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Intracoronary stenting after unsuccessful PTCA. Early restenosis and explantation of stents during bypass surgery
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International Journal of Cardiology 48 (1995) 109-l 13
Intracoronary stenting after unsuccessful PTCA. Early restenosis and explantation of stents ,during bypass surgery Annette Enbergs*avbChristian FechtrupavbSebastian KerberaybThomas Buddea’b, Armin Wilhelm Geiger”, Hans Heinrich Scheldc, Giinter Breithardta” of Cardiology and Angiology, Hospital of the Westfdlische Wilhelms-Universitit, Miinster, Germany blnstitute for Arteriosclerosis Research. Miinster, Germany ‘Department of Thoracic and Cardiovascular Surgery, Hospital of the Westfdlische Wilhelms-Universitiit, Miinster, German) aDepartment
Received 27 April 1994; revision accepted 25 October 1994
Abstract The caseof a 63-year-old man is described, who received two intracoronary Palmaz-Schatz-Stemsafter dissection and occlusion following PTCA of two segmentsof the left anterior descendingbranch of the left coronary artery. Because of recurrent angina caused by early restenosis in the ‘unprotected’ segment between the stents, surgical revascularisation was performed and the stents were removed. Keywords: Intracoronary stenting; Dissection after PTCA; Aorto-coronary bypass grafting
1. Introduction
2. Case history
Several techniques for treatment of acute coronary complications after PTCA are available. The implantation of intracoronary stents has first been described by Sigwart et al. [l]. In this report we describe a casein whom two separatestents within the left anterior descending branch (LAD) were explanted during bypass surgery performed following complicated PTCA.
A 63-year-old man with angina pectoris was admitted for PTCA of a 75% stenosis in the LAD. Repeat coronary angiography revealed a 50%stenosis in the proximal segment and a 75%/v stenosisin the middle segmentof the LAD (Fig. 1); in addition, a 50 %stenosis of the circumflex artery was found. The first dilatation with 8 atm for 60 s with a balloon catheter of 2.5 mm diameter in the middle segment of the LAD lead to a long intimal dissection. It could neither be aligned by prolonged inflations (12 x 8- 10 atm for 60 s) of the samePTCA-balloon nor by the use of a perfu-
* Corresponding author, Medizinische Klinik - Kardiologic und Angiologie, Universitiit Mtinster, 48129 Miinster, Germany.
0167-5273/95/W9.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDZ 0167-5273(94)02223-6
110
A. Enbergs et al. / International
Journal of Cardiology 48 I1 995) IOY- I13
Fig. I. Angiogram of the left coronary artery (40” crania-caudal 40” LAO) showing a 7WIF, segmentedstenosis of the LAD (-).
sion catheter (3.0 mm). After dilatation with 5 atm for 4 and 12 min, complete occlusion occurred. From the beginning of the dissection, the patient almost constantly complained of angina pectoris. A further attempt to stabilize the arterial wall by
several dilatations with 4 atm for 10 min with the perfusion catheter did not reopen the vessel. As the dissection membrane covered a long distance, it was decided to implant two balloon-expandable stents (Palmaz-Schatz) of 3.0 mm diameter as a
Fig. 2. Angiogram of the left coronary artery immediately after implantation of two Palmaz-Schatz stents (-) (90” LAO).
A. Enbergs et al. /International
Journal of Cardiology 48 (1995) 109-113
III
Fig. 3. Angiogram of the left coronary artery 1 day after stent implantation; between the two stentsan ‘unprotected’ part of the native vesselremains, with relevant ‘re-stenosis’(30” caudo-cranial, 30” LAO) (-). In addition, a stenosisdistal to the secondstent hasevolved (-).
