Ann Thorac Surg 2005;79:558-563
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Coronary Endarterectomy and Stent Removal in Patients With In-Stent Restenosis
Toshihiro Fukui, MD*,
Shuichiro Takanashi, MD,
Yasuyuki Hosoda, MD
Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan
Accepted for publication July 14, 2004.
Abbreviations and Acronyms CPB = cardiopulmonary bypass; EF = ejection fraction; INR = international normalized ratio; ISR = in-stent restenosis; LAD = left anterior descending artery; LIMA = left internal mammary artery; PCI = percutaneous coronary intervention; PTCA = percutaneous transluminal coronary angioplasty
* Address reprint requests to Dr Fukui, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba 271-0077, Japan (E-mail: tm-fukui{at}gem.hi-ho.ne.jp).
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Abstract
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BACKGROUND: In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting.
METHODS: Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 ± 9.6 years). The mean number of target vessel interventions was 1.6 ± 0.7. Data were analyzed retrospectively.
RESULTS: The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 ± 1.9 months. The mean number of target vessel interventions was 1.6 ± 0.7. The mean LAD incision length was 57.3 ± 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved.
CONCLUSIONS: Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.
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Introduction
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Intracoronary stents reduce restenosis as compared to balloon angioplasty. However, in-stent restenosis (ISR) remains to be an important clinical problem. Although ISR can be treated with balloon angioplasty, the recurrence rate is significantly high, especially in diffuse ISR. Recently, various interventional treatments have been used for the treatment of ISR including balloon angioplasty [1, 2], directional coronary atherectomy [3, 4], rotational atherectomy [5, 6], additional stenting [7, 8], and radiation treatment [9, 10]. However, the optimal management of ISR is still unknown. Drug-eluting stents have resulted in a decreased restenosis rate for the treatment of de novo coronary stenosis [11–13] and have also been used in patients with ISR. However, interventional methods are often inadequate for use in patients with severe ISR [14]. Moustapha and colleagues [15] reported that coronary artery bypass grafting had a better outcome in patients with ISR, rather than the use of interventional methods.
Coronary endarterectomy is a procedure that may be done concomitantly with coronary artery bypass grafting. This procedure is suitable for diffuse coronary artery disease, in conditions unsuitable for bypass grafting. There were once negative evidences that endarterectomy was associated with a high perioperative risk and poorer long-term results [16, 17]. But recent reports stated the safety and efficacy of bypass grafting with positive angiographic and clinical results [18, 19]. However, there have been only a few reports about coronary endarterectomy for the treatment of ISR [20, 21]. We reviewed our experience of coronary endarterectomy for the treatment of ISR and evaluated the advantages of this procedure in reconstruction of the complicated coronary artery stenosis.
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Patients and Methods
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Patient Population
Between April 2001 and March 2004, we performed coronary artery bypass surgery on 762 patients. Ninety-eight patients (12.9%) were treated previously with coronary stent implantation by interventional cardiologists. Eleven patients underwent coronary endarterectomy and stent removal before bypass grafting. Patient characteristics are listed in Table 1. The age range was from 43 to 75 years old (mean 64.1 ± 9.6 years). The mean Canadian Cardiovascular Society (CCS) functional class was 2.4 ± 0.8. Degree of in-stent narrowing ranged from 75% to 99%, and there was no patient with complete occlusion of the left anterior descending artery (LAD). The mean preoperative ejection fraction (EF) was 58.0 ± 10.7%. Anterior left ventricular wall motions were normokinetic in all patients, except one patient (patient 1) whose anterior wall motion was severely hypokinetic. Interval from the latest intervention ranged from 2 to 8 months (mean 4.8 ± 1.9 months). The mean number of target vessel interventions was 1.6 ± 0.7.
Surgical Technique
The indication for coronary endarterectomy and stent removal is as follows:
- 1 A long segmental stenosis at the stent implantation site with diffuse distal arteriosclerosis.
- 2 A septal perforator or a diagonal branch of the left anterior descending artery that may be relieved from ischemia by endarterectomy.
- 3 Sequential bypass grafting of a diagonal branch and distal LAD cannot be applied because of small distal target or severe disease with arteriosclerosis at anastomosis site.
