Ann Thorac Surg 1997;63:220-221
© 1997 The Society of Thoracic Surgeons
Case Report
Severe Deformity of a Palmaz-Schatz Stent After Normal Surgical Manipulation
Eduardo A. Tovar, MD,
Nathan Blau, MD,
Alan Borsari, MD,
Daniel W. Landa, MD,
Jay M. Packer, MD
Departments of Cardiothoracic Surgery, Cardiology, and Pathology, St. Jude Medical Center, Fullerton, and Department of Cardiothoracic Surgery, University of California, Irvine Medical Center, Orange, California
Accepted for publication September 26, 1996.
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Abstract
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This report describes a case in which normal surgical manipulation during dissection of the heart while performing a repeat revascularization procedure produced a significant deformity in Palmaz-Schatz stents previously implanted in a saphenous vein graft. The graft had shown satisfactory angiographic appearance immediately before the operation, and consideration was given to leaving it in place. Its replacement, however, prevented a major intraoperative mishap.
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Introduction
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It has been suggested that during coronary artery bypass reoperations 5 or more years after the initial procedure, all saphenous vein grafts (SVGs) should be replaced [1, 2]. Others, however, have shown a high incidence of long-term patency of SVGs known to be normal or minimally diseased 5 years after the initial operation [3, 4]. In addition, although angioplasty of focally diseased SVGs carries a prohibitively high incidence of restenosis [5], implantation of Palmaz-Schatz stents in large SVGs with new, focal, nonostial lesions carries a restenosis rate of only 15% at 6 months [6]. This has particular significance when availability of conduit is insufficient and the question arises whether a stented graft with a satisfactory preoperative angiographic result should be left in situ during a coronary artery bypass reoperation.
See also page 37.
In December 1985, a 65-year-old man with a history of hypertension and insulin-dependent diabetes mellitus was seen in consultation. He had a long-standing history of coronary artery interventions. In 1980, after having sustained an inferior wall myocardial infarction, he underwent triple coronary artery bypass grafting. In 1988, after a failed angioplasty, an emergency four-vessel reoperation was performed. He returned in November 1995, at which time he underwent an angioplasty of the proximal posterior descending artery via a saphenous vein graft that supplied the rest of a proximally occluded dominant right coronary artery. In addition, two overlapping Palmaz-Schatz stents were implanted in a focally diseased obtuse marginal graft (Fig 1
). Two weeks, later, a dissected and restenosed proximal posterior descending artery produced preinfarction symptoms. The stented graft appeared widely patent (Fig 2). Of note, both greater saphenous veins had been completely harvested during the two previous operations. We performed four-vessel bypass grafting using the left internal thoracic artery for the left anterior descending coronary artery, the right gastroepiploic artery for the right posterolateral branch, and a lesser saphenous vein graft for the distal posterior descending artery. The stented graft, which we had considered leaving in situ, was also replaced with a lesser saphenous vein graft. We then opened the graft and the overlapping stents were carefully explanted. To our surprise, the stents were markedly deformed (Fig 3). The patient had an uneventful recovery and was discharged home on the seventh postoperative day.
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Fig 1. . New focal, nonostial stenosis in a saphenous vein graft supplying an occluded circumflex system.
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Fig 3. . (A) Overlapping Palmaz-Schatz stents explanted from saphenous vein graft. (B) Lateral view of the same stents. Notice the severe deformity caused by normal surgical manipulation.
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Comment
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Aortocoronary SVGs found widely patent at 5 to 7 years after the original operation have a patency rate of 74% when restudied 5 years later [3]. After coronary reoperations, the published vein graft occlusion rate is 26% at a mean interval of 39 months [7]. This suggests that original grafts with minimal or no disease may be left in place during repeat coronary operations, particularly when adequate conduit is not available. This cannot be extrapolated to stented SVGs. As illustrated in this case, Palmaz-Schatz stents are particularly vulnerable to lateral forces exerted during the necessary dissection and manipulation of the heart that occurs during coronary bypass reoperations. As a result, the deformed stents become intraluminal artifacts that will likely produce early occlusion of the graft.
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Acknowledgments
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We gratefully acknowledge Jean L. Burnette for her assistance in the preparation of the manuscript and Carol Bondurant, St. Jude Medical Center Library, for the compilation of material.
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Footnotes
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Address reprint requests to Dr Tovar, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92835.
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References
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- Lytle BW, Loop FD. Coronary reoperations. Surg Clin North Am 1988;68:559–80.[Medline]
- Marshall WG Jr, Saffitz J, Kouchoukos NT. Management during reoperation of aortocoronary saphenous vein grafts with minimal atherosclerosis by angiography. Ann Thorac Surg 1986;42:163–7.[Abstract]
- Campeau L, Enjalbert M, Lesperance J, Vaislic C, Grondin CM, Bourassa MG. Atherosclerosis and late closure of aortocoronary saphenous vein grafts: sequential angiographic studies at 2 weeks, 1 year, 5 to 7 years, and 10 to 12 years after surgery. Circulation 1983;68(Suppl 2):1–7.
- Campos EE, Cinderella JA, Farhi ER. Long-term angiographic follow-up of normal and minimally diseased saphenous vein grafts. J Am Coll Cardiol 1993;21:1175–80.[Abstract]
- De Feyter PJ, Van Suylen RJ, De Jaegere PP, Topol EJ, Serruys PW. Balloon angioplasty for the treatment of lesions in saphenous vein bypass grafts. J Am Coll Cardiol 1993;21:1539–49.[Abstract]
- Wong SC, Baim DS, Schatz RA, et al. Immediate results and late outcomes after stent implantation in saphenous vein graft lesions: the multicenter U.S. Palmaz-Schatz stent experience. J Am Coll Cardiol 1995;26:704–12.[Abstract]
- Lytle BW, Loop FD, Cosgrove DM, et al. Fifteen hundred coronary reoperations. Results and determinants of early and late survival. J Thorac Cardiovasc Surg 1987;93:847–59.[Abstract]
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Abstract
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