bail-out procedure; one at the end of the dissection membrane, the other at its beginning. This way, a lo-mm portion of the LAD was left ‘unprotected’ (Fig. 2). Becauseof the relatively stiff material of the stents, the implantation of a third stent was considered not feasable with regard to the anatomical angulated course of the vesseland the difficulties to be expectedwhen passing the first stent during implantation. After dilatation with a balloon catheter of 3.0 mm diameter with 8 atm for 90 s in the segment between the stents, the final angiogram showed a good flow in the vessel with no relevant stenosis on its whole distance. At that time the patient was free of angina. The next day, a control angiogram was performed because of recurrence of angina and ECG-changes indicating ischaemia which were persistent after intravenous application of heparine and nitrate. The angiogram showed a significant restenosis in the ‘unprotected’ segment and a stenosis distal to the second stent (Fig. 3). Vasospasmwas excluded by intracoronary injection of nitrate. Intimal dissection was assumedto be the most likely reason for
restenosis, probably in combination with partial thrombus formation in spite of the anticoagulation. As restoring the contours of the vesselin between and distal of the stents by further catheter based techniques did not seem to be adequate, it was then decided to perform bypass surgery. The LAD was opened in the area of the stents, which were removed. At the site of PTCA, including the stent-covered area, the LAD showed severe intimal damage. The stents themselves were still completely expanded. No clot was found in the dissectedarea. Surgical endarteriectomy was performed in this region. In its proximal and distal portions, the intima of the LAD was intact. A Ysaphenous-vein graft was connected to the LAD and the first marginal branch. A long side-to-side anastomosiswas sutured to the LAD that covered the segmentof the vessel which had been opened for the explantation of the stents. At follow-up angiography 4 months later, the patient was free of symptoms. Coronary angiography showed the bypass with patent anastomoses with good flow to the distal native vessel
112
A. Enbergs et al. / Inlernalional
Journal of Cardiology 48 (1995) IOY- f 1.1
Fig. 4. Four-month follow-up angiogram; injection into the aorto-coronary bypass: patent bypass to the LAD and marginal branch with a large vascular lumen in the region of the LAD anastomosis(-). Retrograde flow into the proximal LAD. Unobstructed perfusion of the second diagonal branch (90” LAO).
and significant retrograde flow in the LAD supplying a large diagonal branch (Fig. 4). The long anastomosis with the LAD resulted in a dilated vascular bed. All side branches were patent. 3. Discussion Intraoperative explantation of stents has not been reported before. We, therefore, describe a case in whom two intracoronary stents were implanted after complicated PTCA as a bail-out manoeuvre. Bypass surgery becamenecessarydue to early restenosis and unstable angina; subsequently the two stents were removed. The two stents were implanted in an area of long intimal dissection, leaving a stenosedsegmentproximal to the stents, supplying a major diagonal branch. The total length of the LAD segmentwith intimal dissection was longer than two stents, but for anatomical reasons and due to the good flow, the implantation of a third stent was not attempted. It was not supposed that incomplete expansion of the stents was the reason for the early
restenosis as the angiography immediately after stent implantation showed a good result. Furthermore the stents were completely expanded when removed during bypass surgery. The decision to perform surgery was made becauseno other technique seemedto be able to prevent complete occlusion of this important segment. Due to the position of the stents in the LAD, a bypass anastomosis to the LAD distal to the last stent would have left proximal and medial portions of the LAD unsupplied. In addition the problem of dissection would not have been solved. Therefore, the stents were removed to be enable endarterectomy over the whole distance of damaged intima. A long anastomosis covering that vessel segment allowed perfusion of larger parts of myocardium. Intracoronary stents are associatedwith the risk of early and late occlusion [2]. Long-term anticoagulation with its imminent risks is often necessary.In spite of good initial results after stent implantation, restenosishas to be expected in case the stents are implanted for long intimal dissection in an angulated vesselsegment. Further investigation to solve some of these problems has lead to
A. E&ergs et al. /International
Journal of Cardiology 48 (1995) 109-113
the development of bioabsorbable [3] and removable [4] stems, which are currently under investigation for clinical use. This case shows that removal of intracoronary stents implanted as a bail-out procedure is feasable when aorta-coronary bypass surgery becomes necessaryto achieve a satisfying long term result after unsuccessful placement of stents after complicated FTCA. References [l]
Sigwart U, Euel J, Mirkovitch V, Joffre F, Kappenberger L. Intravascular stents to prevent occlusion and
[2]
[3]
[4]
113
restenosisafter transluminal angioplasty. N Engl J Med 1987; 316: 701-706. Haude M, Erbel R, Straub U, Dietz U, Schatz R, Meyer J. Results of intracoronary stents for management of coronary dissection after balloon angioplasty. Am J Cardiol 1991;67: 691-696. Susawa T, Shiraki K, Shimizu Y. Biodegradable intracoronaty stents in adult dogs. J Am Co11Cardiol 1993; 21: 483A. Khorsandi J, Eigler NL, Litvack F, Mahrer KN, Forester J. Heat activated recoverable temporary stents: histopathologic and angiographic observations for implantations of up to six weeks. J Am COBCardiol 1993; 21: 439A.
