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Coronary artery bypass grafting in a patient with brainstem ischemia
1Department of Surgery, Division II, Kobe University, School of Medicine, Kobe, Japan. ttsukube@med.kobe-u.ac.jp
Insights
This case study highlights successful coronary artery bypass grafting in a patient with severe coronary artery disease and complex cerebrovascular disease. Careful preoperative assessment and cardiopulmonary bypass management were crucial for the positive outcome.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Anesthesiology
Background:
- Severe coronary artery disease (CAD) and complex cerebrovascular disease present significant challenges for surgical intervention.
- The patient had a history of multiple percutaneous transluminal coronary angioplasty procedures with persistent unstable angina.
Observation:
- The patient presented with extensive cerebrovascular disease, including right cerebellar and cerebral infarctions, bilateral vertebral artery occlusion, brainstem ischemia, and significant carotid artery disease.
- Despite maximal medical therapy, unstable angina persisted, necessitating surgical intervention.
Findings:
- Coronary artery bypass grafting (CABG) was successfully performed using propofol anesthesia, perioperative intra-aortic balloon pumping, and mild hypothermic cardiopulmonary bypass with alpha-stat management.
- The surgical team navigated the complex interplay between cardiac and cerebral circulation.
Implications:
- This case underscores the critical importance of thorough preoperative evaluation of intracranial circulation in patients undergoing major cardiac surgery.
- Judicious management of cardiopulmonary bypass is essential to optimize outcomes in patients with coexisting cerebrovascular disease.
- The successful CABG demonstrates the feasibility of advanced surgical techniques in high-risk patients.
Abstract:
We describe a 54-year-old male with severe coronary artery disease and cerebrovascular disease including right cerebellar infarction, total occlusion of the bilateral vertebral arteries, brainstem ischemia, and right cerebral infarction with significant right carotid artery disease. Repeated percutaneous transluminal coronary angioplasty had been performed, however, unstable angina was developed despite maximal medical treatment. Coronary artery bypass grafting was successfully undergone with use of propofol, application of the intra-aortic balloon pumping perioperatively, and mild hypothermic cardiopulmonary bypass with alpha-stat blood gas management. The importance of preoperative evaluation of the intracranial circulation and management of cardiopulmonary bypass are discussed.