Ann Thorac Surg 2006;82:2312-2314
© 2006 The Society of Thoracic Surgeons
How To Do It
Teflon Felt Wrapping Repair for Coronary Perforation After Failed Angioplasty
Yoshito Inoue, MDa,*,
Toshihiko Ueda, MDa,
Shinichi Taguchi, MDa,
Ichiro Kashima, MDa,
Kiyoshi Koizumi, MDa,
Shigetaka Noma, MDb
a Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
b Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
Accepted for publication March 6, 2006.
* Address correspondence to Dr Inoue, Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hosp. 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974 Japan (Email: yosito_inoue{at}saimiya.com).
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Abstract
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Acute type III perforation caused by failed angioplasty is a lethal complication that often requires emergency operation. However, the presence of multiple rigid stents beneath the subepicardial hematoma disturbs optimal revascularization and hemostasis. Teflon felt (Meadox Medical Inc, Oakland, NJ) wrapping repair is a simple salvage technique that allows stable hemostasis and the rescue of the entire blood flow of the coronary artery. This procedure was successfully performed with type III perforation of the left anterior descending coronary artery on 2 patients subjected to multiple stenting.
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Introduction
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Despite the advances of stenting technology, there still are serious complications caused by percutaneous coronary intervention with stents. Emergency surgery for the Ellis type III perforation [1] of the left anterior descending coronary artery (LAD) is especially associated with high morbidity and mortality [2].
The operative procedure is based on the ligation or suturing of the vessel for hemostasis and bypass grafting to the distal vessel. However, when the perforation is located at the edge between two adjacent long stents, it is difficult to control hemorrhage by simple ligation or by suturing. In addition, deployment of multiple long stents also disturbs optimal revascularization. We report 2 patients with double stents complicated by a type III LAD rupture who were successfully treated by salvage operation involving Teflon felt (Meadox Medical Inc, Oakland, NJ) wrapping repair.
The first patient is a 53-year-old man who underwent elective percutaneous coronary intervention for a long segmental 75% stenosis of the LAD (Fig 1A) and complicated dissection of the proximal LAD after the placement of Express 3.0 x 22-mm stent (Boston Scientific Inc, Minneapolis). An Express 3.5 x 20-mm stent was subsequently deployed to treat a proximal dissection, and high-pressure dilation (18 + 26 atmospheres) caused perforation at the joint of the two stents (Fig 1B).
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Fig 1. (A) Coronary angiogram demonstrating the pre-interventional long 75% stenotic lesion of the left anterior descending coronary artery (LAD) (asterisk). (B) Type III rupture of the LAD between two adjacent stents (asterisks).
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The second patient is an 83-year-old man with triple-vessel disease who underwent emergency percutaneous coronary intervention for acute myocardial infarction. Total occlusion of the LAD was treated with Tsunami 3.0 x 20-mm (Terumo Corp, Shizuoka, Japan) and Zeta 2.75 x 23-mm stents (Guidant Corp, Clonmel, Ireland). Insufficient expansion of the Zeta stent (Guidant Corp) required additional high-pressure dilation to the in-stent stenotic lesion, which caused a type III perforation.
Both patients were treated with perfusion balloon for temporary hemostasis, and the emergency operation was subsequently performed.
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Technique
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After initiation of the cardiopulmonary bypass, the stents in the large subepicardial hematoma were localized without epicardial dissection. Also under aortic cross clamp and cardioplegic arrest, coronary artery bypass grafting was performed. In addition, a couple of pledget mattress sutures were placed at the epicardial bleeding point for temporary hemostasis. Then a 25-mm to 30-mm Teflon felt strip (polytetrafluorethylene [Meadox Medical Inc]) was placed along the LAD, and 4-0 polypropylene sutures were placed in a running and en-bloc fashion along the coronary vessel including the ventricular muscle (Figs 2,
3). Compression of the attached felt is sufficient enough for hemostasis, but not so strong as to compress the coronary cavity with stents and rescue the arterial blood flow. Both patients recovered well and were uneventfully discharged. In patient 1 the coronary angiogram obtained 18 months after surgery showed the LAD without stenosis (Fig 4) and the patent left internal thoracic artery with string sign due to flow competition.
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Fig 2. Scheme of the surgical procedure. The bold arrow indicates the subepicardial hematoma, the double arrow represents the felt strip, and the dashed arrow represents the polypropylene suture. (Ao = aorta; LAD = left anterior descending coronary artery; PA = pulmonary artery; RA = right atrium.)
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Fig 3. Polytetrafluoroethylene felt was attached along the left anterior descending coronary artery (LAD). (LITA = left internal thoracic artery; LV = left ventricle.)
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Fig 4. Coronary angiogram obtained 18 months after surgery showing the preserved left anterior descending coronary artery (LAD). The arrow indicates the left internal thoracic artery–LAD anastomosis.
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Comment
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Current advances in stenting technology have allowed interventionists to bail out most of the complications caused by failed angioplasty. However, type III perforation still requires emergency surgical interventions, and postoperative morbidity and mortality have not significantly decreased yet [2].
Salvage operation is most difficult after deployment of multiple long stents in type III perforations. It is difficult to suture or ligate perforation between two adjacent stents, especially beneath a large subepicardial hematoma. Hemostasis by suturing the coronary artery at both ends of the stents would result in a long occluded segment, thereby sacrificing a wide range of septal branches and limiting revascularization by coronary artery bypass grafting, which leads to a serious myocardial infarction.
Teflon felt (Meadox Medical Inc) wrapping repair is an adequate salvage procedure to treat type III perforation associated with multiple stents. It enables stable hemostasis and optimal revascularization. Besides, the surgeon can avoid peeling off the epicardial tissue, which is useful as anchoring tissue for hemostatic suturing.
The postoperative coronary angiogram showed the LAD without stenosis and a pseudoaneurysmal formation at the ruptured site. The string sign of the left internal thoracic artery indicated that there was sufficient blood flow in the LAD, and that Teflon felt (Meadox Medical Inc) wrapping repair may contribute to rescue type III rupture associated with multiple stents independently without requiring concomitant coronary artery bypass grafting.
In conclusion, Teflon felt (Meadox Medical Inc) wrapping repair is a simple and effective surgical procedure to treat type III acute coronary artery rupture associated with multiple stents.
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References
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- Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary artery perforation in the new device eraIncidence, classification, management and outcome. Circulation 1994;90:2725-2730.[Abstract/Free Full Text]
- Seshadri N, Whitlow PL, Acharya N, et al. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era Circulation 2002;106:2346-2350.[Abstract/Free Full Text]
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Abstract
Introduction
