Left Radial Artery Research Articles

Extrafascially Harvested Radial Artery in CABG: Technique of Harvest, Complications, and Mid-Term Angiographic Patency

The initial use of radial artery (RA) for myocardial revascularization was abandoned due to high incidence of early occlusion. The revival of radial artery graft use was attributable to the improved harvesting techniques as well as the introduction of antispasm prophylaxis by calcium channel blockers. Various techniques of harvesting RA have been described and extrafascial harvest is one of the techniques to minimize trauma during harvest. The immediate arm complications and mid-term angiographic patency of the radial artery grafts harvested using extrafascial no-touch technique and used as a conduit for myocardial revascularization were not documented well in the literature. Between January 1997 and February 2003, 385 patients were operated for coronary artery bypass grafting using radial artery graft as one of the conduits. We used extrafascial no-touch technique and a coagulation current cautery at a strength of 10 to 15 W to control the bleeding during the blunt dissection of the radial artery. The complications related to the radial artery harvest were prospectively recorded and analyzed. This conduit was used as a free graft in 272 patients, left internal mammary artery and radial artery Y graft in 61 patients, Right internal mammary artery, and radial artery composite in situ graft in 52 patients. The radial artery donor arm in these patients was evaluated for complications. Angiographic evaluation of the radial artery graft was carried out randomly in 51 patients and angiography was done after an interval of 6 to 72 months (mean 29.55 +/- 21.77 months). In two patients, although the preoperative Allen test was negative, the radial artery was not harvested after completion of the dissection and was left in situ because the pulse could not be felt in the radial artery distal to the clamp after trial occlusion of the mid part of RA. The arm complications noticed were cutaneous parasthesias in 9 patients (2.33%), which subsided in 4 weeks, stitch abscess and superficial wound infection in 4 patients (1.03%), hematoma/seroma treated with drainage in outpatient department in 3 patients (0.78%), and wound infection requiring open drainage in an operating room in one patient (0.76%). Angiographically radial artery was patent in 48 of 51 patients (94.11%). The extrafascial technique of radial artery harvest is safe and an easily reproducible method with minimal arm complications and good mid-term clinical and angiographic results. The mid-term angiographic patency rates of RA harvested using this technique are comparable to that of the published results of intrafascially harvested radial artery grafts and left internal mammary artery grafts.

Total arterial revascularization with internal mammary artery or radial artery π graft configuration

To investigate the clinical use of pi graft in total arterial revascularization and its outcomes, a retrospective analysis of 23 patients out of 1000 patients undergoing total arterial coronary bypass surgery with a pi graft between September 1994 and December 2004 was performed. In the selected patients for the management of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip with the left internal mammary artery (LIMA) or radial artery (RA), the main stem of pi graft, to the left anterior descending coronary artery (LAD) will not work and the right internal mammary artery (RIMA) or right gastroepiploic artery (RGEA) cannot pick up the diagonal/intermediate ramus, hence the LAD and diagonal/intermediate ramus were grafted with a mini Y graft using the distal segment of LIMA, RIMA, RA or RGEA, together with the bilateral internal mammary artery (BIMA) or LIMA-RA T graft to compose pi graft. Twenty-three patients (18 males, 5 females) underwent the pi graft procedure. There were no deaths or episodes of myocardial infarction, stroke, and deep sternal wound infection. One patient required reopening for controlling bleeding. Until the end of 2004, during a mean follow-up of 81.0 +/- 28.4 months, no angina needing re-intervention or operative therapy or coronary related death occurred. In conclusion, in patients with specific coronary artery anatomy/stenosis, the BIMA (sometimes LIMA with RA or RGEA) pi graft can be successfully performed for total arterial revascularization with good midterm outcomes.

