Coronary artery disease (CAD) is a leading cause of mortality worldwide, particularly affecting younger adults with symptomatic atherosclerosis. This case report details a 44-year-old male patient presenting with chest pain and dyspnea, leading to a diagnosis of triple vessel disease (TVD). His medical history included hypertension and tobacco use, with a coronary angiogram revealing 100% occlusion in the left anterior descending artery (LAD) and right coronary artery (RCA), along with significant stenosis in other major vessels. Surgical intervention through coronary artery bypass grafting (CABG) was deemed necessary to restore blood flow. The surgery was conducted under general anesthesia with cardiopulmonary bypass, successfully utilizing both saphenous vein and internal thoracic artery grafts. Post-operative recovery was uneventful, and the patient was extubated within four hours. This case underscores the complexity of CABG in patients with TVD, highlighting the importance of tailored surgical strategies and meticulous technique to optimize outcomes and improve quality of life. The successful revascularization illustrates the potential benefits of CABG in high-risk patients with significant coronary blockages.
Coronary artery disease (CAD) is characterized by the presence of symptomatic atherosclerosis in the coronary circulation in males below the age of 55 and females below the age of 45. (1) Obstructive coronary artery disease (CAD) is a leading cause of death worldwide, both in high-income and low- to middle-income countries (LMIC), including many countries in the Middle East (2). The development of CAD has been studied extensively in middle-aged and elderly individuals, but the disease process has largely been overlooked in younger adults. The disease process of atherosclerosis begins at a young age, but the symptomatic incidence of CAD in adults less than 40 years of age accounts for about 3% of total cases according to studies (3). Three-vessel disease (TVD) represents the most severe form of coronary atherosclerosis. Patients with TVD and/or left main stenosis are considered a high-risk group according to therapeutic guidelines. (4,5)
We report on a 44-year-old male patient who presented with a complains of chest pain with radiating to the back, breathlessness, dyspnea for the past 8 months. Patient was admitted to the hospital in CTVS unit with a provisional diagnosis of CAD for further evaluation and management.
Patient had history of hypertension since 5-year, tobacco chewing for 15 years no history of DM, Asthma and no significant family history.
Patient general examination was average and on systemic examination patient was conscious, oriented and system was with in normal examination findings.
Vital signs indicate a pulse of 76 beats per minute, blood pressure of 130/80 mmHg, a respiratory rate of 18 breaths per minute, afebrile temperature, and an oxygen saturation of 98% on room air. There are no scar marks, pigmentation, or dilated veins, no local temperature rise, guarding, or rigidity, while the abdomen feels soft with a fluid thrill present, and bowel sounds are audible. No other significant systemic examination finding was seen.
Laboratory evaluation coronary angiogram was performed which revealed 100% occlusion in Left Anterior Descending Artery (LAD), 100% occlusion in Right Coronary Artery (RCA), 80-90% stenosis in proximal left circumflex (LCx) artery, 30-40% stenosis in obtuse marginal (OM)1, 80-90% stenosis in OM2 and 70% stenosis in OM3 with normal finding of other vessels. 2D ECHO and colour doppler (figure 1) showed 40% left ventricle ejection fraction (LVEF) with regional wall motion abnormalities (RWMA) and no other significant finding. The treatment choice was discussed among the cardiologist team, and CABG was planned to the patient.
Figure 1. showing the 2D ECHO finding of the patient.
Figure 2. CBC on the day before operation.
Surgery was planned in supine position with general anesthesia. During the surgical procedure, the surgeon initially positioned themselves on the patient's right side. Following median sternotomy, the right and left saphenous vein graft (SVG) were procured. Cardiopulmonary bypass was initiated through aortic and right atrial cannulation. The surgeon then relocated to the patient's left side, inserted a root cannula, and applied an aortic cross-clamp. The SVG was then grafted to the right coronary artery (RCA), while the LITA was connected to the left circumflex artery (LCx) as free grafts. Lastly, the RITA was anastomosed in situ to the left anterior descending artery (LAD). The surgery was completed uneventfully, and the patient was extubated within four hours post-operatively and sifted to the CTVS ICU in stable condition (figure 3, 4).
Figure 3. showing coronary artery bypass surgery
Figure 4. showing coronary artery bypass surgery
Triple artery disease coronary artery bypass surgery is a complex and challenging procedure that requires careful planning and execution. This type of surgery is necessary for patients with significant blockages in all three major coronary arteries: the left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA). The goal of the surgery is to restore blood flow to the heart by bypassing the blocked or narrowed coronary arteries using grafts, such as the internal thoracic arteries (ITAs), radial artery, or saphenous vein grafts (SVGs).
The surgical approach can be either on-pump or off-pump CABG, with the choice depending on the individual patient's anatomy and the surgeon's preference. On-pump CABG uses cardiopulmonary bypass, while off-pump CABG is performed on a beating heart. The graft configuration can be either single, sequential, or Y-graft, with the choice depending on the patient's anatomy and the surgeon's preference.
Despite the complexity of the procedure, triple artery disease CABG has been shown to improve survival rates, reduce angina symptoms, and improve quality of life. Complete revascularization, which can be achieved with CABG, is associated with better outcomes. However, the procedure is also associated with increased operative risk, graft failure, and neurological complications, such as stroke and cognitive decline. Therefore, careful patient selection, meticulous surgical technique, and close post-operative monitoring are essential to minimize complications and optimize outcomes.
A successful Coronary Artery Bypass Grafting (CABG) procedure was performed on a patient with situs triple vessel disease. The surgical team adeptly adapted to this unique anatomy by adjusting the surgeon's position and carefully selecting the optimal bypass grafts, ensuring a safe and effective operation.
Download PDF
Download PDF
Download PDF
Download PDF
+91 9063922599
+91 9063922599
editor@healthcare-bulletin.co.uk
Download XML
