retrograde direction. In January 1948, Beck and col-leagues [6] carried out the described procedure using abrachial artery graft on a patient with severe coronaryartery disease who survived the procedure.

The first report of arterialization of a coronary veinrather than the coronary sinus came from Arealis andcolleagues [2] in 1973. They carried out experiments incalves in which the pedicled left internal mammaryartery was anastomosed to the LAD vein. They were ableto demonstrate reversal of ischemic electrocardiographicchanges after ligation of the LAD artery by opening theleft internal mammary artery graft. The LAD vein hadbeen occluded proximally to prevent antegrade venousflow.

In 1975, Benedict and colleagues [7] published a seriesof three clinical cases of saphenous vein grafting from theaorta to a coronary vein in patients with intractableangina and previous unsuccessful revascularization pro-cedures. Postoperative coronary angiograms revealedpatency in two of the four grafts constructed. Myocardialscanning demonstrated uptake in the regions served bypatent grafts. Previously they had carried out animalexperiments in dogs that had demonstrated evidence ofmyocardial revascularization through the coronary ve-nous system.

Oesterle and colleagues [5] recently reported a suc-cessful case of percutaneous in situ coronary venousarterialization in a patient with similar characteristics tothe patient in this article.

The concept of arterialization of the coronary veins formyocardial revascularization was first laid in the 19thcentury [1]. Several articles on the same principle havebeen published during the last century. The successfuloutcomes, reported by Oesterle and colleagues [5] and byourselves in the current article, support the idea thatthe selective arterialization of the coronary venoussystem should be considered in cases of coronary arterydisease not amenable to traditional revascularizationstrategies.

References

1. Pratt FH. The nutrition of the heart through the vessels ofThebesius and the coronary veins. Am J Physiol 1898;1:86–103.

2. Arealis EG, Volder JGR, Kolff WJ. Arterialization of thecoronary vein coming from an ischemic area. Chest 1973;63:462–3.

3. Roberts JT, Browne RS, Roberts G. Nourishment of themyocardium by way of the coronary veins. Fed Proc 1943;2:90.

4. Prinzmetal M, Simkin B, Bergman HC, Kruger HE. Studies onthe coronary circulation. Am Heart J 1943;33:420–42.

5. Oesterle SN, Reifart N, Hauptmann E, Hayase M, Yeung AC.Percutaneous in situ coronary venous arterialization. Circu-lation 2001;103:253–60.

6. Beck CS, Stanton E, Batiuchok W, Leiter E. Revascularizationof heart by graft of systemic artery into coronary sinus. JAMA1948;5:436–42.

7. Benedict JS, Buhl TL, Henney RP. Cardiac vein myocardialrevascularization. An experimental study and report of 3clinical cases. Ann Thorac Surg 1975;20:550–7.

OPCAB Surgery in a CirrhoticHepatocellular Carcinoma PatientAwaiting Liver TransplantCornelia Carr, FRCS, and Jatin Desai, FRCS

King’s College Hospital, Denmark Hill, London, United Kingdom

Cirrhosis was once thought of as an absolute contraindi-cation to cardiac surgery with the risk of liver decompen-sation following the use of cardiopulmonary bypass.With the advent of off-pump coronary artery bypassgrafting, the possibility of reducing the risk of decom-pensation may make this type of surgery suitable forpatients who will eventually undergo orthotopic livertransplantation. We present the strategy used in a patientwith multifocal hepatocellular carcinoma and cirrhosiswho underwent coronary artery bypass grafts for unsta-ble angina, in order to allow him to undergo livertransplantation at a future date.

(Ann Thorac Surg 2004;78:1460–2)© 2004 by The Society of Thoracic Surgeons

Liver cirrhosis poses particular problems for cardiacsurgery with the risk of hepatic dysfunction and

even fulminant hepatic coma and death. The presence ofsignificant coronary artery disease had been thought ofas an absolute contraindication to orthotopic liver trans-plantation (OLT): increased risk of intraoperative myo-cardial infarction during OLT, and coronary artery by-pass grafting (CABG) with end-stage liver disease hadbeen associated with a poor outcome [1, 2]. Previousattempts to solve this problem have involved combinedsequential CABG and OLT [3].

We discuss a patient with cirrhosis and hepatocellularcarcinoma who was suitable for OPCAB surgery whereavoiding cardiopulmonary bypass may have reduced therisk of potentially fatal liver decompensation. We alsodescribe the operative maneuvers to minimize the risk ofpostoperative bleeding.

