Ann Thorac Surg 2008;85:1586-1590. doi:10.1016/j.athoracsur.2008.01.055
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Surgical Approaches in Left Anterior Descending Artery In-Stent Stenosis
Bayram Yilmazkaya, MDa,
Renda Circi, MDa,*,
Umit Pinar Circi, MDa,
Sami Gurkahraman, MDa,
Mehmet Ali Yukselen, MDb,
Omer Zuhtu Yondem, MDb,
Oguz Tasdemir, MDa
a Department of Cardiovascular Surgery, Akay Hospital, Ankara, Turkey
b Department of Anesthesiology, Akay Hospital, Ankara, Turkey
Accepted for publication January 18, 2008.
* Address correspondence to Dr Renda Circi, Akay Hastanesi Buklum Sokak No 4, Kavaklidere, Ankara, 06660, Turkey (Email: circi2002{at}yahoo.com).
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Abstract
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Background: In-stent stenosis remains the major disadvantage of coronary interventions. Extensive applications of the intracardiac devices especially involving long segments of coronary arteries have resulted in an increase in the number of cases of in-stent stenosis. That may require aggressive surgical approaches.
Methods: Between June 2006 and October 2007, 7 patients with long-segment left anterior descending artery in-stent stenosis were operated on in our institution. Two of the operations were off pump with minimally invasive techniques, whereas the latter 5 patients were operated on through cardiopulmonary bypass.
Results: All patients were male, except for the last patient; their ages were between 43 and 71 years (59.67 ± 12.36). They all had received an intracoronary stent for the left anterior descending artery (3 to 11 months before surgery). The first 2 operations were minimally invasive off-pump procedures; however, the latter 5 were with cardiopulmonary bypass. Mean follow-up was 6.33 ± 4.13 months, and a postoperative coronary angiogram was performed on all the patients.
Conclusions: Although long-segment in-stent stenosis complicates subsequent coronary artery bypass grafting operations, stent removal with coronary endarterectomy seems to be the technique of choice because it is effective and safe.
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Introduction
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With advances in interventional cardiology, indications for intracoronary stent applications are expanding, and the profile of a coronary artery bypass graft (CABG) surgery patient is changing. Invasive cardiologists are using more devices even in the diffusely diseased coronary arteries; therefore, cardiac surgeons are likely to encounter these devices in patients whose disease has progressed to require surgery [1]. Diffusely diseased coronary arteries are a problem for invasive cardiologists because usually more than one stent is necessary to achieve complete revascularization. However in-stent stenosis remains a serious problem and a major disadvantage of percutaneous coronary interventions [2]. Because the left anterior descending artery (LAD) is the major revascularization site in CABG surgery, patients with diffuse LAD disease who had received more than one stent are a challenge for cardiac surgeons [1] (Fig 1).
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Fig 1. Angiogram of the patient with a long-segment in-stent stenosis. The stent reaches the second diagonal branch and occludes the septal branches and the diagonal branches.
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Although the optimal management of in-stent stenosis is still controversial, CABG has a better outcome in these patients. Because of diffuse atherosclerosis and long-segment in-stent stenosis, target vessels may not be graftable, and complete revascularization using conventional techniques may not be possible. Coronary endarterectomy is reported as a suitable option for these patients [3] (Fig 2). Reports on coronary endarterectomy were first published 50 years ago [4], but early reports emphasizing increased perioperative risks and poor outcome have limited its usage [5–7]. Recent reports, however, state the safety and efficacy of coronary endarterectomy [3, 8–11]. Because the LAD is obviously the most important target vessel for CABG, we preferred coronary endarterectomy and stent removal for patients with in-stent stenosis.