Triple Coronary Bypass in a Child with Homozygous Familial Hypercholesterolemia

Here we report triple coronary bypass procedure in a 12-year-old girl with familial homozygous hypercholesterolemia and extensive coronary atherosclerosis. She had successful cardiopulmonary resuscitation at home by her father 4 months before the operation. Total cholesterol level was 1300 mg/dL initially without antilipidemic treatment. Extensive three vessel disease with right coronary proximal stenosis and left coronary ostial stenoses was determined by angiography. Left internal thoracic artery, left radial artery, and saphenous vein grafts were used for coronary revascularization. Saphenous vein graft to right posterior descending artery, radial artery graft to obtuse marginal artery, and LITA to left anterior descending artery anastomoses were performed consecutively. Ten months after the operation, she is in good condition under intensive antilipidemic therapy and weekly lipid apheresis.

Rescue Visceral Revascularization Without Direct Aortic Surgery to Treat Malperfusion Complicating Type B Aortic Dissection

A 75-year-old woman presented with superior mesenteric artery and celiac artery occlusion associated with acute type B dissection. Emergent bypass grafting by using the right gastroepiploic artery and the left radial artery for the superior mesenteric artery and the celiac artery was performed without bowel resection.

CORONARY REVASCULARIZATION WITH THE LEFT INTERNAL THORACIC ARTERY AND RADIAL ARTERY. COMPARISON OF SHORT-TERM CLINICAL EVOLUTION BETWEEN ELECTIVE AND EMERGENCY SURGERY

Left internal thoracic artery-to left anterior descending artery grafting has become a fundamental part of coronary artery bypass grafting. This grafting has led to increased use of other arterial conduits, of which the radial artery is most popular. Whether radial grafting can be used in the emergency patient is not known. This study compares the short-term clinical evolution between elective vs emergency coronary artery bypass grafting surgery with left internal thoracic artery and radial artery. A retrospective study of 47 patients who underwent elective or emergency coronary artery bypass grafting from 1996 to 2003. All patients had coronary stenosis>70% in all target vessels. Only the left internal thoracic artery and radial artery were used as grafts. Patients were divided into elective group (23 patients) and emergency group (24 patients). Emergency criteria were unstable angina and/or critical coronary stenosis with high risk for acute myocardial infarction. Groups were similar for age and number of diseased vessels. The mean number of left internal thoracic artery grafts per patient in the elective and emergency groups were respectively 1.17 and 1.38 (P=.17). The mean number of radial artery grafts per patient in the elective and emergency groups was respectively 2.26 and 2.08 (P=.48). The 30-day mortality was 0. There was no postoperative cardiogenic shock. The elective group had 1 acute myocardial infarction (4.4%) postoperatively, and emergency group had 5 (20.8%). A nonsignificant trend towards acute myocardial infarction was noted in the emergency group (P=.18). Intensive care unit and postoperative stay were similar in both groups. Coronary artery bypass grafting using left internal thoracic artery and radial artery accomplishing complete revascularization can be performed in emergency patients with results similar to those for elective patients.

Bradykinin Preconditions Postischemic Arterial Endothelial Function in Humans

Arterial endothelial dysfunction is an important mechanism of tissue injury caused by ischemia-reperfusion (I/R). Earlier studies of I/R have shown that intracoronary preinfusion with 2.5-5 microg/mL bradykinin (BK) could alleviate the postischemic myocardial damage. Using an experimental human model of I/R, we investigated whether preceding infusion with BK could prevent the I/R-induced arterial endothelial dysfunction. The left radial artery (LRA) from 16 healthy male adults, 18 to 30 years old, was submitted to I/R by completely occluding the left brachial artery with a pressure tourniquet for 20 minutes (ischemia), followed by its release (reperfusion). Prior to I/R, half of the subjects were randomly assigned to receive either BK (5 microg/mL) or saline, both being infused into the left brachial artery (0.5 mL/min, 10 min). The infusion was followed by a 10-minute drug-free period. The endothelial function of the LRA was studied by measuring the flow-mediated dilation (FMD) at baseline (prior to drug infusion), and at 15 minutes of reperfusion. In addition, baseline radial artery diameter, plasma nitrate, and von Willebrand factor were measured at these time points, and immediately before I/R (pre-I/R). BK had no effect on the pre-I/R plasma nitrate (p > 0.5 vs. saline) and diameter of LRA (p > 0.5 vs. baseline). At 15 minutes of reperfusion, FMD was significantly decreased in the saline group as compared to baseline (absolute dilation: 0.08 +/- 0.03 vs. 3.02 +/- 0.8 mm, respectively, p < 0.01; percentage dilation: 3 +/- 0.6 vs. 8 +/- 0.6%, respectively, p < 0.001), but it remained unaffected in the BK group (absolute dilation: 3.06 +/- 0.9 vs. 3.27 +/- 0.8 mm, respectively, p > 0.5; percentage dilation: 7 +/- 0.7 vs. 8 +/- 0.8%, respectively, p > 0.5). A similar trend was observed with regard to plasma nitrate, which remained unchanged in the BK group (37.01 +/- 4.14 vs. 39.14 +/- 4.49 micromol/L, p > 0.5) but decreased in the saline group (35.91 +/- 3.03 vs. 28.91 +/- 2.81 micromol/L, p < 0.1). Infusion of BK could protect the arterial endothelial function against I/R injury in humans, possibly in part by preserving the endothelial NO availability. The findings support the use of BK in the prevention of tissue injury due to I/R and might reveal an additional mechanism whereby ACE inhibitors exert their preconditioning effects on myocardium.

