CASE REPORT:
A 52 year old gentleman presented with renal colic and unstable angina,
for which he was admitted at another centre. . His angiogram, there,
revealed 70% distal left main stem disease along with 90% long segment
disease involving proximal LAD, Cx and RCA. He also had impaired
LVEF(40%). He also had significant skin changes in both lower legs,
with thread-like veins, and had Doppler confirmed bilateral lower limb
peripheral vascular disease and restrictive lung function tests. On
ultrasound multiple renal calculi and an obstructive left ureteric
calculus, dilatation of the pelvi-calyceal system and mild perinephric
collection was observed. Previously he also had bilateral hip
replacements done because of inflammatory arthritis.
In the current COVID-19 pandemic admitting patients for surgical
procedures is fraught with multiple issues. Pre-hospital quarantine and
screening upon admission are some of the measures that are undertaken in
elective cases; however, urgent cases like this pose a bigger challenge.
In the presence of dual pathology both requiring operative intervention
the clinical decision to prioritise one procedure over the other and the
sequence of the operationare. important. multiple procedures or
prolonged hospital admission makes the patient susceptible to hospital
acquired COVID infections. As a result after a multidisciplinary team
meeting a decision to perform a synchronous CABG as well as ureteroscopy
and double-J( DJ) stenting was taken under a single anaesthesia.
Simultaneous CABG and ureteric stone retrieval along with DJ stent was
successfully carried out in this patient with ankylosing spondylitis.
All standard precautions recommended during aerosol generating
procedures were taken during intubation. Because of extreme neck
flexion, a decision to perform intubation aided by fibre-optic
bronchoscopy was taken at the outset. [Figure 1] A non-kinkable size
(7.5Fr) endotracheal tube on a bougie was used. Adequate neck and
cervical spine support was provided.CABG was performed first. Midline
sternotomy incision was made 2 fingers breadth below the sternal notch
to the xiphisternum. The sternum was split using the sternal saw in a
reverse fashion to our usual practice, starting at the xiphisternum
towards the sternal notch. This was done because of a significantly
reduced sterno-mental distance. [Figure 1b] Bilateral internal
thoracic arteries were harvested and a total arterial revascularization
was performed as an off-pump beating heart procedure. Harvesting the ITA
required use of a long tip diathermy as access of the proximal ITA was
As the patient after induction was stable, cysto-ureteroscopy was
performed before CABG. The ureteric stone was retrieved and a doubleJ (DJ ) stent was implanted to relieve
ureteral obstruction.
The patient made an uneventful recovery and was discharged on day seven.