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Ann Thorac Surg 1998;65:1594-1597
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Left Main Coronary Artery Patch Angioplasty: Midterm Experience and Follow-up With Spiral Computed Tomography

^a Department of Cardiac Surgery, Hospital General Universitario de Alicante, Alicante, Spain
^b Department of Radiology, Hospital General Universitario de Alicante, Alicante, Spain

Accepted for publication January 8, 1998.

Address reprint requests to Dr Meseguer, Servicio de Cirugía Cardiaca, Hospital General Universitario de Alicante, C/ Maestro Alonso 109, E-03010 Alicante, Spain
e-mail: (aquilino{at}redestb.es)

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Patch angioplasty is an alternative surgical technique in cases of left main coronary artery stenosis. We report our experience with this technique, with particular mention of the use of spiral computed tomography for the follow-up of our patients.

Methods. In this retrospective study we analyzed the results obtained in all 7 patients (3 women and 4 men) who were operated on with this technique in our institution between July 1992 and August 1994. Five consenting patients also underwent graft patency assessment with spiral computed tomographic imaging.

Results. The operation was uneventful in all patients and there were no hospital deaths. Two patients required reoperation (1 of them dying at reoperation), 1 because of restenosis of the graft and 1 because of the presence of a new stenosis in the proximal anterior descending coronary artery. The remaining 5 patients were asymptomatic after 51 ± 2 months. Spiral computed tomographic images were artifacted and of poor quality.

Conclusions. Patch angioplasty of the left main coronary artery can be a valuable therapeutic method in selected cases. Conventional spiral computed tomography is not an optimal noninvasive method for the assessment of graft patency.

	Introduction

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Surgical patch angioplasty of the left main coronary artery (LMCA) was first reported by Effler and colleagues [1] in 1965, but this technique was soon abandoned because of its high perioperative risk [1, 2]. The advances in myocardial protection, together with stricter clinical and operative criteria, made possible the revival of this procedure and, in 1983, Hitchcock and colleagues [3] reported some very encouraging results in their series. Recently, Dion and coworkers [4] reported their results on 49 such procedures performed in 47 patients and, according to their experience, this technique appears to be a valuable therapeutic method in the treatment of isolated stenosis of the main stem of the left coronary artery.

In the present study we report our clinical experience with this procedure, with particular mention of the use of spiral computed tomography imaging (SCTI) in the follow-up of our patients.

	Material and methods

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We studied retrospectively all patients diagnosed with LMCA stenosis who were treated surgically with a patch angioplasty at our institution. There were 7 patients (3 women and 4 men; mean age, 51.4 ± 7.7 years; range, 40 to 65 years) and their operations were performed between July 1992 and August 1994. In this survey, relevant clinical information was retrieved from our medical records and follow-up data was obtained by personal interviews with the patients. Diagnosis was established in all patients by means of coronary angiography. Relevant preoperative data are summarized in Table 1. Patient 6 also had type II diabetes mellitus and patient 7 had familial hypercholesterolemia. Two patients had previous cardiac surgical procedures: closed mitral commissurotomy (patient 2) and mitral–aortic valve replacement (patient 1).

Within 1 week during November 1996, all survivors were contacted for follow-up. Informed consent was obtained from 5 patients (except patient 2) to undergo graft patency assessment with SCTI. All SCTI investigations were carried out with an Elscint Helicat II (Haifa, Israel) helicoidal tomograph, visualizing the proximal 3 cm of the aortic root by means of 1.1-mm slices overlapped every 0.7 mm. The patients were injected intravenously with 75 mL of iopromide contrast (Clarograf 300; Laboratorios Juste, Madrid, Spain) at an infusion rate of 3 mL/s, followed 25 seconds later by roentgenographic imaging. The scan time was 20 seconds and the patients were kept apneic during this time.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The operation was uneventful in all patients and they were easily weaned from cardiopulmonary bypass. Relevant operative findings were a calcified atheromatous plaque in patient 2 and an ulcerated and hemorrhagic plaque in patient 3, neither detected in the preoperative angiography. There were no hospital deaths or instances of perioperative myocardial infarction, and the patients were symptom free when discharged from hospital. Patients 4 and 5 had unspecific thoracic discomfort within the first postoperative month. Coronary angiography was repeated in these two patients, demonstrating in both cases excellent LMCA patency. Patients 1 to 5 remain asymptomatic from the cardiac point of view at a mean of 51 ± 2 months (range, 48 to 53 months) follow-up.

Patient 6 also presented chest discomfort and sternal dehiscence 1 month after operation. Cardiac catheterization was repeated, failing to demonstrate any significant restenosis of the LMCA. The patient was reoperated on (sternal rewiring) and discharged home asymptomatic. However, 4 months later, he presented with recurrent angina and a coronary angiography was repeated, this time demonstrating 80% stenosis of the LMCA (Fig 1). Patient 7 had frank angina on the third postoperative month, and coronary angiography was also performed, which demonstrated a new stenosis in the proximal anterior descending coronary artery but the LMCA patch angioplasty remained patent (Fig 2). Operation was indicated in both patients 6 and 7, as we considered that percutaneous treatment would be a high-risk procedure in these two subjects. Patient 6 underwent coronary bypass to the anterior descending and first obtuse marginal arteries; the operation was uneventful and the patient remaining asymptomatic after 34 months. Patient 7 died at reoperation as the result of anaphylactic shock during the anesthetic induction, which was attributed to the administration of aprotinin.