Revascularization Using Arterial Conduits for Abdominal Angina Due to Isolated and Spontaneous Dissection of the Superior Mesenteric Artery

Isolated spontaneous dissection of the superior mesenteric artery is rare, and the surgical treatment is not established. We performed successfully total revascularization using arterial conduits (left radial artery and right epigastric artery) and present here the first report to our knowledge of a surgically treated case.

Lack of Durability of Surgical Arterialization of Coronary Veins for the Treatment of Ischemic Heart Disease

Coronary venous arterialization with a catheter-based system has renewed interest in this therapy for the revascularization of areas that cannot be treated by conventional coronary artery bypass graft or angioplasty. However, the durability of the venous system to supply arterial pulsatile blood is still a matter of debate. We report the outcome of four patients that underwent elective coronary artery bypass grafting of the left coronary system and in addition had selective arterialization of the posterior vein due to ungraftable poor distal vessels of the right coronary artery. Complete revascularization of the left side was achieved using the left internal mammary artery and the left radial artery. One vein graft was anastomosed to the postero-inferior vein in three cases and to two postero-inferior veins in the fourth case. No perioperative complications were observed and after 24 months of follow-up; all patients were angina free and without any symptoms of heart failure. The 24 months follow-up also showed (i) normal exercise test in all patients, (ii) ischemic changes in dobutamine stress echocardiography in the areas corresponding with the venous arterialization in two cases, and (iii) occlusion of the graft supplying the coronary veins in the three patients that accepted to undergo selective angiogram. In conclusion, these results indicate that arterialization of the coronary veins is not durable and that it is unlikely that this strategy is a useful technique for the revascularization of the ischemic myocardium.

Coronary Artery Bypass Grafting In A Patient With Dextrocardia With Situs Inversus: A Case Report

