CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 3, May/June 2010
AFRICA
167
Letter to the Editor
Point of view on concomitant coronary and lower-limb
surgical revascularisation
SALVATORE LENTINI, FILIPPO BENEDETTO, AMEDEO CARMIGNANI, ROBERTO GAETA
Dear Sir,
We read with interest the recent paper from Prof Suzer and
co-workers on concomitant coronary artery bypass grafting and
descending aorta-to-bifemoral artery bypass via sternotomy.
1
The authors are to be commended for their work.
The concept of revascularising both the coronary tree and the
lower limbwithin the same surgical session is not new, andhas been
used by different surgical groups both previously
2,3
and recently.
4
In the past we have also used concomitant coronary and
lower-limb surgical revascularisation. We normally utilised the
ascending aorta as inflow for the bifurcated vascular prosthesis
to the femoral arteries. The prosthesis, usually a Dacron tube,
was passed in front of the heart, behind the sternum, usually
protected inside the pericardial space, and then through the ante-
rior abdominal wall to reach the groin. The indication for this
type of concomitant surgery was usually when there was risk
of lower-limb ischaemia during postoperative coronary surgery,
or the presence of critical peripheral arterial ischaemia in an
unstable cardiac patient. The refined technique described by the
authors represents an advancement of the previously used tech-
nique where the tube was passed in front of the heart.
From our past experience we would like to add a few
points on this subject. We consider that there is theoretically
an increased risk when more surgery is performed in the same
session. In particular, a marked reduction of peripheral vascular
resistance may occur due to an abrupt increase of the vascular
bed following lower-limb revascularisation. This haemodynamic
condition would happen just after discontinuation of cardiopul-
monary bypass, and therefore at a critical moment for the heart.
This status could necessitate increased dosage of vasopressor
agents with the risk of postoperative peripheral vasoconstriction,
or arterial coronary graft spasm.
There is an increased risk because one is treating in the same
surgical session not only the mediastinum, but also the retroperi-
toneum and peripheral arterial vessels (femoral). In particular,
the prosthesis passage through the retroperitoneal space or the
abdominal wall may represent a source of occult bleeding in the
postoperative period.
There is also a risk of prosthesis infection, as mentioned by the
authors, both in short- and long-term follow up. The technique
proposed by Suzer
et al
. would leave the prosthesis confined in
the posterior mediastinum, and not in the anterior one, just in
contact with the heart. This could be considered an improvement
compared to the technique using the ascending aorta as inflow,
where an infection could propagate through the Dacron tube
from the groin directly to the pericardial space. However, even in
the technique described by our colleagues, we believe some risk
of infection propagation from one site to another still persists. In
the past, we observed a patient where infection propagated from
the groin up to the pericardial space, this happening a few years
after surgery.
Some patients may need revascularisation below the femo-
ral artery, such as patient number 3 in the Suzer
et al
. report.
Actually, in our series of patients, this represented an adjunc-
tive risk, especially with concomitant bilateral revascularisation
below the knee. This was probably due to extensive peripheral
disease, advanced age and the presence of concomitant pathol-
ogy in this subgroup of patients. Postoperative exacerbation or
abrupt onset of peripheral ischaemia in those patients may repre-
sent a significant complication.
Now, considering that we have a patient with both coronary
and peripheral vascular disease, the question is: ‘In the recent
era of endovascular treatments (both coronary and peripheral
vascular), do we still need concomitant surgery?
Currently, whenever possible, we usually prefer a staged
approach, treating in the first instance the more critical region
(coronary or peripheral). We then use endovascular options as a
bridge to a more definitive treatment in one of the two regions to
allow surgery on the other. We believe that concomitant coronary
and lower-limb surgery is feasible, however it should be reserved
for very selected cases, and the possible complications should be
weighed up.
We again congratulate Prof Suzer and co-workers for their
interesting work.
SALVATORE LENTINI, MD,
FILIPPO BENEDETTO, MD
AMEDEO CARMIGNANI, MD
ROBERTO GAETA, MD
Cardiovascular and Thoracic Department, Policlinico G
Martino, University of Messina, Messina, Italy
ROBERTO GAETA, MD
Cardiac Surgery Unit, Ospedale San Carlo, Potenza, Italy
Submitted 17/12/09, accepted 10/3/10
References
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1.
bypass grafting and concomitant descending aorta-to-bifemoral artery
bypass via sternotomy.
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2009; 20: 300–302.
Jebara VA, Fabiani J, Acar C, Chardigny C, Julia P, Carpentier A.
2.
Combined coronary and femoral revascularization using an ascending
aorta to bifemoral bypass.
Arch Surg
1994;
129
: 275–279.
Suma H, Sato H, Fukumoto H, Takeuchi A. Combined revascularization
3.
of coronary and femoral arteries: a proposed alternative.
Ann Thorac
Surg
1989;
48
: 434–436.
Goksel OS, Ugurlucan M, Alpagut U, Tireli E, Dayioglu E.
4.
Concomitant
coronary and peripheral arterial disease: single-stage revascularization.
J
Card Surg
2008;
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