IJTCVS Moharana et al 11

Original
2010; 26: 11–14 article OPCAB and bifemoral bypass

Efficacy and safety of beating heart coronary

revascularization coupled with ascending aorta-bifemoral
grafting: Analysis of short term results

Manoj Moharana, MS, Saket Agarwal, MCh, Himanshu Pratap, MS, Aditya Singh, MS,
Sadashiv Tamagond, MS, Deepak Kumar Satsangi, MCh
Department of Cardiovascular–Thoracic Surgery, GB Pant Hospital, University of Delhi, New Delhi, India

Abstract
Introduction: Coronary Artery Disease (CAD) frequently coexists with Peripheral Vascular Disease (PVD)
and poses management issues. When there is a concomitant infrarenal aortic occlusive disease, abdominal
aorta is the traditional donor of bypass inflow to the lower limbs. However, the ascending aorta may also be
used as the source of inflow to both the femoral and coronary arteries in patients who present with combined
CAD and PVD. Here, 5 year follow up results of simultaneous off-pump coronary artery bypass grafting
(OPCAB) and Ascending Aorto-Bifemoral Grafting [AABG] are presented and merits of the procedure are
discussed.
Methods: Hospital records of 20 consecutive cases of OPCAB+AABG performed between
January 2004 and April 2009 were reviewed. There were 18 male patients and 2 female patients in the age
group of 40 to 60 years [mean age 48 years]. These patients were followed up for 5 months to 5 years [mean 3.2
years]. The most frequent presenting complaints were angina on exertion, and severe intermittent claudication
and rest pain. In 6 cases there was a history of myocardial infarction and 8 cases had ischemic ulceration of the
foot.
Results: There were no hospital deaths due to the primary procedure and there was no recurrence of angina
over the follow up period. However 4 patients had recurrent limb rest pain resulting from blockage of the
peripheral graft. All four patients died subsequently.
Conclusion: OPCAB combined with AABG is a safe and effective procedure in a select subset of patients
with atherosclerotic disease and offers satisfactory early results. Visibility of the graft and potential risk of
damage from external trauma are disadvantages. (Ind J Thorac Cardiovasc Surg 2010; 26: 11-14)
Key words: Perepheral vascular disease, Coronary artery bypass grafting, Echocardiography

Introduction symptoms, present of rest pain / ischemic ulceration,

extent of aortic component of the disease, condition of
Patients with vascular disease have a high incidence
infra-renal aorta, history of previous abdominal
of coexistence of Coronary Artery Disease [CAD] and
surgery, and presence of suboptimal lung conditions. If
patients with coronary artery disease may have
the ischemia is not limb threatening, and the infra-
associated Peripheral Vascular Disease [PVD]1,2. The
renal aorta is suitable for grafting a staged approach
operative strategy in such patients of combined CAD
may be preferable but in CAD coexisting with
and PVD demand considerations of severity of cardiac
symptomatic aortoiliac occlusive disease concomitant
revascularization procedures may be required and, in
Address for correspondence:
Dr. Saket Agarwal such cases, the ascending aorta may be used as the
Assistant Professor source of inflow to both the femoral and coronary
Department of CVTS arteries.
G.B. Pant Hospital
Though in literature both Off-Pump Coronary
New Delhi, India
E-mail: drsaketagarwal@gmail.com Revascularization [OPCAB] and Ascending Aorto-
© IJTCVS 097091342610310/104 OA Bifemoral Bypass Grafting [AABG], in isolation, are
Received - 27/09/09; Review Completed - 06/01/10; Accepted - 19/01/10. established procedures, reports of the combined
12 Moharana et al IJTCVS
OPCAB and bifemoral bypass 2010; 26: 11–14

procedure are rather few and anecdotal3,4. In this report,
we present our experience with the combined procedure
along with discussion of its merit and review of
literature.
Patients and Methods
The study was conducted at our tertiary care center
which is a major referral center for patients from North
India. Records of last 20 consecutive cases of OPCAB
and AABG were reviewed. During this time period a
total of 35 patients underwent surgery for aorto-iliac
occlusive disease at our institution. Mean age at
operation was 48 years [range 40 to 60 years]. There were
18 male patients and 2 female patients. Twelve patients
were hypertensive and six had history of Diabetes
Mellitus. All the eighteen male patients were smokers.
Pre-operative characteristics of the patients are detailed
in Table 1. All patients had history of angina and
intermittent claudication. Rest pain was present in
fifteen patients while ischemic foot ulcer was present
in eight patients. History of myocardial infarction was
present in six cases. Evaluation included Coronary
Angiography [CAG] and Peripheral Angiography
[PAG] and echocardiography in all patients. Magnetic
resonance angiography was performed in thirteen
patients. Vascular involvement of the lower limb
resulted from an atherosclerotic aortoiliac segment with
multilevel involvement of the aorta. The infrarenal aorta
and the iliac vessels were predominantly involved with
patchy lesions. Extremity vessels seemed adequate for
revascularization. The abdominal aorta was not
aneurysmal and discreet lesions were not seen.
Mean left ventricular ejection fraction was 36% [25
to 40%]. CAG showed triple vessel disease in sixteen
cases and double vessel in 4 cases. Left main disease
was present in four cases. Twelve patients were in New
York Heart Association [NYHA] class III and eight were
in NYHA class II. Fourteen patients had chronic
obstructive pulmonary disease.
Surgical Technique
All cases were done under general anesthesia with
endotracheal intubation. Standard monitoring lines
including Swan Ganz catheter were used. Median
sternotomy and left internal mammary artery
harvesting and saphenous vein harvesting proceeded
simultaneously. Bilateral vertical groin incisions were
given and suitability of the femoral arteries for grafting
was confirmed. All patients in our study had bilaterally
graftable femoral arteries. Off-pump coronary