We present a 47 year old male patient with dextrocardia and situs inversus who underwent successful coronary artery bypass with cardiopulmonary bypass. Vessels revascularized included the left internal mammary artery to the left anterior descending artery, the right internal mammary artery to the circumflex obtuse 2 branch and the radial artery to the right coronary artery posterior descending branch. The patient was discharged to his home after an uneventful recovery. Only a few similar cases of myocardial revascularization in patients with dextrocardia have been reported so far, and this is the first procedure, in patients with dextrocardia, performed with all arterial revascularization. A 47 years old male patient admitted hospital with chest paint. He had anginal complaints before. The electocardiography revaled inferior acute myocardial injury. The patient was hospitalised. With the antiischemic medication his angina revealed. ST segment elevations in the inferior leads returned to the baseline level. The patient had a history of situs inversus with dextrocardia. The past medical history was significant for cigarette smoking, hyperlipidemia and hypertension. On the second day a coronary angiography was performed. On the coronary angiogram the patient was found to have 90% stenosis of the left anterior descending (LAD), 80% of the second obtuse marginal (OM2) branch of the left circumflex coronary artery and 80% stenosis of right coronary artery. There were no associated congenital cardiac abnormalities. Elective coronary artery bypass surgery planned. Under general anestesia a midline sternotomy was performed (figure 1). Figure 1 Figure 1: Intra-operative view LIMA,RIMA and a left radial artery were harvested. Standart aortic and right atrial (left sided) canulation was done. Myocardial protection was obtained with systemic hypotermia 28 C and blood cardioplegia. The radial artery was anastomosed end-to-side to the right corornary artery posterior descending branch and the right internal mammarian artery was anastomosed with an end-to-side fashion to the obtuse 2 branch of the circumflex artery. Llastly, the left internal mammarain artery was anastomosed with an end-to-side fashion to the left anterior descending coronary artery. Under the same cross clamp period proximal anastomose of the radial artery was done to the Coronary Artery Bypass Grafting In A Patient With Dextrocardia With Situs Inversus: A Case Report 2 of 3 aorta. The operation was uneventful. Cross clamp period was 35 minutes. Cardiopulmonary bypass time was 45 minutes. The patient was transfered to intensive care unit. Post operative period was uneventfull. Patient was discharged from the hospital on the sixth day.

Revascularização cirúrgica do miocárdio com enxerto composto de artérias torácica interna esquerda e radial: comparação do fluxo sangüíneo para artéria coronária esquerda com a técnica convencional

INTRODUCAO: Os enxertos compostos tem sido frequentemente utilizados na cirurgia de revascularizacao do miocardio (RM). Entretanto, permanece indefinido se essa tecnica e capaz de oferecer o mesmo fluxo sanguineo (Q) aos ramos da arteria coronaria esquerda (CE) que a tecnica convencional. O objetivo e comparar o Q total aos ramos revascularizados pelas arterias toracica interna esquerda (ATIE) e radial (AR) nas tecnicas compostas e convencional. METODO: Estudamos 42 pacientes distribuidos, aleatoriamente, conforme a tecnica de RM utilizada. Grupo A ou ATIE e AR composta em Y(n=14). Grupo B ou ATIE e AR composta modificada [enxerto intercoronariano com AR e anastomose da ATIE sobreposta a AR ao nivel da arteria interventricular anterior (DA), n=14]. Grupo C ou ATIE pediculada para DA e AR em posicao aorto-coronariana (n=14). Trinta e um pacientes foram submetidos a fluxometria (Fx) com cateter-guia doppler de 12-MHz (0,014 polegada, Flowire, Jometrics Inc.), no pos-operatorio imediato. A reserva de fluxo coronariano (RFC) foi calculada pela determinacao da media da velocidade de pico (APV) em hiperemia apos administracao de adenosina. RESULTADOS: A APV em repouso no inicio da ATIE foi, no grupo A, 28,4±4,8 cm/s; no grupo B, 34,4±7,9 cm/s (p=0,0384 x C) e, no grupo C, 25,8± 8,6 cm/s. A RFC foi de 2,1 ± 0,4, 2 ± 0,3 e 2±0,4 nos grupos A, B e C, (p=0,7208). O Q total distribuido aos ramos da CE revascularizados foi, no grupo A, 110±30 ml/min, no grupo B, 145±59 ml/min e, no grupo C, 133±58 ml/min (p=0,3232 A, B x C). CONCLUSOES: Nao houve diferenca significativa do Q total oferecido ao territorio da CE revascularizado pelas tecnicas de EC e convencional. A RFC da ATIE nos grupos compostos foi satisfatoria.

