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1338 CASE REPORT MILLS ET AL Ann Thorac SurgBILATERAL COMPARTMENT SYNDROME AFTER CABG 2010;90:1338–40

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reservation we achieved a successful result, even withhe cold ischemia time of greater than 3 hours.

The chronic toxicity of immunosuppressive drugs cane of some concern in the organs, such as the liver oridneys, but probably not in the heart. Moreover, itecomes important after a longer period of time. On thether hand, the exposure of an organ to immunosuppres-ive drugs before transplantation can modify the immu-ogenicity of the graft [1], and therefore the risk ofejection can be reduced, which can cause a prolongedraft survival. We suggest that a continuing administra-ion of the primary immunosuppression may have aositive impact.In this era of increasing organ shortage, any additional

onor that can be identified represents an interestingontribution. There are anecdotal reports on vitally im-ortant organ allografts being re-transplanted to a sec-nd recipient [2–6]. Only two studies with a greaterumber of patients come from the United Network forrgan Sharing registry [7, 8]. The Lowell study comprises

5 patients receiving cadaveric organs from 52 donorsho had previously received any prior organ transplantetween 1987 and 1996 [7]. However, in this cohort noatient received the heart from a donor who was primar-

ly a heart transplant recipient. All heart recipients re-eived their grafts from the recipients of other organs.raft survival in the kidney and liver recipients was

omparable with that in the group of patients whoseonors had not been previously transplanted. Survival of

he heart recipients is difficult to evaluate due to themall numbers. The first case of a re-used heart allograftas reported in 1993 by Pasic and colleagues [2]. Since

hen, two other cases have been reported in detail byroups in Munich [9] and Los Angeles [10]. The time

nterval from original implant to donation was 42 hours,days, and 13 days, respectively, in the aforementioned

ases [2, 9, 10]. It is noteworthy to report that theunctional outcome in all of these patients (including ourwn case) was excellent, and that the re-use of the heartraft is a valuable possibility.

he authors thank Mrs Zdena Dolezalova for valuable helpuring manuscript preparation for this article.

eferences

1. Arvieux C, Cornforth B, Gunson B, et al. Use of graftsprocured from organ transplant recipients. Transplantation1999;67:1074–7.

2. Pasic M, Gallino A, Carrel T, et al. Brief report: reuse of atransplanted heart. N Engl J Med 1993;328:319–20.

3. Moreno Gonzales E, Gomez R, Gonzales Pinto I, et al. Reuseof liver grafts after early death of the first recipient. WorldJ Surg 1996;20:309–12.

4. Nafidi O, Letourneau R, Willems BE, Lapointe RW. Reuse ofliver graft from a brain dead recipient. Clin Transplant2007;21:773–6.

5. Rubay R, Wittebolle X, Ciccarelli O, et al. Re-use of liverallograft; an exceptional opportunity to enlarge the organ

pool. Transpl Int 2003;16:595–7.

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2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

6. Tayar C, Karoui M, Laurent A, et al. Successful reuse of livergraft 13 years after initial transplantation. Transplantation2006;82:1547–8.

7. Lowell JA, Smith CR, Brennan DC, et al. The dominotransplant: Transplant recipients as organ donors. Trans-plantation 2000,69:372–6.

8. Ortiz J, Reich DJ, Manzarbeitia C, Humar A. Successfulre-use of liver allografts: three case reports and a review ofthe UNOS database. Am J Transplant 2005;5:189–92.

9. Meiser BM, Uberfuhr P, Reichespurner H, Stang A, KreuzerE, Reichart B. One heart transplanted successfully twice.J Heart Lung Transplant 1994;13:339–4.

0. Simsir SA, Fontana GP, Czer LS, Schwarz ER. Heart allografttransplanted twice. Eur J Cardiothorac Surg 2008;34:918–91.

ilateral Anterior Compartmentyndrome After Routine Coronaryrtery Bypass Surgery and Severeypothyroidism

ane Mills, MBBS, Victor Pretorius, FRCSC,im Lording, MBBS, Ashutosh Hardikar, FRACS, andark Murton, FRACS

ivisions of Cardiothoracic Surgery and Orthopedic Surgeryt the Royal Hobart Hospital, Hobart, Australia

ompartment syndrome is a very rare complication oforonary artery bypass grafting and previously it hasnly been described unilaterally. We describe the devel-pment of compartment syndrome in bilateral anteriorompartments of the lower leg after vein harvest fororonary artery bypass grafting. We describe a series ofredisposing factors contributing to this condition and

ts delayed diagnosis, including severe undiagnosed hy-othyroidism. We advise a high index of suspicion inatients postvein harvest and recommend thyroid func-

ion testing for all patients who have compartment syn-rome develop.

