COMBINED CORONARY ARTERY BYPASS GRAFTING AND EXCISION OF INTRATHORACIC GOITRE IN ONE-STAGE SURGERY: A CASE REPORT

• Published in: Journal of cardiothoracic and vascular anesthesia Vol. 38; no. 12; pp. 18 - 19
• Main Authors: Castellanos, Marta, Pérez, Sergio, Guadalupe, Nerea, Domínguez, Miriam, López, Cristina, Martín-Ortega, Miguel, Koller, Tobias, Tauron, Manel, Molina, Marta, Tabilo, Juan Francisco, Pérez, José Ignacio, Sabaté, Sergi
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.12.2024
• ISSN: 1053-0770
• DOI: 10.1053/j.jvca.2024.09.042

Provided the high prevalence of thyroid diseases, it is likely to come across this problem in cardiac surgery patients. The aim of this report is to assess the feasibility and safety of a combined total thyroidectomy and an on-pump coronary artery bypass grafting (CABG) surgery. We report a 66-year old male presenting with a triple vessel coronary artery disease with preserved left ventricular function candidate to elective coronary revascularization. The patient had been followed for 10 years for an asymptomatic intrathoracic mass. Physical examination revealed an enlargement of the thyroid gland with palpable nodules in both lobes. With the aim of further evaluating the airway for signs of potential difficulty, we conducted a computed tomography (CT). It demonstrated a large cervical thyroid gland with retroesternal extension. Imaging also revealed mechanical compression of the carotid artery and the internal jugular vein and slight tracheal deviation to the right. A multidisciplinary committee consisting of a cardiac surgeon, a general surgeon and a cardiothoracic anesthesiologist assessed the case and decided to perform a one-stage surgery to complete both procedures. During the preoperative visit, we conducted a thorough airway assessment to identify any potential difficulty. After integrating physical examination and CT information, we predicted a low risk of difficult intubation. The preoperative evaluation was supplemented with laboratory tests, pulmonary function tests in order to predict the risk of postoperative complications, a transesophageal echocardiogram (TEE) and a coronary angiography. During the surgery, the recurrent laryngeal nerve function was monitored. Due to the proximity of the mass to major vessels, we inserted a high flow central venous catheter in the internal jugular vein. The total thyroidectomy was performed through a cervical incision. Both recurrent nerves were identified to avoid injuries and the major vessels of the neck were controlled bilaterally. Once complete resection was achieved, a median sternotomy was performed to obtain the left internal mammary artery graft. Simultaneously, the left radial artery graft was removed. Following this, the cardiopulmonary bypass (CPB) was initiated and a quadruple bypass was performed. There were no intraoperative complications and the patient was weaned off CPB without inotropic support. The patient's postoperative course was uneventful. He was extubated in the cardiovascular intensive care unit (ICU) with no complications. There was no wound bleeding despite the need of postoperative anticoagulation and the intraoperative use of heparin. He was discharged from the ICU on postoperative day three and admitted to the general ward. One-stage cardiac surgery and total thyroidectomy is feasible and can be performed safely. It must be considered that a retroesternal mass is a potential cause of a difficult airway, so a careful assessment must be performed. The best surgical approach remains unclear owing to limited evidence. The main controversial issue might be the risk of bleeding due to the use of heparin intraoperatively and postoperatively and to the coagulopathy associated with cardiopulmonary bypass. Our patient had no complication in this regard, but the optimal surgery strategy requires consideration of individual factors and the involvement of a multidisciplinary team.