Cutaneous Zygomycosis Following Attempted Radial Artery Cannulation

A 70-year-old man was seen in a hospital consultation for evaluation of cellulitis of the left arm. The patient had multiple medical problems, including advanced liver disease due to alcohol, diabetes mellitus, congestive heart failure, atrial fibrillation, chronic renal in sufficiency, and hypopituitarism requiring steroid replacement. Most recently, he was admitted to the intensive care unit, where he required intubation and mechanical ventilation support following respiratory failure secondary to pneumonia. At that time, an attempt was also made to place an arterial line in the left radial artery. The patient had multiple areas of ecchymosis on both arms. A large bulla was found on the lateral aspect of the left wrist several days after the attempted arterial line placement. Subsequently, the lesion drained serosanguineous fluid, and, during the next 2 days, it ulcerated with necrosis extending around the wrist and to the elbow. He was started on ampicillin/sulbactam and clindamycin for presumed necrotizing fasciitis. The surgical service performed a very limited debridement,which was partially limited by his coagulopathy from liver disease. The initial tissue culture was positive only for Enterococcus faecium. At the time of the consultation, his temperature was 95' F (35 degrees C), pulse 82 bpm, respirations 16 BPM, and blood pressure 101/56 mmHg. He was awake but not oriented or responsive. His cardiopulmonary exam was unremarkable. Abdominal exam disclosed ascites. His extremities were all grossly edematous with multiple ecchymoses. His left forearm had a circumferential area of ecchymosis and necrosis with macerated margins, sparing only the lateral ulnar epicondyle, and involving deeper structures of subcutaneous fat and muscle(Figures 1-2 showing evolution of the lesion in a period of 1 week). Small tissue clippings were taken from the edge of the lesion and placed on culture plates. By the next morning, the patient's tissue culture grew a mold, later identified as Rhizopus. Amphotericin B was initiated. Surgical intervention (wide debridement with potential conversion to amputation of the left arm) was considered to offer little benefit in view of the patient's multiple and severe comorbidities and his poor prognosis. Amphotericin B was then stopped; the patient died within a week from his multiple medical complications. The family refused an autopsy.

Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm

Background Use of the radial artery as a conduit for coronary artery surgery has increased dramatically. It has been assumed that blood flow to the forearm will not be compromised by its removal. Methods Sixteen patients who had the left radial artery harvested for coronary surgery at least 3 months earlier were studied. The right radial artery was not harvested. The radial, ulnar, and brachial artery diameters and flows were measured using pulsed wave Doppler with a 15-MHz linear array transducer. Measurements were performed at rest, with the right radial artery compressed, and after ischemia with forearm exercise. Results At rest, the (mean ± SE) diameter of the left ulnar artery was consistently greater than the right (2.4 ± 0.09 versus 2.1 ± 0.09 mm, p = 0.001) as was flow (74 ± 9.9 versus 48 ± 8.5 mL/min, p = 0.005). There was no difference between diameters or flows in the brachial arteries. After compression of the radial artery, flow increased in the right ulnar artery from 39 ± 8.0 to 72 ± 17.6 mL/min ( p = 0.019) without an increase in ulnar artery size and was not different from the left ulnar artery flow at rest ( p = 0.440). After ischemic forearm exercise, flow increased in the two brachial arteries almost equally (left, 348 ± 50; right, 371 ± 63 mL/min). Conclusions Blood flow to the forearm and hand is not compromised by harvest of the radial artery.

One-lung ventilation, partial bypass and totally endoscopic CABG

One-lung ventilation, partial bypass and totally endoscopic CABG

Vascular abnormalities in patients with autosomal dominant polycystic kidney disease--the influence on arteriovenous fistula creation.

Patients with autosomal dominant polycystic kidney (ADPKD) present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of aorta and abdominal aortic aneurysms. The aim of our study was to investigate whether vascular abnormalities that occur in wrist vessels, make native arteriovenous fistula creation difficult in this group of patients. The problem was analyzed retrospectively in 783 patients with chronic kidney failure who had had arteriovenous fistula created in our centre in the period between 1991 and 2001. ADPKD was the cause of terminal renal failure in 57 patients (7.3%). These were 31 men and 26 women aged 28 - 69 years (52 +/- 16 years on average). A difference between left and right radial artery diameters and a narrow radial artery (below 2 mm), unsuitable for fistula creation, occurred in 12% of patients with ADPKD and in 0.38% of other patients. Instead of a cephalic vein in the typical place, a few small vessels were present in 14% of patients with ADPKD and in 2.17% of patients with other causes of renal failure. Our experience shows a higher incidence of wrist vascular abnormalities in patients with ADPKD. This decreases the possibility of wrist native arteriovenous fistula creation in this group of patients.