International Journal of Cardiology 48 (1995) 109-l 13
Intracoronary stenting after unsuccessful PTCA. Early restenosis and explantation of stents ,during bypass surgery Annette Enbergs*avbChristian FechtrupavbSebastian KerberaybThomas Buddea’b, Armin Wilhelm Geiger”, Hans Heinrich Scheldc, Giinter Breithardta” of Cardiology and Angiology, Hospital of the Westfdlische Wilhelms-Universitit, Miinster, Germany blnstitute for Arteriosclerosis Research. Miinster, Germany ‘Department of Thoracic and Cardiovascular Surgery, Hospital of the Westfdlische Wilhelms-Universitiit, Miinster, German) aDepartment
Received 27 April 1994; revision accepted 25 October 1994
Abstract The caseof a 63-year-old man is described, who received two intracoronary Palmaz-Schatz-Stemsafter dissection and occlusion following PTCA of two segmentsof the left anterior descendingbranch of the left coronary artery. Because of recurrent angina caused by early restenosis in the ‘unprotected’ segment between the stents, surgical revascularisation was performed and the stents were removed. Keywords: Intracoronary stenting; Dissection after PTCA; Aorto-coronary bypass grafting
1. Introduction
2. Case history
Several techniques for treatment of acute coronary complications after PTCA are available. The implantation of intracoronary stents has first been described by Sigwart et al. [l]. In this report we describe a casein whom two separatestents within the left anterior descending branch (LAD) were explanted during bypass surgery performed following complicated PTCA.
A 63-year-old man with angina pectoris was admitted for PTCA of a 75% stenosis in the LAD. Repeat coronary angiography revealed a 50%stenosis in the proximal segment and a 75%/v stenosisin the middle segmentof the LAD (Fig. 1); in addition, a 50 %stenosis of the circumflex artery was found. The first dilatation with 8 atm for 60 s with a balloon catheter of 2.5 mm diameter in the middle segment of the LAD lead to a long intimal dissection. It could neither be aligned by prolonged inflations (12 x 8- 10 atm for 60 s) of the samePTCA-balloon nor by the use of a perfu-
* Corresponding author, Medizinische Klinik - Kardiologic und Angiologie, Universitiit Mtinster, 48129 Miinster, Germany.
0167-5273/95/W9.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDZ 0167-5273(94)02223-6
110
A. Enbergs et al. / International
Journal of Cardiology 48 I1 995) IOY- I13
Fig. I. Angiogram of the left coronary artery (40” crania-caudal 40” LAO) showing a 7WIF, segmentedstenosis of the LAD (-).
sion catheter (3.0 mm). After dilatation with 5 atm for 4 and 12 min, complete occlusion occurred. From the beginning of the dissection, the patient almost constantly complained of angina pectoris. A further attempt to stabilize the arterial wall by
several dilatations with 4 atm for 10 min with the perfusion catheter did not reopen the vessel. As the dissection membrane covered a long distance, it was decided to implant two balloon-expandable stents (Palmaz-Schatz) of 3.0 mm diameter as a
Fig. 2. Angiogram of the left coronary artery immediately after implantation of two Palmaz-Schatz stents (-) (90” LAO).
A. Enbergs et al. /International
Journal of Cardiology 48 (1995) 109-113
III
Fig. 3. Angiogram of the left coronary artery 1 day after stent implantation; between the two stentsan ‘unprotected’ part of the native vesselremains, with relevant ‘re-stenosis’(30” caudo-cranial, 30” LAO) (-). In addition, a stenosisdistal to the secondstent hasevolved (-).