A 56-year-old man was admitted with unstable angina,with a history of two previous myocardial infarctions. Hewas an insulin-dependent diabetic with cirrhosis second-ary to alcohol abuse and had several esophageal varicealbleeds in the past. Cardiac catheter demonstrated severetriple vessel disease with a blocked left anterior descend-ing artery (LAD), tight ostial circumflex, ostial diagonal,and proximal right coronary artery stenoses. Echocardio-gram illustrated well preserved left ventricular function.

Preoperative workup had revealed deranged liverfunction tests (Table 1) and a reduced platelet count (50 �109/L). Ultrasound and computerized tomography (CT) of

Accepted for publication July 10, 2003.

Address reprint requests to Dr Carr, Department of CardiothoracicSurgery, King’s College Hospital, London SE5 9RS, UK; e-mail:noahalkh@talk21.com.

1460 CASE REPORT CARR AND DESAI Ann Thorac SurgOPCAB SURGERY IN A CIRRHOTIC PATIENT 2004;78:1460–2

© 2004 by The Society of Thoracic Surgeons 0003-4975/04/$30.00Published by Elsevier Inc doi:10.1016/S0003-4975(03)01442-5

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the liver illustrated two contrast enhancing masses in acirrhotic liver: a 2.5-cm lesion in segment 4 with a centralscar and a 1-cm lesion in segment 6. Hepatitis serology wasnegative and �-fetoprotein was not elevated. He had cir-rhosis diagnosed 12 years previously (by biopsy) and hislast variceal bleed was 4 years ago.

He was assessed by the hepatologist who advisedagainst CABG as the risk of decompensation was toogreat and for further evaluation of his liver lesions.Magnetic resonance imaging (MRI) and MRI with man-ganese (Tesla scan) confirmed that the two lesions werelikely to be hepatocellular carcinomas. Further assess-ment by the liver unit concluded that a Child class A(serum bilirubin � 2.0 mg/dL, serum albumin � 3.5 g/dL,no ascites, no neurologic disorder, and excellent nutri-tion) cirrhotic complicated with hepatocellular carcinoma(with two nodules both � 3-cm diameter) in a good physicalstate was a suitable candidate for liver transplant, with aview to cure, and should, therefore, be considered forcoronary revascularization despite its risks. It was decidedan OPCAB strategy would probably minimize the risk ofliver decompensation following revascularization.

His reduced platelet count had previously been diag-nosed as secondary to his chronic liver disease. He wastransfused 2 pools of platelets immediately preopera-tively and depending on the repeat full blood countduring surgery, further transfusion would be titrated.

Following median sternotomy bilateral skeletonized in-ternal thoracic arteries were harvested leaving the pleuraeintact on both sides in order to minimize blood loss post-operatively, due to the reduced platelet count and de-creased clotting product production (intraoperative plateletcount 64 � 109/L). Long saphenous vein was harvested fromthe leg using a minimally invasive “stripper” technique.

Following half-dose heparin OPCAB surgery was per-formed using the Octopus 3 (Medtronic Inc, Minneapolis,MN) stabilizer and intracoronary shunts (Flo-thru; Bio-vascular Inc, St Paul, MN). The left internal thoracicartery was anastomosed to the LAD, the right internalthoracic artery was anastomosed to the first diagonalartery, and lengths of saphenous vein were anastomosedto the distal circumflex and right coronary arteries. Therewas some hemodynamic instability during the circumflexgraft; if this graft had not been feasible a hybrid procedure

would have been performed with percutaneous coronaryangioplasty following the surgery. Following the construc-tion of the proximal anastomoses Tisseel glue (Baxter AG,Vienna, Austria) was sprayed using the Duploject System(Immuno AG, Vienna, Austria) on both internal thoracicartery harvest beds and on all anastomoses, to further aidcontrol of bleeding. It is not our normal policy to usehemostatic aids. The heparin was reversed and a further 2pools of platelets administered. The patient was extubatedat 3 hours postoperatively and the total drainage from themediastinal drains was 425 mLs in 48 hours, no furtherplatelet or blood transfusions were required.

Postoperatively his management was undertaken inclose communication with the hepatologists and, apartfrom a minor chest infection, he made a smooth recoverywith no evidence of hepatic decompensation. The patientwas discharged home on the eighth postoperative day,and his liver transplant was performed 2-months later,from which he made a good recovery.