(Ann Thorac Surg 2010;90:1338–40)© 2010 by The Society of Thoracic Surgeons

cute compartment syndrome of the lower limbsarises due to increased pressures within confined

ascial compartments. This leads to impaired tissue per-usion, resulting in ischemia and potential tissue necro-is. This is a rare complication of coronary artery bypassrafting (CABG) and previously it has only been de-cribed unilaterally. We describe a case of compartmentyndrome in bilateral anterior compartments of the lowereg after vein harvesting for CABG, and a series ofredisposing factors that lead to this condition and itselayed diagnosis. Previously undiagnosed profound hy-othyroidism most likely contributed to the developmentnd severity of this unfortunate complication.

ccepted for publication March 17, 2010.

ddress correspondence to Mr Hardikar, Royal Hobart Hospital, Unit

DS, 48 Liverpool St, Hobart, TAS 7000 Australia; e-mail: ashutos.ardikar@dhhs.tas.gov.au.

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.03.028

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1339Ann Thorac Surg CASE REPORT MILLS ET AL2010;90:1338–40 BILATERAL COMPARTMENT SYNDROME AFTER CABG

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ur patient is a 72-year-old man who presented withcute coronary syndrome without a previous history ofardiac disease. He is an ex-smoker of 1-pack a day for 30ears and was on no medication. He had a mild troponineak (0.193 mcg/L) and a creatine kinase level of 1,168U/L. Coronary angiography revealed severe triple-essel disease with discrete flow-limiting lesions in allhree territories. His left ventricular ejection fraction was0%, with anteroapical wall akinesis. He was referred forrgent CABG and was commenced on aspirin (150 mgaily), metoprolol (25 mg twice a day), rosuvastatin (10g daily), and ramipril (2.5 mg daily) in the interim.The CABG was performed with three grafts involving

he left internal thoracic artery to the left anterior de-cending coronary artery, and the saphenous vein to theosterior descending coronary artery and the first obtusearginal branch. Because the right leg vein was found

nsuitable, a length of vein was harvested from the leftower leg. Leg incisions measured 28 cm on the left and3 cm on the right, and were repaired in two layers withbsorbable sutures.Crepe bandages with mild compression were applied

ilaterally to the lower limbs. There were no intraopera-ive complications. No femoral venous or arterial cathe-ers were inserted.

The postoperative course was complicated by endotra-heal tube malposition resulting in left lower lobe col-apse, as well as hypotension requiring low-dose nor-drenalin infusion. The lower limbs were warm and wellerfused with intact pulses and nail bed circulation atvery assessment for the first 48 hours. The patient’sespiratory function improved and he was weaned off theoradrenalin infusion during a 48-hour period. He wasxtubated on day 2 postoperatively when gas exchangeas adequate. Crepe bandages were removed from the

egs, and bilateral compression stockings were appliedn postoperative day 2.It was noted that the postoperative troponin level riseas minimal (1.71 mcg/L). However, postoperatively the

reatine kinase level increased from 645 to a maximum of7, 956 IU/L by postoperative day 3.Postextubation, the patient reported minimal pain and

ad low analgesia requirements. However, on postoper-tive day 3 it was noted that both legs were tender andense to palpation over the anterior compartments. Painas present with plantar flexion bilaterally, and pedalulses were impalpable but detected on Doppler ultra-ound. The sensation of the first web space was intactilaterally. Anterior compartment pressures were ele-ated at 75 mm Hg bilaterally. Hence, bilateral anteriorompartment syndrome was diagnosed and the patientas urgently taken to theater for fasciotomies. Unfortu-ately the muscle was found to be nonviable and re-uired extensive debridement. Doppler ultrasound ofoth lower limbs excluded deep venous thrombosis.Due to facial features resembling acromegaly the pa-

ient underwent endocrine hormone level screening. Heas found to have significant hypothyroidism with a

hyroid-stimulating hormone level of 42.3 mU/L (refer-

nce range, 0.4 to 4.0 mU/L), free T3 �1.6 pmol/L (refer- t

nce range, 2.3 to 6.3 pmol/L), and free T4 �3.9 pmol/Lreference range, 11.5 to 22.7 pmol/L). His growth hor-

one levels were normal.Our patient made a slow recovery and required bilat-

ral splints for drop feet.