bail-out procedure; one at the end of the dissection membrane, the other at its beginning. This way, a lo-mm portion of the LAD was left ‘unprotected’ (Fig. 2). Becauseof the relatively stiff material of the stents, the implantation of a third stent was considered not feasable with regard to the anatomical angulated course of the vesseland the difficulties to be expectedwhen passing the first stent during implantation. After dilatation with a balloon catheter of 3.0 mm diameter with 8 atm for 90 s in the segment between the stents, the final angiogram showed a good flow in the vessel with no relevant stenosis on its whole distance. At that time the patient was free of angina. The next day, a control angiogram was performed because of recurrence of angina and ECG-changes indicating ischaemia which were persistent after intravenous application of heparine and nitrate. The angiogram showed a significant restenosis in the ‘unprotected’ segment and a stenosis distal to the second stent (Fig. 3). Vasospasmwas excluded by intracoronary injection of nitrate. Intimal dissection was assumedto be the most likely reason for
restenosis, probably in combination with partial thrombus formation in spite of the anticoagulation. As restoring the contours of the vesselin between and distal of the stents by further catheter based techniques did not seem to be adequate, it was then decided to perform bypass surgery. The LAD was opened in the area of the stents, which were removed. At the site of PTCA, including the stent-covered area, the LAD showed severe intimal damage. The stents themselves were still completely expanded. No clot was found in the dissectedarea. Surgical endarteriectomy was performed in this region. In its proximal and distal portions, the intima of the LAD was intact. A Ysaphenous-vein graft was connected to the LAD and the first marginal branch. A long side-to-side anastomosiswas sutured to the LAD that covered the segmentof the vessel which had been opened for the explantation of the stents. At follow-up angiography 4 months later, the patient was free of symptoms. Coronary angiography showed the bypass with patent anastomoses with good flow to the distal native vessel
112
A. Enbergs et al. / Inlernalional
Journal of Cardiology 48 (1995) IOY- f 1.1
Fig. 4. Four-month follow-up angiogram; injection into the aorto-coronary bypass: patent bypass to the LAD and marginal branch with a large vascular lumen in the region of the LAD anastomosis(-). Retrograde flow into the proximal LAD. Unobstructed perfusion of the second diagonal branch (90” LAO).
and significant retrograde flow in the LAD supplying a large diagonal branch (Fig. 4). The long anastomosis with the LAD resulted in a dilated vascular bed. All side branches were patent. 3. Discussion Intraoperative explantation of stents has not been reported before. We, therefore, describe a case in whom two intracoronary stents were implanted after complicated PTCA as a bail-out manoeuvre. Bypass surgery becamenecessarydue to early restenosis and unstable angina; subsequently the two stents were removed. The two stents were implanted in an area of long intimal dissection, leaving a stenosedsegmentproximal to the stents, supplying a major diagonal branch. The total length of the LAD segmentwith intimal dissection was longer than two stents, but for anatomical reasons and due to the good flow, the implantation of a third stent was not attempted. It was not supposed that incomplete expansion of the stents was the reason for the early
restenosis as the angiography immediately after stent implantation showed a good result. Furthermore the stents were completely expanded when removed during bypass surgery. The decision to perform surgery was made becauseno other technique seemedto be able to prevent complete occlusion of this important segment. Due to the position of the stents in the LAD, a bypass anastomosis to the LAD distal to the last stent would have left proximal and medial portions of the LAD unsupplied. In addition the problem of dissection would not have been solved. Therefore, the stents were removed to be enable endarterectomy over the whole distance of damaged intima. A long anastomosis covering that vessel segment allowed perfusion of larger parts of myocardium. Intracoronary stents are associatedwith the risk of early and late occlusion [2]. Long-term anticoagulation with its imminent risks is often necessary.In spite of good initial results after stent implantation, restenosishas to be expected in case the stents are implanted for long intimal dissection in an angulated vesselsegment. Further investigation to solve some of these problems has lead to
A. E&ergs et al. /International
Journal of Cardiology 48 (1995) 109-113
the development of bioabsorbable [3] and removable [4] stems, which are currently under investigation for clinical use. This case shows that removal of intracoronary stents implanted as a bail-out procedure is feasable when aorta-coronary bypass surgery becomes necessaryto achieve a satisfying long term result after unsuccessful placement of stents after complicated FTCA. References [l]
Sigwart U, Euel J, Mirkovitch V, Joffre F, Kappenberger L. Intravascular stents to prevent occlusion and
[2]
[3]
[4]
113
restenosisafter transluminal angioplasty. N Engl J Med 1987; 316: 701-706. Haude M, Erbel R, Straub U, Dietz U, Schatz R, Meyer J. Results of intracoronary stents for management of coronary dissection after balloon angioplasty. Am J Cardiol 1991;67: 691-696. Susawa T, Shiraki K, Shimizu Y. Biodegradable intracoronaty stents in adult dogs. J Am Co11Cardiol 1993; 21: 483A. Khorsandi J, Eigler NL, Litvack F, Mahrer KN, Forester J. Heat activated recoverable temporary stents: histopathologic and angiographic observations for implantations of up to six weeks. J Am COBCardiol 1993; 21: 439A.