Comment

Liver cirrhosis poses particular problems for cardiac sur-gery with reported complication rates for Child class B(serum bilirubin 2.0–3.0 mg/dL, serum albumin 3.0–3.5g/dL, controllable ascites, minimal neurologic disorder,good nutrition) cirrhotic patients undergoing cardiac sur-gery of 100% major morbidity and 80% mortality [1], withdeaths due to postoperative infections and hemorrhagiccomplications leading to hepatic and multiorgan failure.Child class A cirrhotic patients have a quoted 25% risk ofmajor complication, but may not have increased periop-eratively complications [1]. Patients with advanced liverdisease (Child B and C: serum bilirubin � 3.0 mg/dL,serum albumin � 3.0 g/dL, poorly controlled ascites, ad-vanced coma, and nutrition poor) probably have an unac-ceptable risk for cardiac surgery. Bizouarn and associates[2] reported that the incidence of significant complicationsafter cardiac surgery in patients with cirrhosis was highand that health status remained compromised even longafter the surgery. Previous attempts to solve this problemhave involved combined sequential CABG and OLT incirrhotic patients including one with hepatocellular car-cinoma [3], but this may not be a practical solution inpatients with unstable angina requiring urgent CABG.

Progressive hepatic dysfunction is one of the mostsevere postoperative complications in the cirrhotic pa-tient, and it is probably important to maintain stable andsufficient hepatic blood flow in the perioperative periodto avoid further damage [4]. The use of cardiopulmonarybypass may not provide sufficient blood flow to thealready compromised liver and by performing CABGsurgery off-pump a more normal blood pressure andperfusion may reduce the risk of decompensation. Aredo-CABG in a cirrhotic patient performed through aleft thoracotomy without extracorporeal circulatory sup-port has been described [5], but this involved a saphe-nous vein graft to the LAD and anastomosis to thedescending thoracic aorta.

The presence of severe coronary artery disease in a

Table 1. Serial Blood Results in Cirrhotic Patient AwaitingLiver Transplant

Pre-OPCAB Post-OPCAB Pre-OLT Post-OLT

INR 1.2 1.2 1.1 1.2Platelet � 109/L 58 90 59 158Serum albumin

(g/L)40 33 38 40

Serumbilirubin

17 34 33 23

Alkalinephosphatase

7 101 208 116

Gamma GT 357 185 326 172

Gamma GT � gamma-glutamyl transpeptidase ; INR � internationalnormalized ratio; OLT � orthotopic liver transplant; OPCAB �off-pump coronary artery bypass.

1461Ann Thorac Surg CASE REPORT CARR AND DESAI2004;78:1460–2 OPCAB SURGERY IN A CIRRHOTIC PATIENT

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patient who requires liver transplantation should not beconsidered as a contraindication to transplant, and withthe advent of OPCAB and its future refinements the needfor simultaneous CABG and OLT may not be necessary.

References1. Klemperer JD, Wilson K, Krieger KH, et al. Cardiac opera-

tions in patients with cirrhosis. Ann Thorac Surg 1998;65:85–7.2. Bizouarn P, Ausseur A, Desseigne P, et al. Early and late

outcome after elective cardiac surgery in patients with cirrho-sis. Ann Thorac Surg 1999;67:1334–8.

3. Benedetti E, Massad MG, Chami Y, Wiley T, Layden TJ. Is thepresence of surgically treatable coronary artery disease acontraindication to liver transplantation? Clin Transplant1999;13:59–61.

4. Ninomiya M, Takamoto S, Kotsuka Y, Ohtsuka T. Indicationand perioperative management for cardiac surgery in pa-tients with liver cirrhosis. Jpn J Thorac Cardiovasc Surg2001;49:391–4.

5. Sakakibara Y, Imazuru T, Watanabe K, et al. Repeat coronaryartery bypass in a patient with liver cirrhosis. Thorac Cardio-vasc Surg 1998;46:99–100.