Cardiopulmonary bypass (CPB) and aortic cross clamp was used in 4 patients. An arterial cannula was inserted through ascending aorta and venous cannula by right atrial appendage using two-stage cannula. Cardioplegic solution was administered in both antegrade and retrograde fashion. Before endarterectomy, the other coronary vessels were bypassed as usual. Endarterectomy and bypass grafting to the stented vessel was then performed for LAD in all patients. Coronary arteriotomy was started from the distal end of the stent and extended proximally and distally. After the adventitia of the stented artery was carefully dissected and incised, the intima and neointima of the stented artery was removed. The distal incision was extended to nondiseased site. The internal mammary artery graft (LIMA) was incised longitudinally to match the length of the arteriotomy and running 8-0 polypropylene sutures were used for the anastomosis. Several threads were tied and extended in order to avoid purse string effect.
An off-pump technique was used in 7 patients. A Starfish heart positioner and an Octopus tissue stabilizer (Medtronic Inc., Minneapolis, MN) were used. A bloodless field was obtained using a proximal silastic snare suture and a CO2 blower.
The postoperative anticoagulation protocol was as follows:
- 1 Continuous intravenous infusion of low molecular weight heparin (5000 U/day) was started after the operation. This anticoagulation was continued until warfarin was effective.
- 2 Low-dose aspirin (100 mg/day) and warfarin (maintained with target international normalized ratio [INR] of 2.0) were started after the initiation of oral ingestion.
- 3 After 3 months, warfarin was stopped but aspirin was continued permanently.
Follow-Up
Medical records were reviewed and mortality and morbidity of each patient was identified. Postoperative complications included the following: myocardial infarction (new Q wave in electrocardiogram or creatine kinase MB >10%), low cardiac output (a newly placed intraaortic balloon pumping or the use of inotropic agents, dopamine or dobutamine, >5 µg · kg–1 · min–1), ventricular tachycardia or fibrillation, bleeding requiring reexploration, stroke, respiratory failure (intubation time > 48 hours), renal failure, and mediastinitis.
Early postoperative angiography was obtained in all patients before discharge (range, 7 to 23 postoperative days). Interval angiography was performed in 4 patients. The patency of all grafts and endarterectomized vessels was evaluated.
Statistical Analysis
Data are presented as mean ± standard deviation (SD). Continuous data were analyzed by the Student's t test.
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Results
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Procedural Data
Of 98 patients who presented with ISR and underwent coronary bypass grafting, 11 whose LAD was diffusely diseased with an involvement of stent underwent stent removal and LAD endarterectomy. Other 87 patients were treated with simple bypass grafting to LAD or sequential bypass grafting to LAD and a diagonal branch because their side branches were not involved with lesions of ISR or their distal targets were suitable for anastomosis. Intraoperative data are listed in Table 2. The stent removal site was LAD, and LIMA was used for grafting in all patients. All stents were bare metal stents. The mean incision length was 57.3 ± 11.0 mm. The mean operative time was 364.4 ± 69.2 minutes.
The endarterectomized cores were carefully observed. The atherosclerotic neointima was observed in the stented arteries (Fig 1).
Follow-Up
There were no in-hospital deaths. The mean postoperative EF was 58.0% ± 8.3%. There was no significant difference between preoperative EF and postoperative EF. However, in patient 1 his EF improved from 29% to 39% and also his anterior left ventricular wall motion improved from severe hypokinesis to mild hypokinesis. Hospital stay ranged from 9 days to 13 days (mean 11.3 ± 1.3 days). One patient with an early complication suffered a perioperative myocardial infarction and low output syndrome. But his postoperative angiography revealed all grafts including LIMA was patent and target vessels were also patent. Moreover, at his discharge, his EF improved as compared to his preoperative EF (from 29% to 39%). None of these patients had ventricular arrhythmias, respiratory failure, stroke, renal failure, or mediastinitis. No patient required reexploration for bleeding.
The early postoperative angiography (postoperative day 5 to 23) demonstrated that all bypass grafts were patent. The endarterectomized vessels were enlarged (Fig 2A,B). The diagonal and septal branches were patent and demonstrated excellent flow.
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Fig 2. Coronary artery angiography. (A) Preoperative angiogram showing diffuse disease of LAD involved stents. (B) Postoperative angiogram showing LAD reconstructed with LIMA. Reconstructed site was mildly ectatic. (C) One year after the operation. Reconstructed LAD diameter increased to normal size. (LAD = left anterior descending artery; LIMA = left internal mammary artery.)
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During the follow-up period (mean, 17.3 ± 12.8 months) there was no late mortality or morbidity. No patients had recurrent angina or heart failure. All patients remained in New York Heart Association functional class I. Interval angiography (postoperation 10 to 13 months) revealed that the LIMA and LAD were patent (Fig 2C). The mean interval between operation and late angiography was 11.3 ± 1.3 months.
