Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis. 1. Introduction Avulsion of a graft after coronary artery bypass grafting (CABG) surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. It was reported to occur after minimally invasive direct coronary artery bypass (MIDCAB) surgery due to a graft tension and after conventional CABG due to mediastinitis. In this paper we report a very rare case of a left internal mammary artery (LIMA) graft avulsion on the day of CABG surgery in a patient with syphilis. 2. Case Report A 54-year-old male patient presented with 3rd CCS class angina pectoris. Risk factors of coronary artery disease included class I obesity, hypertension, hyperlipidemia, and smoking. Transthoracic echocardiography showed normal size of the ascending aorta with a slight thickening of its wall, normal aortic valve function without regurgitation, and slightly decreasedleft ventricular ejection fraction with local hypokinesia. Pulmonary examination revealed no evidence of chronic obstructive pulmonary disease or marked emphysema. Coronary angiography showed multivessel lesions including proximal left anterior descending artery (LAD) stenosis and occlusion of left circumflex and posterior descending (PDA) arteries. There was no evidence of any arteritis or connective tissue disorder. The patient denied any history of sexually transmitted infection, but preoperative screening for syphilis with rapid plasma reagin (RPR) test was positive (this test is a part of standard examination before surgery in Russia). It was then confirmed with enzyme immunoassay (EIA) test, Treponema pallidum passive particle agglutination assay (TPPA) test, and fluorescent treponemal antibody absorption (FTA-ABS) test. The skin and visible mucous membranes were free from any sign of syphilis. The patient was suspected to have latent syphilis and was offered surgery. CABG was performed by experienced staff surgeon (S.A.B.) using cardiopulmonary bypass (CPB) and cold crystalloid cardioplegia with LIMA to LAD and vein grafts to obtuse marginal artery and PDA. LIMA was dissected from its origin to the bifurcation using pedicled in situ technique, and after cutting off it had a satisfactory blood flow. There was no doubt in the good
References
[1]
H. A. Heggtveit, “Syphilitic aortitis. A clinicopathologic autopsy study of 100 cases, 1950 to 1960,” Circulation, vol. 29, pp. 346–355, 1964.
[2]
V. B. Simonenko, A. V. Popov, N. I. Siuch, O. V. Magaryshkina, and P. A. Dulin, “Syphilitic mesaortitis,” Klinicheskaia Meditsina, vol. 90, pp. 77–79, 2012.
[3]
K. Tanaka, M. Takeda, and K. Nagayama, “Composite Y-graft for syphilitic ostial stenosis in left main coronary artery,” Asian Cardiovascular and Thoracic Annals, vol. 15, no. 2, pp. 159–161, 2007.
[4]
A. Herskowitz, S. Cho, and S. M. Factor, “Syphilitic arteritis. Involving proximal coronary arteries,” New York State Journal of Medicine, vol. 80, no. 6, pp. 971–974, 1980.
[5]
N. E. Al-Shammari, A. H. El-Beltagi, S. A. Al-Far, and Y. M. Abdel-Raouf, “Syphilitic arteritis involving the origin of the cervical internal carotid artery,” Neurosciences, vol. 15, no. 2, pp. 122–125, 2010.
[6]
C. M. Lin, “Left subclavian artery aneurysm secondary to syphilitic arteritis presenting with a right ischemic cerebellar infarction,” Neurology India, vol. 57, no. 3, pp. 344–346, 2009.
[7]
N. Temucin Ogus, C. Cakalagaoglu, F. Cakalagaoglu, and S. Cicek, “Accelerated atherosclerosis in tertiary syphilis and successful treatment with saphenous vein grafting—a case report,” Angiology, vol. 52, no. 8, pp. 549–552, 2001.
[8]
A. P. Asherson, H. A. Vohra, M. J. Mason, and J. A. Gaer, “Non-anastomotic avulsion of a left internal mammary artery graft—a rare complication of minimally invasive direct coronary artery bypass surgery,” Interactive Cardiovascular and Thoracic Surgery, vol. 5, no. 4, pp. 454–455, 2006.
[9]
J. McMahon, J. Bergsland, D. T. Arani, and T. A. Salerno, “Avulsion of the left internal mammary artery after minimally invasive coronary bypass,” Annals of Thoracic Surgery, vol. 63, no. 3, pp. 843–844, 1997.
[10]
M. Ricci, H. L. Karamanoukian, G. D'Ancona, M. R. Jajkowski, J. Bergsland, and T. A. Salerno, “Avulsion of an H graft during closed-chest cardiopulmonary resuscitation after minimally invasive coronary artery bypass graft surgery,” Journal of Cardiothoracic and Vascular Anesthesia, vol. 14, no. 5, pp. 586–587, 2000.
[11]
M. A. Radermecker, T. Grenade, Q. Desiron et al., “Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery,” Annals of Thoracic Surgery, vol. 71, no. 4, pp. 1401–1402, 2001.
[12]
G. Viel, U. Balmaceda, and J. P. Sperhake, “Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery: fatal complication or medical error? A case report,” Medicine, Science and the Law, vol. 49, no. 1, pp. 60–64, 2009.
[13]
D. G. Morritt, S. S. Shah, A. N. Morritt, and P. Kaul, “Acute transection of the left internal mammary artery remote from the anastomosis following coronary artery bypass surgery,” Interactive Cardiovascular and Thoracic Surgery, vol. 3, no. 4, pp. 653–655, 2004.
[14]
J. Draganov, H. M. Klein, A. Ghodsizad, M. Gehrke, and E. Gams, “Rupture of a saphenous vein coronary artery bypass graft due to Aspergillus necrotizing vasculitis,” Annals of Thoracic Surgery, vol. 80, no. 2, pp. 724–726, 2005.
[15]
G. M. Aru, W. P. English, D. Netherland, and B. J. Heath, “Internal thoracic artery rupture in a child with type IV Ehlers-Danlos syndrome,” Journal of Thoracic and Cardiovascular Surgery, vol. 117, no. 5, pp. 1021–1022, 1999.
[16]
R. I. Hasan, P. Krysiak, A. K. Deiranyia, and T. Hooper, “Spontaneous rupture of the internal mammary artery in Ehlers-Danlos syndrome,” Journal of Thoracic and Cardiovascular Surgery, vol. 106, no. 1, pp. 184–185, 1993.
[17]
M. Zilocchi, T. A. Macedo, G. S. Oderich, T. J. Vrtiska, P. R. Biondetti, and A. W. Stanson, “Vascular Ehlers-Danlos syndrome: imaging findings,” The American Journal of Roentgenology, vol. 189, no. 3, pp. 712–719, 2007.