Dexmedetomidina como droga adjuvante no despertar transitório no intra-operatório de correção cirúrgica de escoliose: relato de caso

Scoliosis is a spinal defect very often requiring surgical correction. A uniqueness of this correction is the need for intraoperative emergence and leg movement (wake up test) to rule out central nervous system (CNS) injury after correction of the orthopedic defect. In our report, dexmedetomidine was associated to total intravenous anesthesia with propofol and remifentanil to induce sedation, analgesia and ventilatory stability during wake up test in patient submitted to surgical scoliosis correction.Caucasian, female patient, 16 years old, physical status ASA I, with lumbar and thoracic scoliosis in 12 levels, submitted to surgery under general anesthesia. Patient was premedicated with 2 mg oral lorazepam the day before and 90 minutes before surgery. Venoclysis and left arm radial artery puncture were performed after monitoring; right subclavian vein was punctured with double lumen catheter for drug infusion and hemodynamic evaluation. Anesthesia was induced with 1 microg.kg-1 remifentanil and propofol in target-controlled infusion, for 3 microg.mL-1 plasma concentration. Neuromuscular block was achieved with 0.5 mg.kg-1 atracurium. Anesthesia was maintained with 0.4 microg.kg-1.h-1 dexmedetomidine and 0.3 microg.kg-1.min-1 remifentanil in continuous infusion, and 3 microg.mL-1 propofol in target-controlled infusion. At lower limbs movement test, propofol and remifentanil were withdrawn, but dexmedetomidine was maintained. Patient returned to spontaneous ventilation with anesthetic recovery and 14 minutes after drug withdrawal patient has moved lower limbs at verbal command. During this procedure, patient remained in Ramsay's sedation stage 3 that is, under analgesia, spontaneous ventilation and relaxed.Dexmedetomidine associated to total intravenous anesthesia was an interesting option as adjuvant drug for the wake-up test as well as for perioperative analgesia and sedation.

Peripheral pulse pressure responses to postural stress do not reflect those at the carotid artery

Interpretation of baroreflex cardiovascular control requires accurate assessment of pulse pressure (PP) in central arteries under conditions of varying systemic or hydrostatic pressure. The objective of this study was to examine whether changes in PP during postural stress were similar in the peripheral versus carotid arteries. Protocol A: Pulse pressure was measured in both the left (Millar tonometer) and right (Colin Pilot) radial arteries, and in the finger (Finapres) in seated subjects (n = 7) who performed Valsalva's manoeuvre. Protocol B: PP was measured from the carotid (Millar tonometer), and from the finger and wrist kept at the level of the carotid artery, during supine and 60 degrees head-up postures. Protocol A: Pulse pressures during Valsalva's manoeuvre were highly correlated between all devices (r = 0.6-0.8). Protocol B: compared with supine, PP was reduced in both the finger and wrist during head-up-tilt (HUT) (P<0.05), but not in the carotid artery. During Valsalva manoeuvers the Millar and Colin tonometers similarly tracked PP over a wide range of rapidly changing pressures. This observation provided confidence for the further use of the hand-held device for central measurements during changes in posture. The results from Protocol B indicate that peripheral PP measurements are not suitable surrogates for carotid pulse pressures during HUT.

Coronary artery bypass grafting using a bifurcating radial artery

A 61-year-old man with angina pectoris was admitted for elective coronary artery bypass grafting. The left anterior descending artery, and the two posterolateral branches (PLA1 and PLA2) of the circumflex artery required bypass grafting. At operation, the distal portion of the left radial artery was found to bifurcate, both branches having an equal size. We decided to use the bifurcating radial artery as a conduit for bypass grafting to the branches of the left circumflex artery. One distal end of the radial artery was subsequently anastomosed to the PLA1 branch and the other distal end was anastomosed to PLA2. Postoperative coronary angiography showed both branches of the radial artery to have good patency.

