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[Pseudoaneurysm of saphenous vein graft after CABG]
T Nakamura1, M Shimamoto, F Yamazaki
1Division of Cardiovascular Surgery, Shizuoka City Hospital, Japan.
Insights
A patient developed shock and cardiac arrest after re-administration of aprotinin during a second surgery for a coronary artery bypass grafting pseudoaneurysm. This suggests a potential anaphylactic reaction to aprotinin.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Surgical Complications
Background:
- A 69-year-old male with angina and thoracic descending aorta aneurysm underwent staged surgical repair.
- Initial surgery included coronary artery bypass grafting (CABG) with saphenous vein grafts (SVGs).
- A pseudoaneurysm in a SVG was detected postoperatively, necessitating further intervention.
Observation:
- During the second operation for pseudoaneurysm repair and aortic graft replacement, aprotinin was re-administered.
- The patient experienced sudden shock and cardiac arrest approximately 30 minutes after anesthesia induction.
- Intraoperative findings revealed a bleeding SVG pseudoaneurysm and a dislodged hemostatic clip.
Findings:
- The pseudoaneurysm was attributed to the displacement of a hemostatic clip near a SVG side branch.
- The patient's shock and cardiac arrest were suspected to be an anaphylactic reaction to the re-administered aprotinin.
- Surgical intervention included partial cardiopulmonary bypass, median sternotomy, and repair of the bleeding SVG.
Implications:
- This case highlights a potential risk of anaphylaxis with repeated aprotinin administration in cardiovascular surgery.
- Careful patient monitoring and consideration of alternative hemostatic agents may be warranted.
- Understanding the link between hemostatic clips and SVG complications is crucial for preventing pseudoaneurysms.
Abstract:
A 69-year-old man was admitted because of angina pectoris and thoracic descending aorta aneurysm. Staged operations were planned. First, he underwent CABG (coronary artery bypass grafting) with SVGs (saphenous vein grafts) to #4 PD, #7 and #12. Aprotinin was administrated to reduce blood loss. The routine postoperative graft angiography and enhanced CT showed a pseudoaneurysm in the SVG to #4 PD. We planned an elective operation of pseudoaneurysm repair and graft replacement of thoracic descending aorta. Also in this second operation, continuous infusion of aprotinin was started after the induction of anesthesia. About 30 minutes later, he suddenly fell in shock and cardiac arrest. Partial cardiopulmonary bypass was established and median sternotomy was performed. In the mediastinum, no bleeding was found. We found out a bleeding point of the SVG to #4 PD and a hemostatic clip on the right ventricule, and closed the bleeding point with suture. The cause of the pseudoaneurysm seemed to be defluxion of the hemostatic clip for a side brunch of the SVG. The cause of the preoperative shock may be an anaphylaxis to readministrated aprotinin.