732 CASE REPORT VASQUEZ AND BACIEWICZ
CABG AFTER RECENT TRAM FLAP
Fig 2. The finding of the pathological specimen (magnification,
FEATURE ARTICLES
400). Hyaline change with focal fibrin deposition in the media of
the vessel wall.
pulmonary bypass, save operative time, reduce cardiac
invasions, and keep better myocardial function [8]. In our
case, we chose the off-pump approach to avoid further
myocardial injury. At the two-year follow-up, our pa-
tients myocardial ischemia had decreased (per Thallium
201 scan) and her left ventricular function had improved
(per echocardiography). We think that increased postop-
erative coronary blood flow, avoidance of intraoperative
myocardial injury with the off-pump procedure, and
beneficial effects from the angiotensin converting en-
zyme inhibitor on myocardial remodeling would have
contributed to the improvement of our patients myocar-
dial performance.
In summary, we presented a patient who had multiple
coronary fistulas and an aneurysm complicated with
acute myocardial infarction, was treated successfully by
off-pump surgery. After two years, this patient was found
doing well under regular medications.
References
1. Gillebert C, Van Hoof R, van de Werf F, Piessens J, Geest HD.
Coronary artery fistulas in adult population. Eur Heart J
1986;7:437 43.
2. Lowe JE, Oldham HN, Sabiston DC. Surgical management of
congenital coronary artery fistulas. Ann Surg 1981;194:373 80.
3. Vavuranakis M, Bush CA, Boudoulas H. Coronary artery
fistulas in adults: incidence, angiographic characteristics, nat-
ural history. Cathet Cardiovasc Diagn 1990;21:28 40.
4. Liu PY, Chan SH, Chao TH, et al. Adult coronary artery
fistulaa retrospective analysis of 14 cases. Acta Cardio Sin
2003;19:221 8.
5. Sapin P, Frantz E, Jain A, Nichols TC, Dehmer GJ. Coronary
artery fistulas: an abnormality affecting all age groups. Med-
icine 1990;69:10113.
6. Holman E, Peniston W. Hydrodynamic factors in the produc-
tion of aneurysms. Am J Surg 1995;90:200 9.
7. Magovern JA, Mack MJ, Landreneau RJ, et al. The minimally
invasive approach reduces the morbidity of coronary artery
bypass. Circulation 1996;94(Suppl I):I-51.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;81:7325
8. Akins CW, Boucher CA, Pohost GM. Preservation of inter-
ventricular septal function in patients having coronary artery
bypass grafts without cardiopulmonary bypass. Am Heart J
1984;107:304 9.
Coronary Artery Revascularization
After Chest Wall Reconstruction
With Rectus Abdominis
Myocutaneous Flap
Julio C. Vasquez, MD, and Frank A. Baciewicz, Jr, MD
Division of Cardiothoracic Surgery, Harper University
Hospital, Wayne State University, Detroit, Michigan
The standard incision for a cardiac operation is a median
sternotomy. In special situations, alternative approaches
are needed. We report a 53-year-old woman who required
coronary artery bypass grafting 10 days after chest wall
reconstruction with a transverse rectus abdominis myo-
cutaneous flap. We describe our technique, which al-
lowed us to preserve the flap and resulted in good
functional and aesthetic outcome.
(Ann Thorac Surg 2006;81:7325)
2006 by The Society of Thoracic Surgeons
M edian sternotomy is a standard surgical approach
in cardiac surgery. Nevertheless, there are situa-
tions in which alternative options are necessary. We
present a patient who required urgent coronary artery
revascularization 10 days after chest wall reconstruction
with a pedicled right transverse rectus abdominis myo-
cutaneous (TRAM) flap.