Combined Surgical andEndovascular Approach to Treat aComplex Aortic CoarctationWithout Extracorporeal CirculationThierry P. Carrel, MD, Pascal A. Berdat, MD,Iris Baumgartner, MD, Hans-Peter Dinkel, MD, andJurg Schmidli, MD

Clinic for Cardiovascular Surgery, Division of Angiology, andDivision of Radiology, University Hospital Berne, Berne,Switzerland

Various therapeutic approaches have been proposed totreat complex coarctation of the aorta (eg, recoarctation,which requires repetitive interventions, or coarctation witha hypoplastic aortic arch). Resection followed by end-to-end anastomosis or by graft interposition is technicallydemanding and exposes the patient to considerable periop-erative risks. Cardiopulmonary bypass and deep hypother-mic circulatory arrest may be necessary to control the distalaortic arch. The role of stent technology in treating this typeof lesion has not yet been defined. We present a 21-year-oldwoman with a recurrent coarctation of the aorta associatedwith a hypoplastic aortic arch and a pseudoaneurysm of theproximal descending aorta. She had undergone 4 previousinterventions. Treatment consisted of a combined surgicaland endovascular approach without cardiopulmonary by-pass and included extraanatomic aortic bypass, partial de-branching of the supraaortic vessels, and stent-graft inser-tion to exclude the aneurysm.

(Ann Thorac Surg 2004;78:1462–5)© 2004 by The Society of Thoracic Surgeons

Percutaneous balloon dilation with or without stentingis often considered to be the first therapeutic option

for simple recoarctation in children and adolescents.However, some complex forms of coarctation (eg, thoseassociated with diffuse hypoplasia of the mid and distalaortic arch and those complicated by a pseudoaneurysm)are not amenable to interventional treatment alone. Sur-gical treatment may require cardiopulmonary bypass(CPB) and deep hypothermic circulatory arrest to com-pletely repair the aortic arch, thus exposing the patient tothe risk of cerebrovascular complications [1–4]. My col-leagues and I report on a successful combined surgical/endovascular approach that allowed treatment of a re-current coarctation associated with a tubular hypoplasiaof the mid and distal aortic arch and a pseudoaneurysmat the previous site of repair.

A 21-year-old woman presented with severe exercise-induced arterial hypertension of the upper extremities(systolic blood pressure 220 mm Hg); she had experiencedheadaches for 2 years. Blood pressure at rest was onlyslightly increased. At the age of 3 weeks (in 1981), sheunderwent resection of a coarctation followed by end-to-end anastomosis. When she was 2 years old, percutaneousballoon dilation was performed to treat recoarctation. Atthat time, percutaneous transluminal angioplasty (PTA) of acoarctation was one of the first performed worldwide.

At the age of 6 years, she had arterial hypertensionagain, and a patch enlargement was performed at the siteof recoarctation by using xenopericardial tissue. Againshe did well initially but required antihypertensive treat-ment with a �-blocker and a converting-enzyme inhibitorat the age of 8 years.

When she was 19 years old, severe arterial hyperten-sion developed during exercise (systolic blood pressure� 220 mm Hg), and she experienced headaches. Mag-netic resonance (MR) angiography revealed a long ste-notic segment in the proximal descending aorta (diame-ter, 3 to 4 mm), a tubular hypoplasia of the mid and distalaortic arch (8 mm), and a pseudoaneurysm (2.9 cm) at thesite of the previous coarctation repair. At that time, shewas presented to the cardiologists, who unfortunatelydecided to perform percutaneous balloon dilation andstenting with a 16-mm Wallstent (Boston Scientific,Natick, MA). As expected, the hypoplastic segment couldnot be dilated, the pressure gradient remained constant(90 mm Hg), and the pseudoaneurysm was left untreated(Fig 1). A triple antihypertensive treatment including acalcium-channel blocker was started.

In 2002, at the age of 21 years, she was referred to ourinstitution because she had asked for a definitive treat-ment with less antihypertensive medication. At that time,MR angiography did not show any difference whencompared with that 2 years before, except that the size ofthe aneurysm had increased to 3.5 cm (Fig 2). Theproximal end of the Wallstent was lying in the origin ofthe left carotid artery.

The operation was performed through a median ster-notomy. An arterial perfusion cannula was inserted intothe left radial artery and a sheat was inserted into the

Accepted for publication July 10, 2003.

Address reprint requests to Dr Carrel, Clinic for Cardiovascular Surgery,University Hospital Berne, Freiburgstrasse, CH-3010 Berne, Switzerland;e-mail: thierry.carrel@insel.ch.

1462 CASE REPORT CARREL ET AL Ann Thorac SurgTREATING COMPLEX AORTIC COARCTATION 2004;78:1462–5

© 2004 by The Society of Thoracic Surgeons 0003-4975/04/$30.00Published by Elsevier Inc doi:10.1016/S0003-4975(03)01438-3

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