Gaseous emboli during off-pump surgery with T-graft technique, two different mechanisms

Gaseous embolism is a possible complication during off-pump coronary surgery with the use of a blower and can cause ischemic injuries. We describe two different possible mechanisms of carbon-dioxide embolization.

Out of 2196 coronary bypass surgeries, between 1 January 2007 and 31 December 2009, there were 977 off-pump operations. Two off-pump cases (0.2%) had gaseous (carbon-dioxide) emboli that migrated against blood stream proximally through T-anastomoses and then into the native coronary vessels. These emboli caused a temporary haemodynamic deterioration in other territories. Two types of T-anastomoses were included [saphenous vein on left internal thoracic artery (LITA) or right internal thoracic artery (RITA) on LITA].

Simple procedures and measurements were necessary but enough to regain haemodynamic stability. There was no effect on the postoperative outcome.

We have concluded that carbon-dioxide emboli can also cause massive but temporary haemodynamic deterioration during off-pump surgery despite higher solubility in blood. The blower should be used only when a bull-dog clamp is applied on the graft. Also, proper de-airing and flushing of grafts is very important and avoids consequences of the trapped small emboli.