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Table of Contents
CASE REPORT  
Year : 2023  |  Volume : 26  |  Issue : 1  |  Page : 83-85
Resisting arrest: Perioperative confirmation and management of an iatrogenic aortocoronary arteriovenous fistula after coronary artery bypass grafting for redo cardiac surgery


1 Department of Anesthesiology and Periop Medicine, Mayo Clinic, Rochester, MN, United States, USA
2 Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
3 Cardiovascular Disease, Mayo Clinic, Rochester, MN, United States

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Date of Submission07-Dec-2020
Date of Acceptance13-Apr-2021
Date of Web Publication03-Jan-2023
 

   Abstract 


Although rare, iatrogenic aortocoronary arteriovenous fistulae (ACAVF) occur when a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. Patients may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity, and may have wide pulse pressures with evidence of coronary steal. A thorough insight into the disordered anatomy is critical to safely manage a patient for redo cardiac surgery, especially when attempting to arrest the heart. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.

Keywords: Bypass graft, coronary artery bypass surgery, coronary artery fistula

How to cite this article:
Klompas AM, Kawajiri H, Sinak LJ, Pochettino A. Resisting arrest: Perioperative confirmation and management of an iatrogenic aortocoronary arteriovenous fistula after coronary artery bypass grafting for redo cardiac surgery. Ann Card Anaesth 2023;26:83-5

How to cite this URL:
Klompas AM, Kawajiri H, Sinak LJ, Pochettino A. Resisting arrest: Perioperative confirmation and management of an iatrogenic aortocoronary arteriovenous fistula after coronary artery bypass grafting for redo cardiac surgery. Ann Card Anaesth [serial online] 2023 [cited 2023 Jan 30];26:83-5. Available from: https://www.annals.in/text.asp?2023/26/1/83/367022





   Introduction Top


Although rare, complications following cardiac surgery may remain unnoticed for some time and are discovered only after careful investigation with a high index of suspicion. Iatrogenic aortocoronary arteriovenous fistulae (ACAVF) are one such complication where a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. A thorough understanding of the disordered anatomy is critical to safely manage a patient for redo cardiac surgery. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.


   Case Description Top


A 74-year-old woman presented with a worrisome contained rupture versus a localized dissection of the mid ascending aorta extending into the proximal arch. She had undergone coronary artery bypass grafting (CABG) with a pedicled left internal mammary artery (LIMA) to the left anterior descending (LAD) and a reverse saphenous vein graft (SVG) to a circumflex branch less than a year earlier for treatment of ostial left main coronary stenosis. Before the surgical revascularization, a drug-eluting stent had been deployed in the proximal circumflex, but the ostial left main lesion could not be addressed by catheter-based methods. At surgery, the operative note reported a fragile aorta normal in size with significant plaque. The localized dissection/contained rupture noted now was in close proximity to the origin of the SVG graft, with the maximal diameter of the abnormal aorta at well over 5.5 cm. Her medical history also included treated hypothyroidism, hypertension, primary biliary cirrhosis, and polymyalgia rheumatica not requiring steroids. She also had a history of recurrent pericardial effusions requiring pericardiocentesis on multiple occasions. On examination, she had a continuous murmur heard over the right and left upper sternal border.

After CABG, she had an unremarkable early postoperative course and remained asymptomatic without exertional dyspnea at her 3 month follow-up, when a continuous murmur was first documented on physical exam. Computed tomography angiogram (CTA) obtained then demonstrated the aortic pseudoaneurysm/localized dissection above the sinotubular junction close to the origin of the SVG. She was then referred to our institution for surgical management. A preoperative echocardiogram demonstrated normal biventricular function without valvopathy. Preoperative coronary angiography demonstrated left to right shunt consistent with an aortic to coronary sinus saphenous vein graft [Figure 1]a, with persistent ostial left main stenosis, a near occluded LIMA to the LAD, and a widely patent circumflex system.
Figure 1: (a) Aortogram demonstrating a large left to right shunt. (b) Midesophageal short-axis view of the coronary sinus showing the patent vein graft delivering pulsatile blood in systole. (c and d) Midesophageal 4 chamber retroflexed to highlight the opening of the coronary sinus into the right atrium. In (c) the vein graft is open and there is turbulent flow in the systole. In (d) the vein graft has been occluded, and the turbulent flow in the systole is no longer present

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The patient proceeded to the operating room to address both the abnormal ascending aorta as well as the residual ostial left coronary stenosis. The patient was induced under general anesthesia with radial and femoral arterial lines and a Swan-Ganz catheter placed for monitoring.

