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Saphenous vein graft angioplasty in a teenager
Saphenous Vein Graft Angioplasty in a Teenager Joel K. Kahn, MD, and Geoffrey 0. Hartzler. ercutaneous transluminal coronary angioplasty (PTCA) is a P widely usedtechnique for the elective and emergent revascularization of obstructive coronary artery disease. Due to the increasing frequency of atherosclerosiswith age, PTCA has beenpracticed exclusively in an adult population.’ Although the field of interventional pediatric cardiology has grown tremendouslyin recent years,2 PTCA has not been reported in this age group. We recently performed PTCA in a teenager; to our knowledge this is the youngest patient reported to benefit from this evolving technique. A I5-year-old girl was diagnosed in infancy with anomalous origin of the left main coronary artery from the pulmonary trunk. At age 9 months she underwent surgical ligaFrom Cardiovascular Consultants,Inc., 4320 Wornall Road, Medical Plaza 11-20,Kansas City, Missouri 64111. Manuscript received September 18, 1989,and acceptedSeptember 24.
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tion of the left coronary artery origin. She did well until age 10, when she developed exertional angina1 symptoms. Coronary artery bypass surgery using a reverse saphenous vein graft to the left main stump was performed. The patient subsequently did well until age 15 when she again began to experience angina1 symptoms with exertion. The patient underwent a maximal exercise stress test with thallium-201 tomography. Tomographic images revealed reversible perfusion defects anteriorly at the apex and laterally in the apical and midventricular sections, consistent with ischemia of both the left anterior descending and left circumflex arteries. Angiography demonstrated a 70% anastomotic stenosis with a lucent appearance (Figure I). A 4.0 mm Simpson Ultra Low Profile II balloon catheter (Advanced Cardiovascular Systems) and a 0.014 inch hi torque floppy guidewire (Advanced Cardiovascu-
lar Systems) were steered into the vein graft and through the stenosis into the left circumflex artery. The balloon was positioned in the anastomosis and several inflations were performedfor up to 60 seconds and 6 atmospheres of pressure (Figure 2).
FIGURE 3. Selective injecth of the right uuonary artery using a separate coronarycauwterdlwlngbaaoonlnflation in ths vein graft anastomosis. In this rightanterieroMiquepre~,persistentcoaateralflowfromthsrightsystem to the left cirwanttex artery is apparent.
FIGURE 1. Sekctive injsctfon of the sqhnausveingrafttothsleftmah
!manpinthel5-year-oldfemalepatienL IntKsleft~ehrobliqwproiection,a hentzaneatthegraftanastomosisis appared, and the anastomosis is 70% nan-owed In a band-like manner.
FIGURE 2. placement ofthebalbon dtleteracl.ossthertenotieregloowith M baMoon expansion is demonstrated. The guidewire is in ths left eircumttex artery.
I4. Final selective injsctbns afterbaNoonangiqAastydsmonstrated wide patency of ths anastomosis with good distal run-off.
THE AMERICAN JOURNAL OF CARDIOLOGY JANUARY 15. 1990
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During balloon inflation, the right coronary artery was selectedwith a diagnostic catheter and was injected (Figure 3). Persistent collateraljlow from the right coronary artery to the left circumflex artery was observed (Figure 3). With the balloon catheter and guidewire withdrawn, final angiograms revealed markedly improved patency and good flow through the area (Figure 4). The distal anastomosisappearedto be at least as large as the left main artery. The next day the patient underwent repeat exercisethallium-201 tomography. Tomographic images after stress and I-hour redistribution werenormal by visual and quantitative analysis. At 8-month follow-up, she continues to do well, is free of chestpain and has no limitations of her activities. The patient describedhad anomalous origin of the left main coronary artery from the pulmonary artery, referred to as the Bland-GarlandWhite syndrome.3 Survival into adulthood is dependenton the development of collaterals between the right coronary artery and the left arterial system (Figure 3), and flow through the anomalousleft main artery is retrograde. The anomalous left main artery produces a steal
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phenomenom from the right coronary artery and produces a large mass of ischemic myocardium. Although a number of surgical ap proaches to correct this condition have been described, ligation of the left main artery and construction of a bypassgraft from the aorta to the left main artery or to the left anterior descending artery have been performed most frequently4 with good relief of symptoms. In our patient this approach led to initial relief of symptomsfollowed by recurrent angina after an interval of 5 years.Angiography revealed a constriction at the anastomosisof the vein graft with the left main coronary artery, pre sumably due to surgical technique or intimal thickening. PTCA appeared to be an attractive alternative to repeat cardiac surgery in this young patient. A large balloon catheter (4.0 mm) was used to accommodatethe dimensionsof the vein graft and the left main stump. We have previously describedsimultaneousinflation of 2 balloon catheters in oversized vein grafts, known as hugging balloons5; however, we believe that the result following single balloon inflations had restored the diameter of the anastomosisto that of the left main stump.
