Ann Thorac Surg 1999;67:236-238
© 1999 The Society of Thoracic Surgeons
Case Reports
Rescue revascularization for acute coronary occlusion late after radiotherapy
Thierry Caus, MDa,
Isabelle Canavy, MDa,
Thierry Mesana, MD, PhDa,
Eric Garcia, MDa,
Jean Raoul-Monties, MDa
a Department of Cardiovascular Surgery, Timone Hospital, University Aix-Marseille II, Marseilles, France
Accepted for publication June 16, 1998.
Address reprint requests to Dr Caus, Department of Cardiovascular Surgery, Timone Hospital, University Aix-Marseille II, 13005 Marseilles, France
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Abstract
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Because radiation-induced coronary artery stenoses are frequently severe and located proximally, some patients are admitted in emergency. This report describes the case of a 47-year-old woman with radiation-induced stenosis of the left main coronary artery who presented with cardiac arrest during angiography. The patient was successfully treated using circulatory assistance and percutaneous transluminal coronary angioplasty as a bridge to coronary artery bypass grafting.
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Introduction
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Coronary stenosis is a well-documented, often severe late complication of mediastinal radiation therapy [1, 2]. In this report, we describe the case of a 47-year-old woman who presented prolonged cardiac arrest attributable to occlusion of the left main coronary artery precipitated during angiography. The only significant cardiovascular risk factor in this patient was prior thoracic radiation therapy.
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Case report
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A 47-year-old woman consulted for recent onset of exertional angina. She was an occasional smoker but had no history of systemic hypertension, obesity, hypercholesterolemia, diabetes mellitus, or familial coronary artery disease. Three years earlier she had undergone chemotherapy (nitrogen mustard, procarbazine, prednisone, and vincristine) followed by mantle radiation without protective cardiac shielding (40 Gy over 10 weeks) for non-Hodgkin’s lymphoma.
Exercise testing suggested myocardial ischemia and angiography confirmed isolated high-grade ostial stenosis of the left main coronary artery with normal left ventricular function. The right coronary artery was normal. Selective arteriography demonstrated occlusion of the left internal mammary artery as a consequence of prior left mediastinotomy. However, the right internal mammary artery appeared normal.
Immediately after angiography, while the patient was still in the catheterization laboratory, sudden collapse with ST elevation in precordial leads occurred and led to ventricular fibrillation. Intensive resuscitation using cardiac massage, mechanical ventilation, and intravenous adrenaline failed. Several defibrillation attempts were unsuccessful. Immediate control angiography revealed complete ostial occlusion of the left main coronary artery.
Without interrupting cardiac massage, the cardiologist called the surgical team to institute circulatory support. We started full cardiopulmonary support through the groin vessels using a preheparinized circuit and a Biomedicus centrifugal pump (Medtronic Corp, Anaheim, CA). After establishment of optimal hemodynamic conditions, percutaneous transluminal coronary angioplasty (PTCA) allowed partial reopening of the left main coronary artery (Fig 1). Sinus heart rate spontaneously restored and ST elevation progressively resolved. The interval between cardiac arrest and PTCA was 45 minutes.
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Fig 1. Results of percutaneous transluminal coronary angioplasty with peripheral assistance after acute occlusion of the left main coronary artery. Note the presence of a venous cannulae (VC) in the right atrium through the femoral vein.
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Because of the high risk of reocclusion, the patient was immediately transferred to the operating room for emergency coronary artery bypass grafting. After sternotomy, we harvested the right internal mammary artery and instituted conventional cardiopulmonary bypass. The peripheral cannulas were then removed and the femoral vessels repaired. After two-vessel bypass (vein graft on circumflex branch and right internal mammary artery on left anterior descending coronary artery), the patient was easily weaned from cardiopulmonary bypass despite perioperative transesophageal echocardiography showing left ventricular dysfunction.
