Case Title

Angioplasty standby for failed bypass surgery

Case History

This 59yrs old gentlemen with a history of class-2 angina underwent angiography which showed 80% left main with critical osteal stenoses of LAD and circumflex artries. He also had critical lesion in proximal right coronary & very proximal lesion in the PD branch. He was offered CABG in august 2003 in USA. From November 2003 onwards (within 3 months of bypass surgery) he started getting class -2 angina. He was therefore subjected to post bypass coronary angiographic study.

He received the following grafts during surgery:

• LIMA to LAD
• RIMA to diagonal-2
• Radial to large OM
• Gasteoepieloeic artery to the PDA

(RAO caudal) Left main shows severe critical narrowing at the bifurcation. The LAD shows washout of its distal parts, presumebly indicating patent LIMA .OM1 is very large shows moderate stenosis in its midsegment. Distal OM shows washout phenomenon indicating patent radial graft. RCA injection. Shephard crook curve or the proximal RCA ends in very critical lesion within the midsegment. Additional separate critical lesion in the proximal PDA is seen. Selective injection in RIMA graft into d2.notice markedly attractive and diffusely narrow RIMA graft with very severe stenosis at the distal anastomatic site into the diagonal. Notice large and widely patent radial artery graft into the OM opacifying the entire left coronary arterial tree including the left main. Selective LIMA injection showing large diseased LIMA filling up LAD Shows excellent anastomosis of LIMA with mid segment LAD. Cobra catheter selectively positioned into inferior gastrodeodenal artery showing diffusedly narrowed gastroepipeloeic artery with practically no distal runoff. Interventional strategy Since LIMA to LAD & since radial to OM branches were patent obviousely his angina was coming either through diagonal territory because of occluded RIMA or through right coronary territory because of occuluded gastroepipeloeic artery. My strategy was to open up entire RIMA & the native RCA, its proximal lesion & separate lesion in its PDA. Wire was parked way distal into the diagonal artery. Distal anastomotic lesion was dialated using 2x25mm maverick balloon. Balloon at the site of distal anastomotic lesion. Subsequently entire RIMA graft was sequentially dialated using the same balloon. Note entire graft has now expanded with much richer filling of the native diagonal artery. Note 2.25x33 mm Cypher stent was placed at the distal anastomatic site.subsequently entire RIMA graft was treated by multiple stents overlapping each other. Very proximally in the RIMA graft 2.5x33mm drug eluting stent was deployed. Notice widely open reconstructed RIMA graft with excellent filling of diagonal territory. 6f hockey stick guide catheter was used to engage RCA. The lesion was crossed using stabiliser plus wire and parked into the distal PDA. Notice that lesion was dialated using 2.5x20mm balloon. 2.5x16mm Taxus stent was deployed at the PDA lesion at 8atm. Notice that the stent is overexpanded as compared to ostium but overall result is very good. 4.0x25mm large uncoated stent is positioned into the proximal lesion. Full expansion of the stent at 14 atm Shows excellent results of stenting into the proximal RCA & distal PDA. Please note that the gastroepiploeic artery is opacified in the reverse way (query possible still syndrome).

Comments

It is unfortunate that this patient became symptomatic within 3 months. The most probable cause of arterial graft failure at this stage is usually technical failure. We feel that severe stenosis at the distal anastomosis site of the RIMA graft insertion into d1 could be initiating cause because of up going takeoff of RIMA graft we choose to use IMA catheters. We hope that patient enjoys sustained benefits of reconstruction of entire RIMA graft with the use of multiple drug eluting stents. Although initial result is very rewarding, long term benefits remain to be seen. Many surgeons feel that total arterial grafting is not proved to be superior to alternate option of LIMA to LAD & Vein grafts to remaining vessels. Even gastroepiploeic artery is not preferred by many surgeons.

Proximal native RCA was 4mm in size. Drug coated stents are not available in this size and perhaps it may not be necessary to use drug eluting stents in such large size arteries. The direct stenting of proximal RCA lesion was possible despite of shephard crooks and despite bulky stent because of excellent backup support provided by very well placed hockey stick catheter. The follow up of this case will be very interesting.

Courtesy

Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.

Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com