omment

ith acute compartment syndrome, the tissues are exposedo elevated pressure in an enclosed fascial compartment.his results in reduced tissue perfusion leading to ischemia,nd if prolonged this may result in tissue necrosis. Moreommon causes of compartment syndrome are musculo-keletal or vascular trauma, prolonged limb compression,nd burns. Symptoms are typically unreliable and includeevere pain with tenderness to palpation or passive stretch,araesthesia, and paralysis may also be present. Pulseless-ess is a late sign of compartment syndrome [1–3].Compartment syndrome after venous harvesting for

ABG is rare. A literature search (using PubMed) re-ealed eight published cases of compartment syndromef the leg in four reports. No reports have described theevelopment of bilateral compartment syndrome [1].ocumented, long-term complications arising from com-artment syndrome in these cases varied from paraes-

hesia, foot drop, tibial, and peroneal nerve palsy, and inwo cases, even amputation [2]. Wound closure with splithickness skin grafts was commonly required.

Multiple causes have been implicated as the potentialause for compartment syndrome after CABG. Cardio-ulmonary bypass (CPB) can lead to hypotensive periodsesulting in ischemia-reperfusion injury. This is com-ounded by increased capillary permeability induced

rom the inflammatory response incited by CPB. Theesult is increased interstitial fluid and edema leading toigher compartment pressures with resulting venous andrterial impairment [1, 2]. However, compartment syn-rome has also been reported in a single case of off-ump CABG [4].Other contributing factors include compression ap-

lied with compression bandages and stockings, whichan impair tissue perfusion [2]. The use of inotropes hasnly been reported in one case, and this involved the usef dopamine at low levels [2]. Compartment syndromeas been documented to occur in the absence of periph-ral vascular disease [1, 3].Previous studies have reviewed the use of analgesia

nd its effects on diagnosis of compartment syndromend found that pain is an unreliable symptom, as it isubjective and highly variable and may be absent if theres established nerve injury or if deep posterior compart-

ent syndrome is present [5].Interestingly, there have been three reported cases of

pontaneous compartment syndrome (two bilateral, onenilateral) involving the anterior compartment of the

ower leg associated with hypothyroidism [6–8]. Vascu-ar, muscular, and connective tissue abnormalities werettributed to myxoedema and the development of ante-ior compartment syndrome. This involves a combina-

ion of interstitial edema, glycosaminoglycan deposition,

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1340 CASE REPORT KUBOTA ET AL Ann Thorac SurgPRESSURE-AUGMENTED RETROGRADE CEREBRAL PERFUSION 2010;90:1340–3

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uscle hypertrophy, increased capillary permeability,low lymphatic drainage, and decreased compartmentize from connective tissue hypertrophy. Therefore, thisonstellation predisposes to compartment syndrome [6,]. One case reported development of bilateral compart-ent syndrome associated with the combination of hy-

othyroidism and use of simvastatin.Our patient was from an isolated rural background,

ad little contact with a general practitioner, and had nonown history of thyroid dysfunction. He was com-enced on rosuvastatin approximately 2 weeks prior to

urgery. We believe that in this case a combination ofactors were responsible for this unfortunate complica-ion; severe undiagnosed hypothyroidism and the use of

statin, the use of CPB creating an inflammatory stateith routine reduction of blood pressure throughout theperation, in addition to routine use of crepe compres-ion bandages and compression stockings. Compound-ng these routine factors in our patient were the pro-onged intubation and sedation, which prevented theatient from reporting early symptoms of pain, thusontributing to the late diagnosis.