Permanent myocardial damage was minimal. The electrocardiogram normalized with no Q wave. Maximum of creatine kinase and its MB isoform were observed the day after operation (1,130 UI/mL and 98 UI/mL, respectively). Daily echocardiography showed progressive improvement in left ventricular function with complete recovery 8 days after operation. The patient was discharged from hospital 2 weeks after operation and progressively resumed normal activity. Sixteen months later she remains free from angina and exercise testing is normal.
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Comment
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Coronary artery stenosis is a potential late complication of mediastinal radiation therapy [1, 2]. The severity of radiation-induced coronary artery stenosis and high incidence in young patients is well documented [1–3]. Ostial involvement is common due partly to arteritis involving the ascending aorta as shown on biopsy specimens of the aorta collected after coronary artery bypass grafting from patients with a history of mediastinal radiation [4]. As illustrated by the patient described in this report, some patients with postradiation coronary artery stenosis require emergency treatment [3].
Although radiation-induced coronary artery disease is attributable more to the formation of fibrosis than deposition of plaque, management options including PTCA or coronary artery bypass grafting are the same as for atherosclerotic disease [2, 3]. A point of special concern in surgical cases is possible calcification of the ascending aorta or concomitant aortic valve disease [2]. Van Son and colleagues [5] demonstrated the feasibility of coronary artery bypass grafting using the patent internal mammary artery in patients with lesions after mediastinal radiation therapy. However, late failure of internal mammary artery bypass grafts has been reported in such patients [6], despite preoperative angiographic evidence of a patent internal mammary artery as in our patient. Because of the potential late complications, our patient is kept under close medical surveillance with regular exercise testing.
In this context of emergency, our decision to use the right internal mammary artery can be criticized. Hence, it is general opinion [7] that the internal mammary artery may be inappropriate for emergency revascularization because of the additional ischemic time involved in harvesting the artery. We considered that it was safe to take an extra 15 minutes to harvest the right internal mammary artery as the patient was under circulatory assistance and ischemia had been reversed by PTCA.
Acute occlusion of the coronary artery after angiography or PTCA can lead to low cardiac output or cardiac arrest. If conventional management techniques fail, cardiopulmonary support or another type of circulatory assistance must be established as soon as possible [8]. In our patient, prompt institution of cardiopulmonary support reversed cardiogenic shock before irreversible damage to the brain or other organs and allowed rescue PTCA with subsequent defibrillation of the heart. We believe that early reperfusion as a bridge to operation was the key to successful weaning from circulatory support with ad-integrum recovery of the stunned myocardium after coronary artery bypass grafting.
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References
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Orzan F., Brusca A., Conte M.R., Presbitero P., Figliomeni M.C. Severe coronary artery disease after radiation therapy of the chest and mediastinum: clinical presentation and treatment. Br Heart J 1993;69:496-500.[Abstract/Free Full Text]
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Veeragangham R.S., Goldin M.D. Surgical management of radiation-induced heart disease. Ann Thorac Surg 1998;65:1014-1019.[Abstract/Free Full Text]
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Om A., Vetrovec G.W. Coronary angioplasty of radiation-induced stenosis. Am Heart J 1993;125:1164-1166.[Medline]
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Tenet W., Missri J., Hager P. Radiation-induced stenosis of the left main coronary artery. Cathet Cardiovasc Diag 1986;12:169-171.[Medline]
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Van Son J.A.M., Noyez L., Van Asten W.N.J.C. Use of internal mammary artery in myocardial revascularization after mediastinal irradiation. J Thorac Cardiovasc Surg 1992;104:1539-1544.[Abstract]
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Gaudiani V.A., Siegel S.B., McIntosh-Yellin N.L. Left main coronary artery reconstruction after radiation therapy. Ann Thorac Surg 1994;58:567-569.[Abstract]
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Carey J.A., Davies S.W., Balcon R., et al. Emergency surgical revascularisation for coronary angioplasty complications. Br Heart J 1994;72:428-435.[Abstract/Free Full Text]
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Monties J.R., Caus T., Mesana T., Pomane C., Mouly-Bandini A., Guez P. Clinical situations and results of cardiopulmonary support by peripheral access for resuscitation and recovery. Artif Organs 1995;19:750-755.[Medline]
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Abstract
Introduction