A 53 year-old woman who had breast cancer was referred
for urgent coronary artery bypass grafting soon after a
left mastectomy with chest wall reconstruction. She ini-
tially had breast cancer in 1977 and was treated with a
right modified radical mastectomy and radiotherapy. As
a consequence, she had severe right arm lymphedema
develop. In 1983, a malignancy was found in her left
breast and she underwent a lumpectomy with axillary
node dissection followed by radiotherapy; this also re-
sulted in severe lymphedema of the left arm. In 1998, she
had resection and replacement of her right common
carotid artery with a polytetrafluoroethylene graft for
symptomatic radiation-induced stenosis. In April 2003, a
new lesion was found in the residual left breast. She also
had three nonhealing radiation-induced skin ulcers de-
velop in her left chest, one of which was above the left
sternal border. A completion left mastectomy was per-
formed in August 2003. As part of the same procedure,
the anterior table of the left hemisternum, which had
radiation induced osteonecrosis, and a portion of skin
containing the ulcers were resected; a pedicled right
Accepted for publication Oct 22, 2004.
Address correspondence to Dr Baciewicz, Division of Cardiothoracic
Surgery, Harper University Hospital, 3990 John R, Suite 2101, Detroit,
MI 48201; e-mail: fbaciewi@dmc.org.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2004.10.044
Ann Thorac Surg
2006;81:7325
Fig 1. Appearance of the initial chest wall reconstruction. (This pho-
tograph was taken just prior to proceeding with the coronary artery
revascularization.)
TRAM flap was used for chest wall reconstruction (Fig 1).
On postoperative day 3, she had acute pulmonary edema
develop, which required mechanical ventilation. She was
known to have interstitial changes in both lungs from
radiation injury. No significant electrocardiogram
changes were found, but she had a high serum level of
cardiac enzymes (troponin 50 ng/mL) that suggested a
myocardial infarction. A cardiac catherization showed
severe coronary artery disease with stenosis in the fol-
lowing arteries: diffuse left main, 70%; ostial left anterior
descending, 90%; ostial left circumflex, 80%; and ostial
right coronary artery, 90%. In view of the distribution of
lesions, they were believed to be radiation induced. An
intraaortic balloon pump was placed, low-dose inotropic
support (dopamine, 4 g kg1 min1), as well as a
heparin drip for anticoagulation, nitroglycerin infusion,
and cautious diuresis was started. The patient remained
without chest pain, and her condition gradually im-
proved; she was extubated 2 days later. After careful
planning with the plastic surgery team, she was taken to
the operating room for coronary artery revascularization
about 10 days after chest wall reconstruction.
The operation started with the careful take down of the
flap, which was secured with interrupted sutures to the
skin of the right chest wall, avoiding kinking of the
vascular pedicle. The capillary refill of the skin flap was
periodically examined. The heart was exposed by resect-
ing the remainder of the left hemisternum and the
anterior portion of the fourth, fifth, and sixth ribs (Fig 2).
There were radiation-induced changes in the pericar-
dium, which had dense adhesions to the surface of the
heart. Also, the ascending aorta and right atrium had
very thick and sclerotic walls. Full anticoagulation was
given with heparin, and the activated clotting time was
kept at 500 seconds. After heparin administration,
-aminocaproic acid (Amicar, Xanodyne Pharmaceuti-
cals, Florence, KY) was given at a dose of 5 g bolus
intravenously for 1 hour, followed by an infusion of 1g/h,
CASE REPORT VASQUEZ AND BACIEWICZ 733
CABG AFTER RECENT TRAM FLAP
which was discontinued at the end of cardiopulmonary
bypass. Cannulation and the conduct of the operation
were standard. The aortic cross-clamp time was 78 min-
utes, and the total bypass time was 117 minutes. Systemic
blood flow was kept at 2.0 /L min/m2. A neosynephrine
infusion was titrated as needed during cardiopulmonary
bypass, to keep a minimum mean blood pressure of 70
mm Hg. The lowest temperature of the patient was
30.9C. We did not resect any portion of the pericardium,
but it was carefully dissected away from the heart to
