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

Alexei V Barsuk

Kirill O Barbuhatti

Sergei A Belash

Vasily I Kaleda

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Clinical Study
Perioperative Avulsion of a Left Internal Mammary Artery Graft
in a Patient with Syphilis
Vasily I. Kaleda,1 Sergei A. Belash,1 Alexei V. Barsuk,2 and Kirill O. Barbuhatti1
1 Department of Adult Cardiac Surgery, Ochapowski Regional Hospital #1, Chest Surgery Center, 140, Rossiyskaya Street,
Krasnodar 350086, Russia
2 Pathomorphology Lab, Ochapowski Regional Hospital #1, Chest Surgery Center, 140, Rossiyskaya Street, Krasnodar 350086, Russia
Correspondence should be addressed to Vasily I. Kaleda; vasily.kaleda@gmail.com
Received 12 August 2013; Revised 22 September 2013; Accepted 6 October 2013; Published 2 January 2014
Academic Editor: T. A. Salerno
Copyright © 2014 Vasily I. Kaleda et al.This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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 decreased left 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 crys-
talloid 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 quality of the graft. LIMA-to-
LAD anastomosis was performed using running 8-0 prolene
suture, and paravascular fat was fixed to epicardium with
two 6-0 prolene sutures. Coronary probe or flow-probe was
not used while or after performing the anastomosis. Before
closing chest the LIMA-to-LAD anastomosis and the LIMA
itself were examined carefully, and no bleeding or LIMA
tension was observed.
Hindawi Publishing Corporation
Surgery Research and Practice
Volume 2014, Article ID 574346, 3 pages
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2 Surgery Research and Practice
Avulsion
site
Figure 1: Finding during reexploration. LIMA: left internal mam-
mary artery graft; LAD: left anterior descending artery.
After an uneventful operation the patient was placed
to ICU where 1.5 liter of blood drained suddenly through
the chest tubes in 1.5 hours after CABG. The patient was
returned to the operation room (OR) and reexplored by
the same surgeon. Avulsion of the LIMA graft was found
at the site of the heel of anastomosis with LAD (Figure 1).
There was sufficient length of the LIMA graft, and excessive
lung inflation was unlikely to cause tension of the graft. The
LIMA itself was examined carefully and had normal external
appearance. Technical error was considered to be the cause
of LIMA avulsion. The tip of the LIMA graft was resected,
and a new LIMA to LAD anastomosis was constructed using
CPB and cardioplegia. But in 9 hours of stay in ICU new
massive bleeding occurred. The patient was reexplored in
the OR again, and similar LIMA graft rupture was revealed.
LIMA graft was removed and LAD was bypassed with vein
graft using CPB and cardioplegia.
Perioperatively ceftriaxone 2mg per day was adminis-
tered intravenously for 2 weeks for syphilis. Early postop-
erative period was complicated with delirium, deep sternal
wound infection, necrotizing pancreatitis, and perforated
peptic ulcer. Due to these conditions the patient underwent
long mechanical ventilation and tracheostomy, vacuum-
assisted closure therapy and secondary sternal wound clo-
sure, ultrasound-guided percutaneous catheter drainage for
pancreatitis, and surgical repair of the gastric perforation.The
patient was discharged home in two months after surgery.
Three years after surgery, the condition of the patient is
satisfactory.
Histological examination of the resected LIMA showed
weakening of the arterial wall possibly due to syphilitic
process: mucoid degeneration with mucopolysaccharide
accumulation, elastic fibers alteration, and fragmentation
(Figure 2).
3. Discussion
Syphilis is well known to be the cause of aortitis which tends
to result in aortic aneurysms, aortic valve regurgitation, and
ostial coronary artery stenosis [1–3]. Proximal saphenous
vein graft occlusion after CABG due to syphilitic aortitis was
reported [4]. Subclavian, carotid, and innominate arteries
also could be affected by the syphilitic process [1, 5, 6], but
Figure 2: Mucoid degeneration of the LIMA wall. Alcian blue stain
(×100).
internal mammary arteries are very seldom involved [3, 7].
Moreover, to our knowledge, it has never been reported to be
the cause of LIMA graft avulsion.
Avulsion of a graft is a rare complication of CABG
surgery. It can have a number of causes. Several authors
reported LIMA graft avulsion after MIDCAB [8–12]. Morritt
et al. reported LIMA graft avulsion 4 hours after conventional
CABG surgery occurring at the time of weaning from
ventilator [13]. Inadequate length of the LIMA, interaction of
the artery with the edge of the pericardium, inadequate side
branch clipping, and adhesion of the conduit to surround-
ing anatomical structures such as chest wall, mediastinum,
or lung make it susceptible to excessive traction, while
cardiopulmonary resuscitation, hyperventilation, coughing,
sneezing or weight lifting were named as possible causes
in these cases. Mediastinitis was reported to be a cause of
saphenous vein graft rupture 2-3 weeks after surgery [14], but
potentially it can affect LIMAgraft, too. Evenwithout surgery,
spontaneous internal mammary rupture has been described
in patients with type IV Ehlers-Danlos syndrome [15, 16].
Similar cases were reported to be provoked by catheterization
[17].
In our case there were no signs of syphilis prior to surgery
such as skin lesion, aortic dilatation, aortic valve insufficiency,
or isolated ostial coronary arteries lesion, but blood tests
(RPR, EIA, TPPA, and FTA-ABS) were strongly positive
for syphilis. LIMA appeared normal during dissection and
performing anastomosis with LAD. After first avulsion the
LIMA graft was examined carefully and had normal external
appearance. Technical error was considered to be the cause of
LIMA avulsion. That is why we used the graft again. Never-
theless, further histological examination of the LIMA showed
weakening of the arterial wall with such changes as mucoid
degeneration withmucopolysaccharide accumulation, elastic
fibers alteration, and fragmentation in arterial wall. These
findings are not specific for syphilis or any other disease.
Similar findings can be found in patients with infectious or
systemic arteritis and connective tissue disorders. But there
Surgery Research and Practice 3
was no systemic manifestation of possible disorder in our 54-
year-old patient prior to surgery andduring the 3-year follow-
up. The only manifestation was LIMA graft rupture. Because
of serology strongly positive for syphilis and the absence of
another reason of LIMA graft rupture, we suspect syphilis to
be the cause of LIMA wall weakening which leads to rupture
in our case.
This clinical situation gave us a good practical suggestion:
avoid using of a ruptured graft again. Good vein is better than
compromised LIMA even if the latest looks externally well!.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Acknowledgments
The authors thank Sasha Shtratnikova for her illustration.
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Clinical Study Perioperative Avulsion of a Left Internal Mammary Artery Graft in a Patient with Syphilis

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Clinical Study Perioperative Avulsion of a Left Internal Mammary Artery Graft in a Patient with Syphilis

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