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Ann Thorac Surg 1997;64:545-546
© 1997 The Society of Thoracic Surgeons

Case Reports

Minimally Invasive Coronary Bypass for Protected Left Main Coronary Stenosis Angioplasty

Michael J. Mack, MD, David L. Brown, MD, Aarthi Sankaran, BA

Department of Surgery, Columbia Hospital at Medical City Dallas, Dallas, Texas

Accepted for publication March 24, 1997.


   Abstract
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 Footnotes
 Abstract
Introduction
 Comment
 References
 
A case is presented of left main coronary artery stenosis in a patient with significant comorbidities who was successfully managed with minimally invasive direct coronary artery bypass as protection before percutaneous transluminal coronary angioplasty. This "hybrid" approach for the management of a high-risk patient led to a favorable outcome.


   Introduction
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Conventional management of left main coronary artery disease is coronary artery bypass grafting with cardiopulmonary bypass for circulatory support. Percutaneous transluminal coronary angioplasty has not been acceptable for management of "unprotected" left main coronary artery disease due to the hazards of vessel occlusion during or after the procedure [1]. We present a case of combined minimally invasive direct coronary artery bypass and catheter intervention for the management of a high-risk patient with unstable angina and left main coronary artery disease.

A 73-year-old woman with known coronary artery disease presented with unstable rest angina. Maximal medical management was attempted including intravenous nitroglycerin, but was unsuccessful. Due to failure of maximal medical management, cardiac catheterization was performed, which revealed a 90% occlusion of the left main coronary artery (Fig 1Go) as well as three-vessel coronary artery disease with a 90% occlusion of the left anterior descending coronary artery and moderate disease of the circumflex and right coronary arteries.



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  		Fig 1. . Coronary angiogram showing stenosis of left main and left anterior descending coronary arteries (arrows).

 
Surgical consultation for conventional coronary artery bypass grafting was obtained, but the patient was turned down for surgical consideration by two independent surgeons due to significant comorbidities. These included early presenile dementia, scleroderma of the esophagus causing aspiration, pulmonary fibrosis due to involvement of the lung with scleroderma, and moderately severe pulmonary hypertension (pulmonary artery pressures 75% of systemic blood pressure) with right ventricular dysfunction and tricuspid regurgitation. Further attempts were made to manage the patient medically and wean intravenous nitroglycerin, but were unsuccessful due to rest angina.

A combined surgical and catheter intervention was undertaken. The patient underwent a minimally invasive direct coronary artery bypass procedure in which the left internal mammary artery was placed to the left anteriordescending without cardiopulmonary bypass through a limited left anterior thoracotomy (Fig 2Go). This was performed on a beating heart with stabilization through a 6-cm incision in the fourth intercostal space without rib resection. After heparinization with 10,000 U and test occlusion of the left anterior descending artery, the fully harvested left internal mammary artery was anastomosed with 7-0 Prolene (Ethicon, Somerville, NJ). No arrhythmia or hemodynamic compromise was encountered during the 16-minute occlusion time. The patient was able to be extubated in the operating room and 4 days postoperatively underwent successful percutaneous transluminal coronary angioplasty of the left main coronary artery and the left anterior descending artery (Fig 3Go). Occlusion of the left main coronary artery by the balloon was tolerated without difficulty. A stent was not used because of concern regarding compromise of the circumflex coronary artery. She was able to be discharged asymptomatic from the hospital 3 days after the catheter procedure. She is alive and well, free of angina, 10 months after this combined procedure. Due to her debilitated condition, follow-up catheterization or exercise testing was not performed.



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  		Fig 2. . Coronary angiogram demonstrating left internal mammary artery (arrow) placed to the left anterior descending coronary artery by minimally invasive direct coronary artery bypass grafting approach.

 


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  		Fig 3. . Result after percutaneous transluminal coronary angioplasty of the left main and left anterior descending coronary arteries.

 

   Comment
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References
 
This patient presented with anatomy suitable for conventional coronary artery bypass grafting; however, due to significant comorbidities, the patient was not thought to be a candidate for traditional surgical intervention. Because of the presence of a severe left main coronary artery stenosis, unprotected angioplasty of this vessel was not thought to be appropriate. A recent report by Lopez and associates [1] describes percutaneous treatment of left main coronary stenoses; however, 42 of the 46 interventions were performed in patients with "protected" coronary stenoses owing to previously placed surgical bypass grafts. This patient was not thought to be a candidate for conventional revascularization with coronary artery bypass by two surgeons or for "unprotected" catheter intervention by her cardiologists.

Significant risk factors that add to the morbidity of conventional coronary artery bypass grafting include the median sternotomy incision and cardiopulmonary bypass. Minimally invasive coronary artery bypass grafting eliminates both of these factors. Recent experience with minimally invasive direct coronary artery bypass grafting has demonstrated successful surgical revascularization of the left anterior descending coronary artery through a limited left anterior thoracotomy without cardiopulmonary bypass [2].

This patient was able to be successfully managed by a "hybrid" approach in which a left internal mammary artery was placed to the left anterior descending coronary artery, which served as "protection" that allowed a safe catheter intervention to be performed on the left main coronary artery. This combined approach has recently been described in another high-risk patient [3], and we have subsequently successfully used this approach in another high-risk ventilator-dependent patient.

Concern may exist regarding competitive flow in the left internal mammary artery graft after dilation of more proximal disease in the left anterior descending artery. However, long-term sequelae of the graft in this circumstance are unknown, and although a "string sign" may exist, theoretically left internal mammary artery flow could increase again if restenosis occurs.

Another management modality in this patient could have been catheter intervention on the left main artery stenosis with percutaneously femoral cardiopulmonary bypass standby. Because of previous experience with this modality in our institution we chose the hybrid approach described here.

We believe that this "hybrid" approach of minimally invasive coronary bypass and catheter intervention may serve as a useful management modality in isolated patients who present as high risk for either procedure alone. We continue, however, to routinely manage left main coronary stenoses with conventional coronary bypass grafting.


   Footnotes
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Address reprint requests to Dr Mack, 7777 Forest Lane, Suite 323-A, Dallas, TX 75230.


   References
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 Abstract
 Introduction
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 References
 

  1. Lopez JJ, Ho KKL, Stoler RC, et al. Percutaneous treatment of protected and unprotected left main coronary stenoses with new devices: immediate angiographic results and intermediate-term follow-up. J Am Coll Cardiol 1997;29:345–52.[Abstract]
  2. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]
  3. Liekweg WG, Misra R. Minimally invasive direct coronary artery bypass, percutaneous transluminal coronary angioplasty, and stent placement for left main stenosis. J Thorac Cardiovasc Surg 1997;113:411–2.[Free Full Text]



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This Article
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David L. Brown
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Right arrow Articles by Sankaran, A.

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