Following sternotomy and tissue dissection and before initiating cardiopulmonary bypass, the anatomy of the saphenous vein graft anastomosis was confirmed using several techniques. Surgical exposure allowed manipulation and temporary clamping of the vein graft while the effects on coronary sinus flow were interrogated in real-time. Real-time transesophageal echocardiography demonstrated robust pulsatility and turbulent flow within the coronary sinus that decreased significantly upon clamping the vein graft [Figure 1]b, [Figure 1]c, [Figure 1]d. A retrograde cardioplegia catheter was placed into the coronary sinus and was transduced, again demonstrating robust pulsatility and near aortic systolic pressures [Figure 2]. In addition, the coronary sinus catheter was also opened to atmospheric pressure and assessed visually. As can be seen in Video 1, when the vein graft was unclamped, bright red and pulsatile arterial blood could be seen ejecting from the catheter into the surgical field; however, when the vein graft was occluded, the flow significantly decreased, and the blood color darkened to appear venous.
Figure 2: Physiologic monitors including ECG, systemic arterial blood pressure, and coronary sinus pressure. Near systemic pressures can be appreciated in the coronary sinus tracing until the vein graft from the aorta to the coronary sinus is occluded with a clamp (arrow), where the pressure and absolute pulsatility decrease

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The vein graft and the barely flowing LIMA were occluded and the aortic cross-clamp placed at the base of the innominate artery, followed by both anterograde and retrograde cardioplegia. The patient was cooled to achieve flat-line electroencephalogram (EEG). During the cooling phase, the previous SVG graft was amputated near the distal anastomosis to a distal cardiac vein, followed by placement of a new SVG graft to the mid LAD. The abnormal proximal ascending aorta was also debrided proximally to the level of the sino-tubular junction. With flat-line EEG demonstrated for over 5 min, at about 20 degrees C, a brief period of circulatory arrest with adjunctive retrograde cerebral perfusion was utilized to excise the remaining distal ascending aorta and the proximal arch, which were then replaced with a 30 mm Dacron graft. During the rewarming phase, the relatively normal-appearing aortic valve was resuspended, and the proximal ascending aorta was replaced with a 24 mm Dacron graft to match the aortic annular size. The SVG to the LAD was connected proximally to the ascending Dacron graft, while the LIMA to LAD graft was left in place despite evidence of minimal flows.

She had an uneventful postoperative course and was discharged to home on postoperative day 9 with normal biventricular function.


   Discussion Top


Iatrogenic aortocoronary arteriovenous fistulae are rare complications of coronary artery bypass grafting with fewer than 40 reported cases.[1] This occurs when a graft is mistakenly anastomosed to an epicardial vein rather than its intended artery, most commonly to the great cardiac vein.[1] Traditionally, these fistulae have been diagnosed with coronary angiography or CTA. Patients with ACAVF may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity.[1] Patients may also demonstrate a wide pulse pressure due to excessive diastolic runoff and develop coronary steal.[2] Medical management has become the treatment of choice; however, coiling, occlusion device placement, and surgical interventions have all been performed successfully.[1],[2],[3]

If reoperation is indicated, the errant graft must be occluded before delivery of cardioplegia or cardiac arrest may be ineffective or impossible. Without graft occlusion, anterograde cardioplegia will enter the right atrium via the low resistance graft. Similarly, retrograde cardioplegia will be ineffective by passing from the coronary sinus to the aorta through the graft and be delivered systemically. With occlusion of the errant graft, both cardioplegia strategies should be effective.

This case effectively highlights the value of thorough preoperative imaging and planning before surgical intervention and the benefits of using multiple investigative techniques to corroborate an atypical finding. Understanding the patient's coronary anatomy after surgical intervention can be critical to achieving successful reoperation, especially in the presence of an unusual complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gardner JD, Maddox WR and Calkins JB Jr. Iatrogenic aortocoronary arteriovenous fistula following coronary artery bypass surgery: A case report and complete review of the literature. Case Rep Cardiol 2012;2012:652086.  Back to cited text no. 1
    
2.
Sreenivasan J, Ayub M, Yadav N, Golzar Y. Rare cause of late recurrent angina following coronary artery bypass grafting: Iatrogenic aortocoronary arteriovenous fistula causing coronary steal. Case Rep Cardiol 2018;2018:6913737.  Back to cited text no. 2
    
3.
Bagherli A, Bews H, Vo M, Ducas J, Jassal DS, Ravandi A. Iatrogenic great cardiac vein anastomosis during coronary artery bypass surgery. Int J Angiol 2017;26:201-4.  Back to cited text no. 3
    

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Correspondence Address:
Allan M Klompas
Mayo Clinic, 200 1st St. SW, Rochester MN - 55905
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.aca_310_20

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