Ann Thorac Surg 2006;82:1889-1891
© 2006 The Society of Thoracic Surgeons
Case Reports
Successful Coronary Revascularization Using the PAS-Port System in a Patient With Takayasu's Arteritis and Behcet's Disease
Kenji Iino, MD*,
Shigeyuki Tomita, MD,
Koichi Higashidani, MD,
Toshimi Ujiie, MD,
Sadahiko Arai, MD,
Go Watanabe, MD
Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
Accepted for publication February 27, 2006.
* Address correspondence to Dr Iino, Department of General and Cardiothoracic Surgery, Kanazawa University of Medicine, 13-1 Takaramachi, Kanazawa, 920-8641 Japan. (Email: k-iino{at}m8.dion.ne.jp).
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Abstract
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Coronary artery disease is rare in patients with Takayasu's arteritis or Behcet's disease. We report the case of a patient with concomitant Takayasu's arteritis and Behcet's disease who had angina pectoris develop due to severe narrowing of the left main coronary artery. The patient underwent revascularization with saphenous vein grafts with the assistance of the PAS–Port Proximal Anastomosis System (Cardica, Inc, Redwood City, CA). In conclusion, the PAS–Port Proximal Anastomosis System seems to be a safe and effective method of facilitating revascularization, particularly when severe calcification of the ascending aorta precludes cross-clamping during off-pump coronary artery bypass grafting.
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Introduction
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Coronary artery disease is rare in patients with Takayasu's arteritis or Behcet's disease, and there are relatively few reports of coronary procedures in these patient populations [1, 2]. Indeed, the various sequelae of Takayasu's arteritis and Behcet's disease (including porcelain aorta, stenosis, or obstruction of its main branches, and local inflammation) make determination of the optimal surgical strategy (including the choice of conduit and the site of proximal source) problematic.
A 54-year-old woman was referred for surgical revascularization secondary to progressive angina pectoris related to a tight ostial stenosis of the left main coronary artery. The patient had received ongoing steroid therapy for 33 years for a diagnosis of Takayasu's arteritis and was receiving colchicine therapy for 10 years for a diagnosis of Behcet's disease. Takayasu's arteritis was clinically diagnosed at the age of 21 years on the basis of a difference in blood pressure between the left and right arms, reduced left brachial pulse, left arm claudication, and stenosis of the common carotid arteries and the left subclavian arteries as demonstrated by aortography. Behcet's disease was diagnosed at the age of 44 years on the basis of oral aphthous ulcers, genital ulcers, and multiple gastrointestinal tract ulcers.
On evaluation at our facility, coronary angiography showed a 90% stenosis in the left main coronary artery. Echocardiography revealed no abnormalities, and left ventricular function was within normal limits. A computed tomographic scan revealed severe calcification of the ascending aorta and stenosis of the carotid arteries, left subclavian artery, and celiac artery, and occlusion of the superior mesenteric artery. Laboratory evaluation was unremarkable except for elevated C-reactive protein (3.5 mg/dL), elevated erythrocyte sedimentation rate (55 mm per hour), and the presence of human lymphocyte antigen–B51.
Preoperative arterial duplex studies demonstrated absence of flow in the bilateral internal thoracic arteries and normal flow in the radial arteries (RA), with a vessel diameter of 29 to 37 mm in the right RA and vessel diameter of 25 to 30 mm in the left RA. Furthermore, peak velocity was lower and acceleration time was prolonged in the left RA when compared with the right RA. Preoperative duplex studies also demonstrated normal flow and absence of thrombus in the bilateral saphenous veins, with vessel diameters of 35 to 50 mm. Based on these findings, an off-pump coronary artery bypass was performed using a right RA graft and bilateral saphenous vein (SV) grafts.
Surgery was performed through a median sternotomy. The wall of the ascending aorta was evaluated using epiaortic echography. The thickness of the aortic wall was thinner than 5 mm, and only a small anterior portion (32 x 25 mm) of the aorta was free from calcification. First, the right RA graft intended to supply the left anterior descending artery was anastomosed to the ascending aorta using the Heartstring Proximal Seal System (Guidant Corp, Santa Clara, CA) without aortic partial clamping. However, graft vasospasm occurred, limiting blood flow, and the RA graft was subsequently ligated and cut above the proximal anastomosis. Then two SV grafts intended to supply the left anterior descending artery and the obtuse marginal branch were attached to the ascending aorta using the Proximal Anastomosis System-Port System (PAS-Port System). Graft blood flow was deemed adequate, and the distal ends of the vein grafts were subsequently anastomosed to the left anterior descending artery and the obtuse marginal branch using the off-pump coronary artery bypass technique.
Two weeks after the surgery a multi-detector, computed tomographic scan demonstrated that all SV grafts were patent without anastomotic complication (Fig 1). Four months after surgery the patient remains clinically well without recurrent angina.
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Fig 1. Postoperative multi-detector computed tomographic scan demonstrates patent two saphenous vein grafts without anastomotic complication. (Inset: Sagittal section of the chest CT.)