expose the coronary arteries; this increased our cross-
clamp time because it was difficult to locate them in the
presence of dense adhesions and scar tissue. Three
aortocoronary vein grafts were placed (one to the left
anterior descending, one to the first obtuse marginal, and
one to the posterior descending branch of the right
coronary artery). After discontinuation of cardiopulmo-
nary bypass, protamine was given to normalize the
activated clotting time, chest drains were placed, and the
pectoralis major and intercostal muscles were folded
over the free edge of the ribs to cover them. The TRAM
FEATURE ARTICLES
flap was resutured to its previous position to cover the
left chest wall defect. No mesh was used and only
interrupted absorbable sutures were placed to secure the
flap. The postoperative course was uneventful with min-
imal inotropic support needed for the first 24 hours
postoperatively. Extubation and removal of the intraaor-
tic balloon pump were performed on postoperative day 1,
and she was discharged home on postoperative day 7. A
readmission was required 2 weeks later for management
of a left pleural effusion, which was drained with ultra-
sound-guided thoracentesis; examination of the flap
showed that it was viable (Fig 3). At follow up, 1 year
later, she was enjoying good overall activity level. The
lack of a small portion of the anterior rib cage did not
have any significant consequence. She was asymptomatic
Fig 2. View of the operative field. Notice the transverse rectus abdo-
minis myocutaneous (TRAM) flap (large arrow) secured temporarily
to the skin of the right chest. The TRAM pedicle (small arrow) is
also visible. The right half of the sternum (asterisk) is also shown.
The heart has been exposed after partial resection of the rib cage
and left half of the sternum.
 734 CASE REPORT VASQUEZ AND BACIEWICZ
CABG AFTER RECENT TRAM FLAP
FEATURE ARTICLES
Fig 3. Final appearance of the chest wall 3 weeks after coronary
artery revascularization showing viability of the transverse rectus
abdominis myocutaneous flap.
from the cardiac and respiratory standpoint, with only
slight paradoxical motion of the flap during breathing,
but no evidence of recurring breast cancer.
Comment
Chest wall irradiation is a well established therapeutic
modality in the management of breast cancer. Unfortu-
nately, it can alter the normal structures of the chest and
neck, resulting in conditions such as skin ulceration,
osteonecrosis, lung damage, and arteriosclerosis. Radia-
tion-induced heart disease is a recognized entity that is
usually underestimated and can involve the pericardium,
the myocardium, or the endocardium. The overall inci-
dence of clinically detectable radiation-induced heart
disease varies with factors such as the amount of medi-
astinal irradiation and the age of the patient; but in
patients treated with radiotherapy for lymphoma
(Hodgkins and non Hodgkins) and carcinoma (ie,
breast, lung, esophagus), it is about 5% to 30% depending
on the method of diagnosis [1]. It commonly damages the
coronary vessels, valvular and subvalvular apparatus,
and conduction system. Typically, the coronary artery
lesions are located in the ostial or proximal regions and
are amenable to surgical revascularization [1, 2].
The TRAM flap is especially useful in large defects of
Ann Thorac Surg
2006;81:7325
the chest wall; it carries healthy skin with it, giving a good
cosmetic appearance [3]. It has also been used with good
results in patients with delayed sternal closure [4]. In our
patient, an angiogram before the construction of the
TRAM flap showed mild diffuse stenosis in both internal
mammary arteries, although the presence of osteonecro-
sis in the left side of the sternum was suggestive of severe
damage to the left internal mammary artery distribution.
We believe that a median sternotomy approach in our
patient had a prohibitive risk of dehiscence. Also, this
approach carried a small but real risk of injury to the
right internal mammary artery during placement of ster-
nal wires at the time of closure, which could result in
immediate ischemia of the TRAM flap. For these reasons,
we opted to expose the heart through the left anterior
chest wall. A left thoracotomy was not a good alternative
in view of the previous mastectomy and radiation-
induced damage to the chest wall and lungs.
