Acute Compartment Syndrome of the Lower Leg after Coronary Artery Bypass Grafting: A Silent but Dangerous Complication

Abstract

Background Acute compartment syndrome (ACoS) is a serious, limb-threatening condition, but ACoS after coronary artery bypass grafting (CABG) is rare. ACoS is diagnosed with the help of typical symptoms, but due to the use of analgesics in a postoperative setting, these symptoms may vary. Identifying risk factors for ACoS after CABG could reduce the risk of developing this complication.

Methods We describe the clinical presentation, diagnosis, and management of five cases of ACoS arising from CABG procedures at our institution during the last 5 years. We also review all cases found in literature about this complication.

Discussion Both systemic and local factors may contribute to ACoS of the lower leg. These factors include increased microvascular permeability caused by cardiopulmonary bypass (CPB), the use of cardiac-assist devices causing arterial occlusion and reperfusion injury, diminished arterial blood flow in patients with peripheral vascular disease due to lithotomy position and the use of elastic bandages and local trauma and hematoma formation due to the harvesting of the greater saphenous vein (GSV).

Conclusion To prevent this serious complication, we advise to pay extra attention to the patients with a greater risk. Hemostasis after venectomy in CABG surgery is mandatory, especially in the endoscopic harvesting of the GSV. Elastic bandages should be applied after weaning from CPB. Elevated creatine phosphokinase values may indicate ACoS. When suspicion arises, intracompartmental pressure measurement is the preferred tool for early recognition and diagnosis. To prevent irreversible, extensive tissue damage and permanent disability fasciotomy must be performed immediately after the diagnosis is made.

Keywords

coronary artery bypass grafts surgery - CABG - anesthesia - cardiopulmonary bypass - CPB - IABP - intensive care - postoperative care

• References

• 1 Mabvuure NT, Malahias M, Hindocha S, Khan W, Juma A. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J 2012; 6 (Suppl. 03) 535-543
• 2 Asgun HF, Kirilmaz B. Compartment syndrome of the vein donor leg following an uneventful coronary artery bypass surgery. J Card Surg 2013; 28 (1) 30-32
• 3 Al-Sarraf N, Al-Shammari F, Vislocky I, Malek L. Lower limb compartment syndrome following coronary artery bypass surgery: a rare entity. Gen Thorac Cardiovasc Surg 2010; 58 (3) 131-133
• 4 Barkhordari K, Yousefshahi F, Khajavi MR, Karimi A. Continuous sedation-analgesia delays diagnosis of compartment syndrome in a patient with intra-aortic balloon pump. Arch Iran Med 2012; 15 (6) 387-388
• 5 James T, Friedman SG, Scher L, Hall M. Lower extremity compartment syndrome after coronary artery bypass. J Vasc Surg 2002; 36 (5) 1069-1070
• 6 Kolli A, Au JT, Lee DC, Klinoff N, Ko W. Compartment syndrome after endoscopic harvest of the great saphenous vein during coronary artery bypass grafting. Ann Thorac Surg 2010; 89 (1) 271-273
• 7 Mills J, Pretorius V, Lording T, Hardikar A, Murton M. Bilateral anterior compartment syndrome after routine coronary artery bypass surgery and severe hypothyroidism. Ann Thorac Surg 2010; 90 (4) 1338-1340
• 8 Papas TT, Mikroulis D, Papanas N, Lazarides MK, Bougioukas G. Lower extremity compartment sindrome following coronary artery bypass. J Cardiovasc Surg (Torino) 2007; 48 (2) 249-252
• 9 Pasic M, Carrel T, Tönz M, Vogt P, von Segesser L, Turina M. Acute compartment syndrome after aortocoronary bypass. Lancet 1993; 341 (8849) 897
• 10 Vaidyanathan KR, Sundaramoorthi T, Byalal JR , et al. Lower extremity compartment syndrome after off-pump aortocoronary bypass. J Thorac Cardiovasc Surg 2006; 131 (5) 1173-1174
• 11 Velez CA, Kahn J. Compartment syndrome from balloon pump. Catheter Cardiovasc Interv 2000; 51 (2) 217-219
• 12 van den Wildenberg FA, Houben PF, Maessen JG. Compartment-syndrome of the lower extremity after CABG. J Cardiovasc Surg (Torino) 1996; 37 (3) 237-241
• 13 Cox Jr CS, Allen SJ, Brennan M. Analysis of intestinal microvascular permeability associated with cardiopulmonary bypass. J Surg Res 1999; 83 (1) 19-26
• 14 Teeples TJ, Rallis DJ, Rieck KL, Viozzi CF. Lower extremity compartment syndrome associated with hypotensive general anesthesia for orthognathic surgery: a case report and review of the disease. J Oral Maxillofac Surg 2010; 68 (5) 1166-1170
• 15 Cheng D, Allen K, Cohn W , et al. Endoscopic vascular harvest in coronary artery bypass grafting surgery: a meta-analysis of randomized trials and controlled trials. Innovations (Phila) 2005; 1 (2) 61-74
• 16 Busch T, Sîrbu H, Zenker D, Dalichau H. Vascular complications related to intraaortic balloon counterpulsation: an analysis of ten years experience. Thorac Cardiovasc Surg 1997; 45 (2) 55-59
• 17 Beraldo S, Dodds SR. Lower limb acute compartment syndrome after colorectal surgery in prolonged lithotomy position. Dis Colon Rectum 2006; 49 (11) 1772-1780
• 18 Scott JR, Daneker G, Lumsden AB. Prevention of compartment syndrome associated with dorsal lithotomy position. Am Surg 1997; 63 (9) 801-806
• 19 Flamini S, Zoccali C, Persi E, Calvisi V. Spontaneous compartment syndrome in a patient with diabetes and statin administration: a case report. J Orthop Traumatol 2008; 9 (2) 101-103
• 20 Jose RM, Viswanathan N, Aldlyami E, Wilson Y, Moiemen N, Thomas R. A spontaneous compartment syndrome in a patient with diabetes. J Bone Joint Surg Br 2004; 86 (7) 1068-1070
• 21 Chochola M, Lubanda JC, Skalicka L , et al. Bilateral leg compartment syndrome due to severe myonecrosis caused by inappropriate use of simvastatin [in French]. J Mal Vasc 2008; 33 (4-5) 229-233
• 22 Walker JL, Smith GH, Gaston MS, Robinson CM. Spontaneous compartment syndrome in association with simvastatin-induced myositis. Emerg Med J 2008; 25 (5) 305-306
• 23 Valdez C, Schroeder E, Amdur R, Pascual J, Sarani B. Serum creatine kinase levels are associated with extremity compartment syndrome. J Trauma Acute Care Surg 2013; 74 (2) 441-445 , discussion 445–447
• 24 Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World J Surg 2003; 27 (6) 744-747
• 25 Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13 (7) 436-444
• 26 Mubarak SJ, Hargens AR, Owen CA, Garetto LP, Akeson WH. The wick catheter technique for measurement of intramuscular pressure. A new research and clinical tool. J Bone Joint Surg Am 1976; 58 (7) 1016-1020