View larger version (62K): [in this window] [in a new window]   Fig 1. Angiographic findings in patient 6. (A) Preoperative view showing stenosis of the left main coronary artery. (B) Postoperative view at 1 month shows no significant left main coronary artery stenosis is found. (C) Postoperative view at 4 months; note restenosis of left main coronary artery.

View larger version (73K): [in this window] [in a new window]   Fig 2. Angiographic findings in patient 7. (A) Preoperative view showing stenosis of left main coronary artery. (B) Postoperative view at 3 months; note the new stenosis of the proximal anterior descending coronary artery (arrow) and the patency of the left main coronary artery patch angioplasty.

	Comment

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Isolated stenosis of the LMCA is a relatively rare feature that accounts for less than 1% of all cases of coronary artery disease [5, 6]. Its most frequent cause is atherosclerosis [7], although a congenital membrane [8], syphylitic aortitis [9], and Takayasu’s aortitis [10] are also known causes of this entity.

Operation is the best therapy for this condition [7] and conventional coronary artery bypass grafting is normally carried out in these patients. However, this technique may lead to certain undesirable consequences, such as pressure loss retrograde to the anastomotic site [3, 5], LMCA occlusion [7], or accelerated vein graft atherosclerosis due to aortic systolic pressure wave exposure [5], which could be potentially avoided with a patch angioplasty. Also, patch angioplasty could be useful in patients with intramyocardial coronary arteries or with inadequate venous conduits for grafting.

Nevertheless, surgical patch angioplasty of the LMCA is not always a suitable option. Patients with noncalcified stenosis involving only the proximal LMCA and less than 60 years of age [5, 7] are the best candidates for this procedure. Right coronary artery stenosis does not appear to be a contraindication for this technique [7]. However, the procedure is controversial in patients more than 60 years of age (who may present unforeseen calcified lesions, as occurred in our experience), patients with atherosclerosis affecting the distal LMCA, and in those with known calcified disease or requiring an endarterectomy [5, 7, 11].

In the first patient of our series we used the posterior approach as described by Hitchcock and colleagues [3]. In the remaining patients, however, the LMCA was approached anteriorly [7], as we believe it offered a better exposure of the main stem and its bifurcation. The aggressive transpulmonary approach, reported with success by some researchers [12], was not used in any instance.

Our early results were satisfactory in all patients, with no perioperative morbidity or mortality. Also, good midterm results were achieved in 5 of 7 patients, all of them remaining symptom free after a mean of 51 months. However, early restenosis occurred in 2 patients, both of them had noncalcified stenosis affecting the proximal third of the LMCA and had a pericardial patch. Operative technical failure usually leads to immediate and severe impairment of left ventricular performance, which often requires conventional vein bypass grafting [7, 13, 14], but this was not the case in these 2 patients. For this reason and in the light of the subsequent events (as illustrated by Figs 1 and 2), we believe that the early restenosis of our 2 patients was the result of accelerated degeneration of the pericardial graft or the appearance of new stenotic lesions. Yet, it is remarkable that all 4 patients with strictly ostial stenoses did well with this procedure, whereas 2 of 3 patients with nonostial lesions had unsatisfactory surgical results.

At present, coronary angiography is the standard method to visualize the coronary arteries, including the LMCA. However, because it is not free from complications, this invasive technique is not adequate for follow-up control of the patients. There have been some attempts to use noninvasive follow-up methods and, along this reasoning, Briffa and colleagues [15] visualized in detail the LMCA by means of spin-echo and gradient-echo magnetic resonance techniques, which may provide information on graft patency with 90% accuracy [16].

Spiral computed tomographic imaging has been reported to be a useful noninvasive technique for the assessment of aortocoronary graft patency [17–19] and, on this basis, we attempted to visualize the LMCA with this method. However, the images obtained were blurred and artifacted in most instances. The long scan time required for this imaging technique (20 seconds) added to the small diameter and the spatial disposition of the LMCA (running in the same plane as the x-ray beam) in the context of a moving heart could account for the disappointing results. In this respect, electron beam computed tomography, a new development in tomographic imaging capable of providing high-resolution images with scan times in the range of milliseconds [20], is likely to offer a much better image definition of the coronary tree, including the LMCA. However, at present, this technique is available only in a few centers throughout the world because of its novelty and high cost. Other artifacting mechanisms found with conventional SCTI were the inability to obtain an optimal infusion rate of contrast through a conventional peripheral venous line in many patients and the presence of a valvular prosthesis in the aortic position.

We conclude that surgical patch angioplasty may be a valuable therapeutic method in selected cases of LMCA stenosis. In our experience, conventional SCTI does not appear to be an optimal noninvasive method to assess LMCA patency.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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