Table 1. Pre-operative characteristics of patients receiving combined coronary re-vascularization and ascending aorto-bifemoral
grafting
S. No. Age Sex Rest Ischemic H/T DM History Coronary NYHA COPD
(yrs) limb pain Foot ulcer of MI Lesion class
1 48 M + - + - - TVD III +
2 45 M + - + - - TVD III -
3 51 M - - - - - LM + TVD II +
4 58 M + + - + + TVD II +
5 48 M + - + + + DVD III -
6 41 M + + + - - TVD III +
7 45 M - - - - - TVD II +
8 44 F + + - - - TVD II -
9 52 M + + + + - DVD III +
10 48 M + + + - + LM + TVD III +
11 49 M + - - - - TVD III -
12 47 M - - - + + TVD III +
13 40 F + + + - - TVD II
14 60 M - - + + + DVD II +
15 46 M + + - - - TVD III +
16 46 M + - + - - LM + TVD III +
17 48 M + + - - - DVD II +
18 48 M - - - + + LM + TVD III +
19 42 M + - + - - TVD II -
20 54 M + - + - - TVD III +
+: present, -: absent, M: male, F: female, H/T: hypertension, DM: Diabetes Mellitus, MI: myocardial infarction, TVD: triple vessel disease,
DVD: double vessel disease, LM: left main disease, NYHA: New York Heart Association, COPD: chronic obstructive pulmonary disease
IJTCVS
2010; 26: 11–14
revascularization was done by standard technique.
Normothermia was maintained by keeping the
operating room warm and using warm intravenous
fluids, if needed. Systolic blood pressure was
maintained at around 100 mm of mercury with the help
of intravenous fluid, position changes and use of
inotropes. Heart rate was maintained between 60 to 80
beats per minute. Heparinisation was done using
1.5 mg per kg of heparin to keep activated clotting time
around 250 to 300 seconds. An octopus 3 stabilizer
[Medtronic, inc., Minneapolis, MN, USA] was used
during distal anastomoses and intracoronary shunts
[Chase Medical, Richardson, TX, USA] of appropriate
sizes were used to maintain flow to the distal
myocardium during the anastomosis. Distal
anastomoses were done using 8/0 polypropylene suture
for arterial grafts and 7/0 for venous graft; proximal
anastomoses were performed by applying partial
occlusion clamp on the aorta and using 6/0
polypropylene sutures.
AABG followed CABG. A subcutaneous tunnel was
made from the lower end of sternal wound to the
umbilicus and further extended as two separate tunnels
to the groins where bilateral vertical incisions had
exposed the femoral arteries. Y graft of 16x8x8 cm
polytetrafluorethylene [Gore-Tex] was placed in the
tunnel and length adjusted on three ends. The proximal
end of the graft was anastomosed end to side with the
ascending aorta after applying a partial occlusion clamp
on the aorta and using 4-0 continuous prolene. The
lower ends of the graft were allowed to fill with blood
and length adjustments made in the graft; subsequently
end to side anastomoses performed between the graft
and the femoral arteries using 5-0 continuous prolene.
Necessary deairing and hemostasis of the graft followed.
Post Operative Care
Patients were extubated on the morning after the
surgery and discharged when stable, usually on 6th or
7th post operative day. All patients were prescribed
warfarin [to keep INR between 2.0 to 3.0] along with
aspirin and the necessary cardiac medications for CAD.
Results
There were no operative deaths. The average number
of grafts placed per patient was 3.2 (2 to 5). Patients
were followed up for 5 months to 5 years [mean 3.2
years]. There was no history of recurrence of angina in
any patient. Sustained pedal vascular patency,
confirmed by Doppler, was achieved in all cases in the
Moharana et al 13
OPCAB and bifemoral bypass
immediate post-operative period and was present at the
time of discharge. Three cases had recurrence of
ischemic symptoms, associated with angiographically
demonstrated graft occlusion, in the follow up period
at a mean interval of 11.2 months. In all cases of graft
occlusion irregular intake of anticoagulants was noted
with resultant sub therapeutic INR. Graft revision was
successfully attempted in one case but the patient died
of unrelated cause (road traffic accident) 2.5 years after
the primary surgery. In 2 patients unsuccessful
thrombectomy was attempted before amputation of one
limb was resorted to; both these patients subsequently
died of cerebrovascular accident, 1year and 3 years after
surgery. Graft infection occurred in the fourth case, 3
years after surgery, necessitating explantation and
amputation, the patient died eventually of sepsis. No
case of aneurysm formation was noted in our series.
Discussion
Atherosclerosis is often a generalized disease,
affecting not only the coronary circulation, but other
parts of the vascular system as well1,2. Vascular diseases
most commonly encountered in patients with coronary
atherosclerosis are carotid disease, abdominal aortic