We do not believe the vein harvest incisions, whichealed without complication, played a major role in theevelopment of compartment syndrome on the oppositeide of the leg in the anterior compartment where spon-aneous development of compartment syndrome haseen previously reported in hypothyroidism.

omment

e report the first case of bilateral compartment syndrome,very rare and potentially catastrophic complication afterPB and CABG with saphenous vein harvesting. We be-

ieve multiple factors predisposed and contributed to ouratient’s complication, including severe and previouslyndiagnosed hypothyroidism, use of statin therapy, CPB,ilateral vein harvesting, compression bandages, ino-

ropes, and delayed extubation, combined with a lowevel of clinical suspicion. In the future we would advise

high index of suspicion in patients with postveinarvest in which they are found to have a creatine kinase

evel rise of more than 1,000 IU/L, as noted. We recom-end thyroid function testing in all patients who have

ower limb compartment syndrome develop.

e acknowledge the staff from the intensive care unit andrthopedic department at Royal Hobart Hospital’s for their

nvolvement in the care of our patient.

eferences

. Papas TT, Mikroulis D, Papanas N, Lazarides ML, BougioukasG. Lower extremity compartment syndrome following coro-nary artery bypass. J Vasc Surg 2007;48:249–52.

. James T, Friedman SG, Scher L, Hall M. Lower extremitycompartment syndrome after coronary artery bypass. J VascSurg 2002;36:1069–70.

. Van Den Wildenberg FAJM, Houben PFJ, Maessen JG. Com-

partment-syndrome of the lower extremity after CABG. J Car-diovasc Surg 1996;37:237–41.

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. Vaidyanathan KR, Sundaramoorthi T, Bayalal JR, et al. Lowerextremity compartment syndrome after off-pump aortocoro-nary bypass. J Thorac Cardiovasc Surg 2006;131:1173–4.

. Mar GJ, Barrington MJ, McGuirk BR. Acute compartmentsyndrome of the lower limb and the effect of postoperativeanalgesia on diagnosis. British Journal of Anaesthessia 2009;102:3–11.

. Thacker AK, Agrawal D, Sarkari NBS. Bilateral anterior tibialcompartment syndrome in association with hypothyroidism.Postgrad Med J 1993;69:881–3.

. Ramdass MJ, Singh G, Andrews B. Simvastatin-induced bi-lateral leg compartment syndrome and myonecrosis associ-ated with hypothyroidism. Postgrad Med J 2007;83:152–3.

. Hsu SI, Thadhani RI, Daniels GH. Acute compartment syn-drome in a hypothyroid patient. Thyroid 1995;5:305–8.

linical Application of Intermittentressure-Augmented Retrogradeerebral Perfusion

iroshi Kubota, MD, PhD,hinichi Takamoto, MD, PhD,ideaki Yoshino, MD, PhD,azuhiko Kitahori, MD, PhD,itsuhiro Kawata, MD, PhD,

unihiko Tonari, MD, PhD, Hidehito Endo, MD,iroshi Tsuchiya, MD, Yusuke Inaba, MD,u Takahashi, MD, and Kenichi Sudo, MD, PhD

epartments of Cardiovascular Surgery and Cardiology,yorin University, Department of Cardiac Surgery, Mitsuiemorial Hospital, Department of Cardiac Surgery, Tokyoniversity, Tokyo, Japan

rain protection is important during aortic arch surgery,specially in patients with cerebral ischemia. We clini-ally applied the effectiveness of a novel protocol ofetrograde cerebral perfusion with intermittent pressureugmentation for brain protection in a canine model, asescribed in a previous report. Although, in our patient

he brachiocephalic artery and left subclavian artery wereccluded as a result of aortitis, there was a history of righterebral infarction, recovery of consciousness, and noeurologic sequelae. Near-infrared oximetry showed re-overy of intracranial blood oxygen saturation every timehe pressure was augmented.

(Ann Thorac Surg 2010;90:1340–3)© 2010 by The Society of Thoracic Surgeons

rain protection during aortic arch surgery is impor-tant, especially in patients with cerebral ischemia.

o prolong the safe limits of conventional retrogradeerebral perfusion (RCP), Kitahori and colleagues [1],nd Kawata and colleagues [2, 3] assessed a novel proto-ol, intermittent pressure-augmented retrograde cere-ral perfusion (IPA-RCP), in a canine model [1–3]. Welinically applied this new protocol in a young womanith aortitis syndrome. Although her brachiocephalic

ccepted for publication March 16, 2010.

ddress correspondence to Dr Kubota, 6-20-2, Shinkawa, Mitaka, Tokyo,81-8611, Japan; e-mail: kub@ks.kyorin-u.ac.jp.

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.03.024