Reconstruction with myocutaneous flaps has been suc-
cessfully used for radiodystrophy and radionecrosis of
the chest wall [5]. The cardinal rule is that once the flap
is positioned, it should not be disturbed because it can
result in impaired blood flow with subsequent necrosis.
We opted to take down the flap about 10 days after its
implantation to allow exposure for coronary revascular-
ization. We could not find reports of successful take
down and repositioning of this type of flap, and we were
uncertain about the fate of the flap under the conditions
encountered during cardiopulmonary bypass, such as
low temperature, low blood flow, low blood pressure,
vasoconstriction from inotrope infusions, and systemic
anticoagulation. Certainly, the longer the interval since
the TRAM flap is in place, the riskier the manipulation
would become, as its newly established blood supply is
being interrupted. Options for reconstruction when this
happens are limited. An alternative for our patient, in
case of TRAM failure, was the use of a latissimus dorsi
myocutaneous flap, although this requires a lateral de-
cubitus position for the harvesting portion of the opera-
tion [6, 7].
In conclusion, we have shown that a TRAM flap can be
temporarily taken down within 10 days of implantation to
allow access for cardiac operations. The flap can remain
viable, even with low blood flow resulting from cardio-
pulmonary bypass, and then it can be safely reimplanted
with good functional and esthetical outcome.
References
1. Veeragandham RS, Goldin MD. Surgical management of
radiation-induced heart disease. Ann Thorac Surg 1998;65:
1014 9.
2. Hicks GL Jr. Coronary artery operation in radiation-
associated atherosclerosis: long term follow up. Ann Thorac
Surg 1992;53:670 4.
3. Al-Kattan KM, Breach NM, Kaplan DK, Goldstraw P. Soft
tissue reconstruction in thoracic surgery. Ann Thorac Surg
1995;60:13725.
4. Shibata T, Hattori K, Hirai H, Fujii H, Aoyama T, Seuhiro S.
Rectus abdominis myocutaneous flap after unsuccessful de-
layed sternal closure. Ann Thorac Surg 2003;76:956 8.
Ann Thorac Surg
2006;81:7357
5. Rouanet P, Fabre JM, Tica V, Anaf V, Jozwick M, Pujol H.
Chest wall reconstruction for radionecrosis after breast car-
cinoma therapy. Ann Plast Surg 1995;34:46570.
6. Samuels L, Granick MS, Ramasastry S, Solomon MP, Hurwitz
D. Reconstruction of radiation-induced chest wall lesions.
Ann Plast Surg 1993;31:399 405.
7. Arnold PG, Pairolero PC. Chest wall reconstruction: an ac-
count of 500 consecutive patients. Plast Reconstr Surg
1996;98:804 10.
Rescue Surgical Embolectomy for
Fatal Pulmonary Embolism in
Patient With Intracranial
Hemorrhage
Ikuo Fukuda, MD, Kozo Fukui, MD,
Masahito Minakawa, MD, Masayuki Koyama, MD,
Ikko Ichinoseki, MD, and Yasuyuki Suzuki, MD
Department of Surgery, Hirosaki University School of
Medicine, Hirosaki, Aomori, Department of Cardiovascular
Surgery, Tsukuba Medical Center, Tsukuba, Ibaraki, Japan
The incidence of pulmonary embolism is relatively high
in stroke patients due to prolonged bed rest, paralysis of
the lower extremities, and dehydration. We herein report
three cases of pulmonary embolectomy for patients with
intracranial hemorrhage. All patients had massive central
pulmonary embolism and were in deep shock. The
interval between the onset of intracranial bleeding and
surgical embolectomy was 7 to 16 days. All patients
underwent emergent pulmonary embolectomy using car-
diopulmonary bypass and survived without any neuro-
logic exacerbation. Surgical pulmonary embolectomy is a
treatment of choice to save patients with massive pulmo-
nary embolism after intracranial hemorrhage.