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Patients and Methods
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In our institution, 7 patients with long-segment LAD in-stent stenosis underwent coronary endarterectomy with stent removal before CABG between June 2006 and October 2007. Informed consent was obtained from all the patients, and the study was approved by the Institutional Ethics Committee on Human Research. The patient characteristics are listed in Table 1. Mean age was 59.67 ± 12.36 years (range, 43 to 71), and all the patients were male except for the last patient. All the patients were smokers and 2 of them were diabetic. The degree of in-stent stenosis was 84.17% ± 12.81% (range, 70% to 100%). Although all of the patients suffered from unstable angina pectoris, none had myocardial infarction as a result of the stent stenosis or occlusion. The patients had received stents of mean 68.67 ± 21.83 mm (Fig 3). All the patients had received clopidogrel bisulphate 75 mg daily for 1 month after the intervention. The LAD was always the target vessel with or without other vessels.
Surgical Procedure
The first 2 patients had one-vessel disease. The patients preferred and insisted on minimally invasive CABG surgery. Because of long-segment stenting, there was only a little site of the artery to bypass. After general anesthesia, the radial artery from the nondominant arm was harvested, and a limited anteriolateral thoracotomy was performed over the fifth rib (the length of the incision did not exceed 7 cm). The left internal thoracic artery (LITA) was made visible by removing the cartilaginous portion of the fifth rib. The LITA was then clipped distally after systemic administration of heparin (200 u/kg). The pericardium was opened, and the distal LAD segment was identified and immobilized by using elastic vessel loops proximally and distally to the site of the anastomosis After an arteriotomy to the LAD, the radial artery was anastomosed with running 8-0 polypropylene suture. The radial artery was then anastomosed to the LITA with 8-0 polypropylene suture in a continuous fashion. After leaving a chest tube in the left thoracic space, if the left pleura was entered, a Hemovac drain (Medimark Europe, Grenoble Cedex 2, France) was inserted in the pericardial space, and the wounds were closed in a standard manner.
In the latter 5 patients, standard cardiopulmonary bypass techniques were used. After the cardiopulmonary bypass was initiated, the ascending aorta was cross-clamped, and crystalloid and blood cardioplegia were administered in both antegrade and retrograde fashion, as previously described [12]. The patients were cooled to 28°C to 29°C, and cold saline was used for topical cooling. The other target vessels were bypassed in the usual manner. In all our patients, the stented segment reached the second diagonal branch. After a small arteriotomy, we carefully dissected the arterial wall to the nondiseased distal segment of the artery. After denuding the atherosclerotic core and the stent, we dissected the artery to the proximal site of the vessel and always reached to the first septal branch ostium. We removed the atherosclerotic plaque and the stent. All branches of the LAD were directly observed when the intima was carefully removed (Fig 4).
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Fig 4. After removing the atherosclerotic plaque and the stent carefully, the septal and the diagonal branches are clearly examined. The artery is prepared for reconstruction.
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The LITA was prepared as an on-lay graft, and an extended patch anastomosis was performed over the arteriotomy using a single running 8-0 polypropylene suture. During anastomosis, care was taken to rebuild a new artery with an optimal diameter not too much wider than that of the native artery, to avoid the unfavorable hemodynamic effects of diameter discrepancies. That is why we used the LITA instead of the saphenous vein.
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Results
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Intraoperative data and follow-up are shown in Table 2. Average time for stenosis was 6.5 ± 3.27 months. All patients received an angiogram on the fifth postoperative day. The grafts were patent; however, in the first and the second patients, in whom we did not perform coronary endarterectomy, the LITA could supply blood flow only to the distal segment of the LAD. The diagonal and septal perforator branches that originate from the stented segment of the LAD could not be visualized.
The mean follow-up period was 6.3 ± 4.13 months. Six patients received repeat coronary angiograms during the sixth postoperative month. The angiograms of the first and second patients revealed similar findings with their early postoperative angiograms. In all of the patients in whom we performed coronary endarterectomy, grafts were patent, whereas the left internal thoracic arteries showed a "string sign" in 2 of them. That is most probably because of graft competition as we removed the atherosclerotic plaque and the stent. Septal and diagonal branches of all the endarterectomized left anterior descending arteries were visible.