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Comment
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Takayasu's arteritis is a form of chronic vasculitis involving the aorta and its main branches, the pulmonary arteries, and the coronary tree. Patients with this disease often have arterial stenoses secondary to fibrosis and thrombus formation develop or aneurysms secondary to weakening of the vessel wall develop. Pathologic features include various cardiac abnormalities (as many as 40% of cases), aortic regurgitation secondary to aortic root dilation (20% of cases), hypertension (33% of cases, which are usually related to renal artery stenosis), pulmonary artery stenosis (15% to 17% of cases), and angina pectoris (6% to 16% of cases) [3]. More rarely, pericarditis, palpitations, and congestive cardiac failure may occur.
Behcet's disease is a systemic generalized chronic inflammatory disease characterized by oral aphthous ulcers, genital ulcers, and ocular lesions. Cardiac involvement is seen in 5% to 10% of cases and may present as coronary arteritis, myocardial infarction, conduction disturbances, or aortic regurgitation. Coronary aneurysms are more frequent than stenotic lesions, and coronary artery disease is extremely uncommon in patients with this disease. However, coronary occlusion may occur secondary to intimal thickening in the context of local vasculitis [2].
The present case was an extremely rare presentation of coronary artery involvement in a patient with Takayasu's arteritis and Behcet's disease. Surgical treatment of the coronary disease is complicated by the various sequelae of these diseases, including porcelain aorta, arterial stenosis, and arterial inflammation. Off-pump beating aorta-nontouch techniques with the use of in situ arterial grafts are indicated for surgical coronary revascularization in patients with Behcet's disease, whereas the use of SV grafts combined with off-pump coronary artery bypass techniques should be considered in patients with Takayasu's arteritis. In this case, in situ arterial grafts, such as the left internal thoracic artery (LITA), right internal thoracic artery (RITA), or gastroepiploic artery (GEA), were not suitable for use because of vasculitis-related stenosis or obstruction of the main aortic branches. In the present case, the right RA was used for the initial attempt at revascularization and was anastomosed to the ascending aorta using the Heartstring Proximal Seal System (Guidant Corp) without partial aortic clamping. This device is designed to facilitate establishment of clampless hand-sewn proximal anastomosis [4]. However, the graft was discarded secondary to spasmodic twitching and unstable free flow, despite the use of antispasmodic agents. Pathologic evaluation of the RA failed to detect active arteritis or vasculitis. Because of its relatively thick muscular layer, the RA is prone to develop spasms in response to mechanical stimuli [5]. However, it is not clear whether there was any correlation between RA hyper-reactivity and Takayasu's arteritis in this case. Regardless, this case illustrates that great caution should be taken when considering the use of the RA as a conduit for coronary artery bypass grafting in patients with Takayasu's arteritis.
The PAS-Port System was designed to facilitate the establishment of the proximal anastomosis to the aorta with minimal aortic manipulation. This device deploys a metal connector to aid in the creation of an end-to-side anastomosis between the graft and the aorta. Advantages of this device include the ability to produce precise and fast proximal anastomosis with reduced postoperative cerebrovascular events.
The PAS-Port System is designed so that the anchoring stainless steal stent is not exposed to blood elements on the inside of the SV graft at the proximal anastomotic site, and the transfer sheath dose not pass through inside of the SV graft at the loading, thereby preventing any damage to the SV graft endothelium and reducing in-stent thrombosis or re-stenosis that may result from reactive intimal hyperplasia. However, even with the use of the PAS-Port System, several critical factors must be assured, including the site of proximal anastomosis, the estimation of the definitive length of SV graft, a 90° take-off angle of the SV graft from the ascending aorta, and the absence of graft kinking. In addition, using this device with a radial artery graft is not warranted, which is another limitation. Furthermore, adequate follow-up is necessary, because long patency of vein grafts anastomosed with the PAS-Port System remain unknown.
In conclusion, the PAS-Port System seems to be a safe and effective method of facilitating revascularization, particularly when severe calcification of the ascending aorta precludes cross-clamping during off-pump coronary artery bypass grafting. These data suggest that SV grafts combined with off-pump coronary artery bypass techniques should be considered when surgical coronary revascularization is elected in patients with Takayasu's arteritis and Behcet's disease.
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References
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- Yamaguchi A, Endo H, Adachi H, et al. Off-pump coronary artery bypass in patients with Takayasu's disease Ann Thorac Surg 2004;77:2186-2188.[Abstract/Free Full Text]
- Song MH, Watanabe T, Nakamura H. Successful off-pump coronary artery bypass for Behcet's disease Ann Thorac Surg 2004;77:1451-1454.[Abstract/Free Full Text]
- Malik IS, Harare O, AL-Nahhas A, et al. Takayasu's arteritis: management of left main stem stenosis Heart 2003;89:e9.[Abstract/Free Full Text]
- Vicol C, Oberhoffer M, Nollert G, et al. First clinical experience with the Heartstring, a device for proximal anastomoses in coronary surgery Ann Thorac Surg 2005;79:1732-1737.[Abstract/Free Full Text]
- Conant AR, Shackcloth MJ, Oo AY, et al. Phenoxybenzamine treatment is in sufficient to prevent spasm in the radial artery: The effect of other vasodilators J Thorac Cardiovasc Surg 2003;126:448-454.[Abstract/Free Full Text]
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Abstract
Introduction