aneurysm and obliterative atherosclerosis in aortoiliac
segment. This is not surprising since the so-called
coronary risk factors are common to all atherosclerotic
diseases: diabetes and smoking connote a higher relative
risk for PAD than CAD, whereas hypertension, family
history of premature atherosclerotic disease, and
hypercholesterolemia serve as the major common risk
factors.
In a scenario where significant CAD coexists with
symptomatic PVD, one may opt for staged intervention
or perform Coronary Artery Bypass Grafting (CABG)
and peripheral vascular procedures during a single
operation. Obvious advantage of the latter approach is
that the patient has to undergo only one operation,
though perceived disadvantage is a possible increase
in operative mortality or morbidity5,6. But when both
the disease components are symptomatically significant
and not amenable to conservative or percutaneous
interventions, a combined surgical approach has to be
usually adopted4.
Abdominal aorta has been the classical ‘gold-
standard’ donor artery for the bypass operations for
critical limb ischemia. It has an excellent patency rate
but the procedure is a major surgical undertaking7,8.
Moreover, a diffusely diseased abdominal aorta may
make such a procedure undesirable, lest the lesion may
progress to involve the donor site, sooner or later. Also,
14 Moharana et al
OPCAB and bifemoral bypass
with a CAD coexisting, the magnitude of the combined
procedure may well be daunting and, particularly when
the sternum is already open, it makes sense to use the
ascending aorta as the donor artery.
The extracavitary methods like axillobifemoral
bypass are generally regarded as poor alternatives to
aortofemoral bypass with reported patency rate of
50% at 3 years, and use of descending thoracic aorta
requires a left thoracotomy and total or subtotal cross-
clamping of thoracic aorta4,8,9. Against such backdrop
of selective use and few alternatives, experience with
ascending aortobifemoral graft has been small but
encouraging3,4.
Historically, when faced with an inoperable infra-
renal aorta, the descending thoracic aorta has been used
as the site of the inflow3,4. During the course of a
standard aorta-femoral operation, Frantz et al.10 found
the abdominal aorta inoperable and extended the
midline laparotomy to a median sternotomy, and
performed probably the first ascending aortofemoral
graft procedure, routed retroperitoneally. In 1976, Baird
and Madras 11 from Canada published their report
“Ascending Aorta to Bilateral Femoral Artery Graft via
a Ventral Subcutaneous Route”, and found that the
procedure… “is technically easy, rapidly performed,
provides a higher flow rate, and is probably more
durable…”.
Advantages of such a method to deal with pedal
ischemia include
1. Simplicity of the procedure
2. avoidance of laparotomy,
3. better blood flow than axillofemoral graft,
4. possible even in presence of subclavian stenosis
which is often present in such patients of diffuse
vasculopathy
5. easier reoperation as one works largely in a
subcutaneous plane and
6. faster recovery and shorter hospital stay.
Visibility of the pulsation and potential risk of
damage from external trauma are disadvantages
prompting some to place the graft behind the rectus in
a preperitoneal plane; we have not had complaints from
the patients on this account. Since the groins have to be
exposed there is a theoretical risk of infection but, as
reported by others as well4, infection is not a common
problem of the procedure. We have thus far had only
one case of infected prosthesis.
Baird et al have reported a 70% 5-year patency of
AABG which is comparable with our experience12.
Jebara et al, in a modified version of AABG, followed
their 10 patients for upto 35 months without any
incidence of graft blockage4.
IJTCVS
2010; 26: 11–14
To summarize, combined CAD and PVD of a
magnitude that demands operative intervention at both
levels is fortunately an uncommon surgical invitation
where ascending aorta offers itself as a satisfactory
common donor artery.
This procedure is particularly suited in presence of
multilevel involvement of abdominal aorta, history of
previous abdominal surgery and suboptimal lung
function or comorbididy where an expeditiously
performed procedure seems safer.
Conclusion
The combined procedure is a both safe and effective
method to deal with multilevel vascular disease. Mid-
term follow up has demonstrated reasonable patency
rates for the peripheral vascular graft. However, longer
term follow-up is still required to demonstrate
superiority of this procedure over conventional
techniques.
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