2024 FSA Podium and Poster Abstracts
P092: VASO-OCCLUSIVE DEVICE FAILURE IN OFF PUMP CABG FOR PORCELAIN AORTA
Emily Eachus, BS1; Adriana Grossman, MD, MPH, MHA2; Kevin Dazen, MD2; Michael Fabbro II, DO2; 1University of Miami Miller School of Medicine; 2UM/Jackson Memorial Hospital
Introduction: Off pump coronary artery bypass (CABG) procedures are preferred for patients at increased risk of complications due to aortic arch pathologies such as extensive calcification, a porcelain aorta, and Stanford Type A aortic dissections. In these cases, vaso-occlusive devices can be deployed in order to facilitate a safe closure of the aortic anastomotic site. However, when such occlusive devices, like the Heart String III in this case, fail the difficulty of troubleshooting outweighs the potentially imminent blood loss through the incision made.
Methods: This patient is a 68 year-old female with a past medical history of HTN, CAD (80% occlusion of the LAD, 75% occlusion of the LCx, and 60% occlusion of the RCA), COPD, 3.6 cm abdominal aortic aneurysm, severe aortic valve stenosis, and a porcelain aorta. The patient’s cardiologist evaluated the possibility of transcatheter aortic valve replacement prior to surgery and deemed it too high risk. The plan for an off-pump CABG included use of the Heart String III device to occlude the site of anastomosis for the left mammary artery and superficial tibial vein until the anastomosis had been closed completely. The cardiopulmonary bypass (CPB) machine and perfusionist were on stand-by.
Results: Ventilation and induction were uneventful. The procedure progressed without incident until time came to make the incision for the aortic anastomotic site. The vaso-occlusive device was deployed but would not remain open to cover the incision. Though there was moderate blood loss, the patient remained stable and the incision was then held together by the surgeon to prevent further bleeding. At this time, the representative for the device was called but could not be reached. Despite all efforts, the cause of the device malfunction was unknown. A freshly opened device was deployed again, still without success. At this time there was precipitous blood loss and the patient was prepared for CPB. Resuscitative efforts were initiated and the patient was quickly cooled to 28 degrees celsius for circulatory arrest. At this time the patient was cannulated for CPB for a modified Bentall procedure. The patient was successfully taken off of CPB and transferred to CVICU where she made a full recovery.
Discussion: In the use of vaso-occlusive devices for the purposes of anastomosis, the predominant hurdle is troubleshooting the device. During troubleshooting, the patients often continued to lose blood and progress to instability as the decision to transition to CPB is not swift. The cost of troubleshooting of the device to salvage the patient’s original plan for surgery impinges on preparations for CPB. In three of the five case reports with such device failures, mass transfusion protocols were initiated and the cases concluded with the patient unable to transition from CPB; veno-arterial extracorporeal membrane oxygenation was required1.
References:
1. Shaefi S, Mittel A, Loberman D, Ramakrishna H. Off-Pump Versus On-Pump Coronary Artery Bypass Grafting-A Systematic Review and Analysis of Clinical Outcomes. J Cardiothorac Vasc Anesth. 2019 Jan;33(1):232-244. doi: 10.1053/j.jvca.2018.04.012. Epub 2018 Apr 4. PMID: 29753665