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Comment
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Coronary in-stent restenosis remains a significant clinical problem, especially in the setting of diffuse disease [22]. Repeat percutaneous transluminal coronary angioplasty (PTCA) remains the most commonly used technique for ISR, but the rate of recurrence is very high, particularly in patients with diffuse ISR. Besides PTCA, ISR was treated by various other interventional techniques. However, long-term efficacy is unsatisfactory. Revascularization in diffusely diseased vessels may require endarterectomy. Coronary endarterectomy is an established method of surgical reconstruction with recent reports supporting endarterectomy [18, 19]. Patients with distally or diffusely diseased coronary arteries that are unsuitable for simple bypass grafting are candidates for endarterectomy. Two case reports previously have described coronary endarterectomy and stent removal for diffusely diseased vessels, but they did not apply this method in a group of patients as our experience [20, 21]. We think that these complex methods reported here are necessary only for the patients who are not suitable to receive simple bypass grafting to distal targets of LAD and its diagonal branches. We believe this method could be one of the surgical options in patients whose LAD, immediately distal to ISR, is also diffusely diseased with the involvement of major side branches.
This clinical report demonstrated that stent removal and endarterectomy with LIMA grafting is a safe and effective treatment for ISR. One patient had a low cardiac output in the early postoperative period. Early angiography revealed that the LAD and LIMA were patent in all patients, but the contour of the reconstructed LAD showed diffuse ectatic irregularities. However, interval angiography demonstrated that the reconstructed LAD appeared smoothened. The reason why the reconstructed LAD with LIMA remodeled in time is unknown. However, our follow-up revealed interval angiograms (mean, 11.3 ± 1.3 months) after endarterectomy with stent removal showed no recurrence or restenosis of LAD. Furthermore, there was no late mortality or morbidity during the follow-up period, (mean, 17.3 ± 12.8 months). These findings suggest that the advantage of this surgical method is superior to percutaneous intervention in this complex setting.
Endarterectomy of the stented artery is technically demanding and care must be taken in dissecting the atherosclerotic core from the adventitia. The incision of the adventitia of LAD was started just distal of stents, and stents could be dissected with fine forceps. Further incision of adventitia could be performed both proximally and distally. Stents may be removed simultaneously by removing the atherosclerotic intimal core because the stents were buried within the neointimal layer (Fig 1). We could find the proper plane in all patients. We think the most important point of our method is that the orifices of side branches should not be occluded during anastomosis of LIMA. In many patients, the stent implantation sites are usually proximal side of LAD. We would use an ultrasonic scalpel to dissect the LAD when the stent is in an intramyocardial LAD. We can dissect the proximal LAD using an ultrasonic scalpel without muscular stimulation, bleeding and injuring vessel [23]. The decision to use CPB or not was made intraoperatively. Coronary endarterectomy with off-pump technique was used in 3 patients. Coronary endarterectomy with off-pump technique may be performed safely [24]; however, the procedure is difficult in a dilated or poorly functioning heart. Because LAD endarterectomy and on-lay anastomosis took longer time than usual grafting, it may be accompanied with increased risk. However, we think that the myocardium can usually stand a longer ischemic time because of the existent collateral circulation developed in diffuse severely diseased artery.
Fortunately, we were able to perform this coronary endarterectomy with stent removal in a patient with severe hypokinetic left ventricular wall motion (patient 1). In this particular patient, postoperative EF improved from 29% to 39%, and also anteroseptal wall motion improved. Thus we believe that this method may possibly be applied for the increasing proportion of patients presenting even with depressed ventricular function.
A strict postoperative anticoagulation protocol was utilized. Warfarin was maintained to reach at the level of INR of 2.0 for 6 months and low-dose aspirin was continued permanently. This target level of INR seems low even if it is combined with aspirin. However, this target level of INR is reasonable therapeutic level (between 1.8 and 2.8) in the Japanese population [25–27]. Avoidance of early thrombus formation is important to avoid early occlusion of the endarterectomized vessel.
The limitations of this clinical study are that the number of patients is small and the length of clinical follow-up was up to 36 months. And the major weakness of this study is that the follow-up angiography could be obtained in only 4 patients. Furthermore, this is a retrospective observational study and is not a randomized. There was no control; thus we cannot assert that this method is superior to percutaneous coronary intervention (PCI) because we did not compare the superiority between this method and PCI.
In conclusion, our early results indicated that combined coronary endarterectomy and stent removal is a safe and effective technique to treat patients with ISR involving a diffusely diseased target vessel. We believe the indication of this method is for the patients whose LAD could not be treated with usual bypass grafting because their distal targets are involved in severe arteriosclerosis.
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Abstract
Introduction