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Comment
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As technology for interventional cardiology has developed, percutaneous interventions are increasingly used for LAD lesions. The LAD is becoming the major revascularization site for interventional cardiologists; however, both angioplasty and stenting accelerate the atherosclerotic disease process because of the superimposition of mechanical injury. Some authors suggested that C-reactive protein may promote the inflammatory component of atherosclerosis by inducing the expression of intracellular adhesion molecule-1 [11, 13]. Thus, stenting coronary arteries may jeopardize the subsequent procedures because the vessel becomes diffusely diseased. Especially for LAD, this causes occlusion of the valuable septal and diagonal branches by the stent.
Coronary in-stent stenosis remains a challenge for both cardiologists and cardiac surgeons. The most commonly used technique for in-stent stenosis is percutaneous transluminal coronary angioplasty, but the recurrence rate is very high and long-term efficacy is unsatisfactory [2, 14]. Stenting a diffusely diseased vessel because of in-stent stenosis increases the stented segment length. A longer stented segment is an independent predictor of stenosis [14].
Patients who underwent CABG for treatment of in-stent stenosis had a significantly better outcome than those who underwent percutaneous interventions [15]. The presence of long LAD stents complicates the surgical procedure and may result in having difficulties finding an appropriate site for bypass grafting when conventional bypass techniques are used. Modifications of bypass techniques may be used for these patients, and coronary endarterectomy seems to be the most suitable one of them. Coronary endarterectomy has been used as an adjunct to surgical revascularization since the early years of CABG surgery. Recent studies show that mortality and morbidity rates are now similar to CABG without coronary endarterectomy [1, 7, 10, 16–19]. However, endarterectomy is technically demanding, it is a time-consuming procedure, and it requires experience. The "traction" technique is extremely hard and inappropriate for these patients, because the stent clings firmly to the intima and the atherosclerotic plaque. Using the traction method in these patients may cause destruction of the artery. Hence, we recommend the "open" technique of endarterectomy by which we directly inspect the plaque and the stent by opening the artery and carefully removing the whole stent (Fig 5). Orifices of the septal and the diagonal branches are observed carefully to avoid leaving remnants of the plaque.
Early and long-term angiograms of the first 2 patients in whom we did not perform an endarterectomy revealed absence of blood flow in the stented segment of the LAD artery and septal and diagonal branches; however, the grafts were patent. Nevertheless, follow-up angiograms showed patent grafts and blood flow in septal and diagonal branches of all the endarterectomized vessels, whereas a "string sign" was seen in two of them. We decided not to perform any further interventions because a considerable flow in the LAD was obvious without any narrowing, and preoperatively occluded septal perforator and diagonal branches were visible on angiogram. We believe that coronary endarterectomy with stent removal is necessary to maintain blood flow to the septal perforators and diagonal branches that are occluded by the stent.
Several authors have recommended a strict postoperative anticoagulation protocol using aspirin, dipyridamole, heparin, and warfarin for several months [1, 2, 8, 9]. We use acetylsalicylic acid 300 mg daily starting from the first postoperative day.
The limitation of this study is the small number of patients. That is particularly because of the choice of the patients, who were not informed about the high restenosis rate of recurrent percutaneous interventions and favorable results of surgical revascularization.
In conclusion, recurrent stent applications may cause difficulties in performing conventional CABG techniques subsequent to in-stent stenosis. We believe it is best to avoid long-segment stenting if possible. Surgical revascularization of the portion distal to the occluded stent can not provide blood to the proximal segment. We recommend stent removal with coronary endarterectomy, which is safe and beneficial. Since the stent removal is impossible by the traction method, an open technique of an endarterectomy must be used. It allows observing the orifices of the septal and the diagonal branches that have been occluded by the stent. Although some recent literature and also our findings demonstrate favorable results after endarterectomy, performing a long-segment coronary endarterectomy can be very difficult for even experienced surgeons. As the length of the stented coronary segment increases, the necessity of endarterectomy rises, and performing endarterectomy becomes more challenging.
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Abstract
Introduction