(Ann Thorac Surg 2006;81:7357)
2006 by The Society of Thoracic Surgeons
T he incidence of pulmonary embolism is relatively
high in stroke patients due to prolonged bed rest,
paralysis of the lower extremities, and dehydration due
to hyperosmolar therapy [1]. Pulmonary embolism is one
of the major causes of death after stroke. This is a review
of patients who underwent surgical embolectomy for
management of pulmonary embolus complicating intra-
cranial hemorrhage.
Case Reports
Patient 1
A 57-year-old woman was admitted as a patient due to
cerebral contusion, subdural hematoma, and fracture of
the pelvis and cervical spine caused by a traffic accident.
Decompression and fixation of the cervical spine was
performed on day 10 because of exacerbation of tetrapa-
Accepted for publication Oct 28, 2004.
Address correspondence to Dr Fukuda, Department of Surgery, Hirosaki
University School of Medicine, 5-Zaifucho, Hirosaki, Aomori, 036 8562
Japan; e-mail: ikuofuku@cc.hirosaki-u.ac.jp.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CASE REPORT FUKUDA ET AL 735
RESCUE SURGICAL EMBOLECTOMY
resis. On day 16, the patient suddenly exhibited circula-
tory collapse and stupor. Emergent pulmonary angiogra-
phy revealed massive pulmonary embolism in bilateral
main pulmonary arteries. Because the patient exhibited
bradycardia and severe hypotension after angiography,
the patient was transferred to the operating room for
emergent pulmonary embolectomy. Extracorporeal cir-
culation was instituted through the right femoral artery
and vein, and pulmonary embolectomy was performed
through a median sternotomy. The interval between
onset and embolectomy was 7 hours, and the interval
between definitive diagnosis and institution of cardiopul-
monary bypass was 30 minutes. The patients hemody-
namics stabilized and no neurologic deficit remained. To
prevent recurrence, continuous infusion of heparin so-
dium was given after the surgery. However, intracranial
hemorrhage occurred on postoperative day 6. Infusion of
the heparin was discontinued and interruption of the
inferior vena cava was performed. The patient was dis-
charged without any neurologic deficit.
FEATURE ARTICLES
Patient 2
A 63-year-old woman was admitted as a patient due to
subarachnoid hemorrhage. Intracranial aneurysm could
not be detected by repeat cerebral angiography. On day
7, the patient lost consciousness and went into shock.
Echocardiography revealed right ventricular distension,
left ventricular collapse, and tachycardia. Urgent pulmo-
nary angiography revealed massive pulmonary thrombo-
embolism in bilateral main pulmonary arteries. Although
catheter directed fragmentation was attempted, the pa-
tient fell into deep shock, and exhibited bradycardia.
Cardiac massage was begun, and the patient was trans-
ferred to the operating room immediately. Pulmonary
embolectomy was successfully performed under cardio-
pulmonary bypass. Inferior vena cava filter was inserted
after the operation. Anticoagulant therapy was not per-
formed. The patient was discharged without any neuro-
logic deficit.
Patient 3
The patient was a 67-year-old man who had right hemi-
plegia due to hypertensive intracranial hemorrhage (Fig
1). On day 8 after the onset of stroke, the patient went
into circulatory collapse and lost consciousness in the
rehabilitation room. Cardiopulmonary resuscitation was
begun immediately, but the patient was still in deep
shock. Enhanced computed tomographic scan of the
chest revealed massive pulmonary emboli in the pulmo-
nary trunk and bilateral main pulmonary arteries (Fig 2).
The patient was transferred to our hospital 6 hours after
the onset. Because fibrinolytic therapy was contraindi-
cated, emergent pulmonary embolectomy and insertion
of an inferior vena cava filter was carried out immedi-
ately (Fig 3). After the operation, hemodynamics of the
patient became stable and the patient regained con-
sciousness. Computed tomography of the brain revealed
no exacerbation of intracranial hematoma. The patient
was transferred to the rehabilitation home. His neuro-
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2004.10.061