Surgical approach for a patient with aortic stenosis and a frozen mediastinum

41-YEAR-OLD MAN was admitted with a 6-month history of worsening angina, dizziness, and dyspnea on exertion. His past medical history was significant for Hodgkin’s lymphoma, diagnosed at age 5, for which he was subsequently treated with chemotherapy and mantle radiation. On admission, his physical examination was notable for an asymmetrical pectus excavatum localized to the upper half of his sternum, and he was noted to have a harsh, crescendo/decrescendo systolic ejection murmur in the right second intercostal interspace radiating to the carotid arteries. Electrocardiogram revealed left ventricular hypertrophy. Cardiac catheterization revealed a focal 10% stenosis in the proximal third of the left main coronary artery, and all other coronary vessels were angiographically normal. Additionally, he was noted to have a calcified aortic valve and severely calcified ascending aorta, with a peak left ventricle (LV)-to-aortic gradient of 50 mmHg and elevated left ventricular filling pressures. The aortic valve area was 0.7 cm 2 by the Gorlin formula. The LV ejection fraction was 45% to 50%. The patient also had mild pulmonary hypertension. Because of the extensive calcification of the ascending aorta, a preoperative computerized tomography scan was performed, which revealed LV hypertrophy and extensive calcification from the aortic valve extending throughout the aortic arch. The upper thoracic cavity was asymmetrically smaller on the left, and marked atrophy of the paraspinal muscles and chest wall musculature was noted. On the computed tomography scan after radiation therapy, fibrotic changes were seen throughout the anterior mediastinum. A magnetic resonance imaging study of the neck and thorax confirmed the presence of normal, nondistorted airway anatomy. The patient was brought to the operating room, and general anesthesia was induced with a combination of midazolam, fentanyl, sodium thiopental, and pancuronium. Hemodynamic monitoring consisted of a left radial artery catheter, an Oximetric, pulmonary artery catheter, and continuous transesophageal echocardiography (TEE) (Omniplane, Sonos 5500: HewlettPackard, Andover, MA). Because of the frozen mediastinum, surgical exposure for the procedure was via a left posterolateral thoracotomy. The results of the surgery are seen on the intraoperative TEE (Figs 1 and 2). What procedure was performed?

Acute aortic dissection during vertical displacement of the heart in off-pump coronary artery bypass grafting (OPCAB)

respectively, by which we judged that the patient would tolerate the operation. A coronary angiogram revealed stenoses in segments 1, 2, 5, and 13. An OPCAB was planned to include grafting the left internal thoracic artery (LITA) to segment 8, the right internal thoracic artery (RITA) to segment 2, and the radial artery (RA) to segment 14. After induction of general anesthesia with tracheal intubation, we established vital monitoring, including direct arterial pressure (with a catheter placed in the right RA), pulmonary arterial pressure, central venous pressure, and continuous cardiac output (with a pulmonary artery catheter through the right internal jugular vein). After median sternotomy, designated grafts were obtained from the LITA, the RITA, and the left RA. Because significant decreases in cardiac output and blood pressure were expected during the procedure, due to the age of the patient, we employed percutaneous/partial cardiopulmonary support (PCPS). The PCPS was operated with cannulations into the right femoral artery and the right atrium. During grafting of the RA graft to segment 14, when the heart was vertically displaced with a Star-fish stabilizer (Medtronic, Minneapolis, MN, USA) (Fig. 1), the monitored pressure waveform from the right RA abruptly disappeared. Simultaneously, an operator noticed a change in the color of the surface of the ascending aorta. The operator examined the aorta by direct ultrasonography, which revealed acute dissection of the ascending aorta. The surgeons decided to perform a graft replacement of the ascending aorta, and started to establish CPB with an arterial cannula placed into the right femoral artery, as well as venous cannulae placed into the superior and inferior cavenous veins through the right atrium. During the preparation for CPB, we intravenously administered thiamylal (5mg·kg 1), a continuous infusion of which was started simultaneously at a rate of 4mg·kg 1·h 1, and we began to chill the patient’s head with ice bags so as to protect his brain from hypoxic

Gangrene of digits associated with radial artery cannulation

Gangrene of digits associated with radial artery cannulation