:Kolvenbach ;andcolleaguesreportonaseriesof32patients ;withcompletereplacementoftheinnOminateartery ;usingaDacronprothesiswithanexcellent ;perioperativeoutcomeand100%long-termPatency- ;rate.Wolfhardandcolleaguesaswellas

    ;Matsuyamaandcolleagues..reportoncombined ;thyroidectomyandcardiacsurgery.However,the ;patient-cohortisprettysmallorrepresentseveniust ;asinglecase.

    ;Timingofendocrinesurgeryincardiacpatientsis ;stilldiscussedcontroversially.12ltwouldbe ;prohibitivetotermthethyroidoperationincasesof ;cardiacriskpriortocardiacsurgery.Theanatomic ;vicinityofboththeinnOminatearteryandthethyroid ;gland,especiallyincasesofretrosternalgoiter,to ;thethoracicorgansfaciliatesthesurgicalfeasibility ;ofthreeprocedures.1nclusionofthesethreeorigins ;inthesameoperativefieldallowspromptcardiac ;interventionintheeventofpotentiallyfailing ;hemodynamicscomplicatingendocrineorvascular ;surgery.

    ;Theextensionoftheentiresurgicalprocedure.i.e. ;thecombinationwiththeoperationofcardiacorigin. ;however,hastobementionedasaprobablefactor ;thatmayimpairtheimmediateperioperative ;outcomewithallwellknownadverseevents.Our ;currentcase,thatisreportedforthefirsttime. ;indicatesacceptabletimesforperfusionand

    ;ischemia,seeingthatthewholedurationsof ;operationandanesthesiaareprolonged.This, ;however,doesnotresultinseriouscomplications. ;eveninthepresenceofreducedleft-ventricular ;function.

    ;Besidesthat.proceedinginsubsequentprocedures ;meanstoundertakere-dO-surgerythatisknownto ;impairthepostoperativeoutcome.Thus.wedraw ;theconclusionthatcombinedopenheartsurgeryin ;combinationwithcentralvascularsurgeryandeven ;withadditionalendocrinesurgerycanbeperformed ;withanacceptableimmediateperioperativeriskand ;shouldtakepreferenceofproceduresintwooreven ;threedifferentsettings.

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    ;(ReceivedDecember3,2004)

    ;EditedbyWANGMou-yueandL|UHuan

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