Ann Thorac Surg 1999;68:2346-2349
© 1999 The Society of Thoracic Surgeons
Case Reports
Successful surgical endarterectomy of a stented coronary artery
Virginia M. Walley, MDa,
Jean-Francois Marquis, MDb,
Wilbert J. Keon, MDc
a Department of Laboratory Medicine, University of Ottawa Heart Institute at the Ottawa Civic Hospital, Ottowa, Ontario, Canada
b Department of Medicine, University of Ottawa Heart Institute at the Ottawa Civic Hospital, Ottowa, Ontario, Canada
c Department of Surgery, University of Ottawa Heart Institute at the Ottawa Civic Hospital, Ottawa, Ontario, Canada
Address reprint requests to Dr Walley, Anatomical Pathology, Queen Elizabeth II Health Sciences Centre, Mackenzie Building, 5788 University Ave, Halifax, NS, Canada, B3J 1V8
e-mail: plmvmw{at}qe2-hsc.ns.ca
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Abstract
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An occlusion in this 61-year-old male’s distal right coronary artery was initially successfully opened with balloon angioplasty and three "half" Palmaz-Schatz stents (Johnson and Johnson International Systems, Warren, NJ). Subsequent occlusion of the RCA occurred and prompted bypass grafting 2 years later. An extensive manual surgical endarterectomy removed the stents, demonstrating the technical feasibility of surgically removing failed stents in accessible coronary arteries.
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Introduction
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It was 1957 when Bailey and associates reported the first clinical use of coronary artery endarterectomy [1, 6]. Since that time endarterectomy has been variably popular or controversial, with indications for the procedure recently becoming more limited and better defined. The case report here demonstrates that manual endarterectomy can be safely performed in the presence of previously placed devices in the coronary arteries.
The patient was 61-year-old, mildly obese white male ex-smoker, with hypercholesterolemia and insulin-dependent diabetes mellitus. The patient presented with class II to class III angina with a positive thallium scan showing a large reversible defect in his inferior left ventricle. A left-heart catheterization showed a class II ventricle. A coronary artery angiogram showed a 40% stenosis in the mid-left anterior descending coronary artery (LAD). The right coronary artery (RCA) was dominant with diffuse moderate disease, a 95% stenosis in its middle portion, and an occlusion distally, just proximal to the crux, with retrograde filling from the LAD (Fig 1A). About 6 weeks later a percuta neous transluminal coronary angioplasty (PTCA) was undertaken in the distal RCA.
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Fig 1. These radiographs are all of the right coronary artery in the 30°-LAO projection and show: (A) the initial occlusion between the middle and distal segments (arrow); (B) wire recanalization with inflation using a 2-mm balloon; (C) three "half" stents deployed in the middle and distal segments (arrows); (D) patency at the end of the procedure; and (E) reocclusion 7 weeks later.
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Europass non-compliant dilation balloons were used with 4 inflations at 6 to 18 atm for periods of 5 to 67 seconds. Because of inadequate dilatation, three "half" Palmaz-Schatz stents (Johnson and Johnson International Systems) were placed successfully in the dilated segments with demonstrated wide patency (10% to 20% stenosis) of the distal RCA and its branches, with antegrade flow (Figs 1B–1D). The patient was subsequently asymptomatic.
Seven weeks later, the patient had recurrence of his angina and returned for PTCA of his mid-RCA lesion. Injection of the RCA showed that it was occluded, the occlusion beginning at, and including, the mid-RCA lesion (Fig 1E). A guidewire could not be passed through this area and the PTCA was not performed. Medical therapy was continued but the patient remained symptomatic.
Repeat ventriculogram and coronary angiogram 2 years subsequently showed again the class II ventricle and mid-RCA occlusion. The LAD stenosis had worsened to 70%. Because of his ongoing stable angina, the patient went for elective bypass grafting 4 months later. A vein graft to the distal RCA just proximal to the crux was placed after a manual endarterectomy of the RCA. The endarterectomy incision extended from 3 mm above the bifurcation to the proximal end of the stents. The vein graft was sutured over the incision with a patch angioplasty of approximately 15 mm in length. The vein was injected with crystalloid cardioplegia containing cardio-green dye (25 mg per 100 mL cardioplegia) demonstrating full patency of all distal branches of the RCA. The LAD was grafted with the left internal thoracic artery. The patient had an uncomplicated course after surgery and was discharged home after 4 days. (He was well 2 months later. No repeat angiogram has been indicated to date.)
The endarterectomy specimen consisted of two cores of tissue, 5.8 and 1.8 cm long. At its largest, the specimen was 0.5 cm in diameter. A radiograph of the longer piece (Fig 2) demonstrated the three "half" stents present in the endarterectomy’s middle portion. Some variable distortion and collapse of the stents was considered to be due to the iatrogenic trauma of surgical extraction. Histologic examination of the specimen revealed diffuse old occlusive luminal thrombosis, on a background of atherosclerotic stenosis, surrounded by a rim of normal media.
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Fig 2. This radiograph of the largest of the two endarterectomy pieces shows the three stents. There is distortion of the stents, presumed due to some surgical trauma at the core’s extraction.
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Comment
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Coronary artery endarterectomy as an adjunct to bypass grafting has been used for many years. The role of endarterectomy has become better defined in recent years; it appears suitable in situations of distal or diffuse disease where arteries would otherwise be difficult or impossible to graft [2–6, 8]. In appropriately selected patients and circumstances, endarterectomy has acceptable rates of mortality and morbidity [2–4, 6, 8].
A previous report demonstrated the feasibility of removing, by manual endarterectomy, a broken and entrapped percutaneous angioplasty catheter from the mid-right coronary artery [7]. The present report shows that it is also technically feasible to perform endarterectomy in the presence of coronary artery stents. Because invasive cardiology is using more devices in the coronary arteries, there will be increasing numbers of circumstances wherein cardiac surgeons encounter these devices in patients whose disease has progressed to require surgery. The presence of such retained or implanted coronary artery devices should not be considered a contraindication to manual endarterectomy. Indeed, the procedure may provide a solution to the situation where stents occlude the proximal LAD over a major septal perforator.
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Acknowledgments
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The authors thank Mr William A. Stinson for technical assistance and Ms Chris Morelli for preparing the manuscript.
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References
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Bailey C.P., May A., Lemon W.M. Survival after coronary endarterectomy in man. J Am Med Assoc 1957;164:641-646.
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Christakis G.T., Rao V., Fremes S.E., et al. Does coronary endarterectomy adversely affect the results of bypass surgery?. J Cardiac Surg 1993;8:72-78.[Medline]
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Djalilian A.R., Shumway S.J. Adjunctive coronary endarterectomy. Ann Thorac Surg 1995;60:1749-1754.[Abstract/Free Full Text]
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Goldstein J., Cooper E., Saltups A., Boxall J. Angiographic assessment of graft patency after coronary endarterectomy. J Thorac Cardiovasc Surg 1991;102:539-545.[Abstract]
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Keon W.J., Hendry P., Boyd W.D., Walley V.M. Long-term follow-up of coronary endarterectomy. Adv Cardiol 1988;36:19-26.[Medline]
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Keon W.J., Masters R.G., Koshal A., Hendry P., Farrell E.M. Coronary endarterectomy. Surg Clin North Am 1988;68:669-678.[Medline]
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Sommerhaug R.G., Wolfe S.F., Reid D.A., Lindsey D.E. Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease. Am J Cardiol 1990;66:651-659.[Medline]
Accepted for publication May 15, 1999.
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Abstract
Introduction
