[HSF] off-pump CABG and mesenteric ischemia

[erdinç naseri]

I would like to share the following case and have the members' thoughts:
76 Y/O female,had acute inferior MI 5 days ago with post MI chest pain on full medication( including aggrastat) and sedation in ICU
CAG:3 vessel disease with diffuse LAD and CRX lesions ,RCA completely occluded with TIMI I flow.Not suitable for PTCA and reffered for urgent CABG.
taken to operation 6 days after AMI.
Uneventful off-pump CABG( LAD,D1,OM2;OM3,PDA).Lima harvested but not used  because of the dissection in the mid-segment.Fresh thombus in the RCA and arteriotomy site.After closing the sternum the anesthesiolgist noticed that temp was 33C.Started having multifocal VPC.s.Put NGtube and started warming by warm saline through NG and foley cath and externaly by blanket.One bout of VF which was successfully defibrilated.Took 90 minutes to bring the temp to 36.5. Taken to ICU stable with no inotropes and in sinus rhythm.Anticoagulated after few hours and ceasation of drainage with 4X 1 cc heparin.( routine off-pump protocol)Extubate on 12.th hour.Lab completely normal.ABG normal.Now after 10 hours  she developed severe abdominal pain.Consulted with general surgeon .We pushed him to do an exploratory lap .on lap everything was normal except dilataion of colon ( no sign of necrosis,msenteric vessels pulsatile end bleeding, colon shiny but somehow dilated ) small bowel + for peristalsis but colon was silent. She had adhesions around the R upper quadrant due to previous cholecystectomy.Put rectal tube and and drains in Douglass and paracolic gutters and closed abdomen.TEE+TTE showed good cardiac action and no tamponade  She was in good condition and with no pain on CPAP 10 hours after lap.In a matter of 30 minutes she developed R foot drop and no pulse there.R femoral arterial cath was withdrawn with no improvement .Started having metabolic acidosis. Bedsite femoral embolectomy revealed acute occlusion of the R ilia c artery with good antedgrade and retrogrde flow.Arteriotomy closed primarily but the limb didn't improved .opened the arteriotomy .good forward bleeding but no back bleeding .did embolectomy. nothing retrieved . washed with heparinized serum and local anesthetic.no back bleeding .Closed areteriotomy with patch and put a line inside the artery and started giving NTG.Opened femoral vein .let it bleed 1-2 minutes and then closed the vein. Limb improved but metab acidosis progressing very severely. called general surgeon  and opened the abdomen. To the suprise of the general surgeon ( he was against reopening) colon was dead from ceacum to the junction of sigmoid.Total colectomy and ... .Unfortunate end.
What would be members' strategy in this patient.(
PS:hemodynamics very stable untill late in the process with good urinationand CBc and ABG.On sinus rhythm untill the last hours .