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 65
We expect that the problems experienced by this young patient will be seenmore often in the future as patients with congenital heart disease survive for longer periods because of more aggressivetherapies. Young patients with anomalousorigin of the left coronary arterial system from the right sinusof Valsalva6 provide another population that during follow-up may require PTCA. 1. Dorros G, Cowley MJ, SimpsonJ, Bentivoglio LG. Block PC, BourassaM, Detre K, GosselinAJ, Grunt& AR, Kelsev SF. Kent KM. Mock MB. Mullin SM. Tyler RiC, PArnan EP,‘Stertze.rSH: Williams DO. Percutaneoustransluminal coronary angioplasty: report of complications from the National Heart, Lung and Blood Institute PTCA Registry. Circulation 1983,67:723-730. 2. Perry SB, KeaneJF, Lock JE. Interventional catheterization in pediatric congenitaland acquiredheart disease.Am J Cardiol 1988,61:1096-117G. 3. Bland EF, White PD. Garland J. Congenital anomaliesof the coronary arteries: report of an unusual caseassociatedwith cardiac hypertrophy. Am Hewt J 1933;8:787-792. 4. Moodie DS, Fyfe D, Gill CC, Cook SA, Lytle BW. Tavlor PC. Fitzgerald R. SheldonWC. Anomalousorigin of the leff corona& artery from the pulmonary artery (Bland-White-Garland syndrome) in adult patients:long term follow-up after surgery.Am Heart J 1983:106:381-386. 5. Teirstein PS. Johnson WL Jr. Rutherford BD. Hartzler GO. Hugging balloons~coronary angii plasty of oversizedvesselswith side-by-sideballoons. Cathet Cwdiovasc Diagn 1988:1X52-54. 6. Barth CW III, Roberts WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary artery. JACC 1986;7:366-373.
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tion of the left coronary artery origin. She did well until age 10, when she developed exertional angina1 symptoms. Coronary artery bypass surgery using a reverse saphenous vein graft to the left main stump was performed. The patient subsequently did well until age 15 when she again began to experience angina1 symptoms with exertion. The patient underwent a maximal exercise stress test with thallium-201 tomography. Tomographic images revealed reversible perfusion defects anteriorly at the apex and laterally in the apical and midventricular sections, consistent with ischemia of both the left anterior descending and left circumflex arteries. Angiography demonstrated a 70% anastomotic stenosis with a lucent appearance (Figure I). A 4.0 mm Simpson Ultra Low Profile II balloon catheter (Advanced Cardiovascular Systems) and a 0.014 inch hi torque floppy guidewire (Advanced Cardiovascu-
lar Systems) were steered into the vein graft and through the stenosis into the left circumflex artery. The balloon was positioned in the anastomosis and several inflations were performedfor up to 60 seconds and 6 atmospheres of pressure (Figure 2).
FIGURE 3. Selective injecth of the right uuonary artery using a separate coronarycauwterdlwlngbaaoonlnflation in ths vein graft anastomosis. In this rightanterieroMiquepre~,persistentcoaateralflowfromthsrightsystem to the left cirwanttex artery is apparent.
FIGURE 1. Sekctive injsctfon of the sqhnausveingrafttothsleftmah
!manpinthel5-year-oldfemalepatienL IntKsleft~ehrobliqwproiection,a hentzaneatthegraftanastomosisis appared, and the anastomosis is 70% nan-owed In a band-like manner.
FIGURE 2. placement ofthebalbon dtleteracl.ossthertenotieregloowith M baMoon expansion is demonstrated. The guidewire is in ths left eircumttex artery.
I4. Final selective injsctbns afterbaNoonangiqAastydsmonstrated wide patency of ths anastomosis with good distal run-off.
THE AMERICAN JOURNAL OF CARDIOLOGY JANUARY 15. 1990
259
During balloon inflation, the right coronary artery was selectedwith a diagnostic catheter and was injected (Figure 3). Persistent collateraljlow from the right coronary artery to the left circumflex artery was observed (Figure 3). With the balloon catheter and guidewire withdrawn, final angiograms revealed markedly improved patency and good flow through the area (Figure 4). The distal anastomosisappearedto be at least as large as the left main artery. The next day the patient underwent repeat exercisethallium-201 tomography. Tomographic images after stress and I-hour redistribution werenormal by visual and quantitative analysis. At 8-month follow-up, she continues to do well, is free of chestpain and has no limitations of her activities. The patient describedhad anomalous origin of the left main coronary artery from the pulmonary artery, referred to as the Bland-GarlandWhite syndrome.3 Survival into adulthood is dependenton the development of collaterals between the right coronary artery and the left arterial system (Figure 3), and flow through the anomalousleft main artery is retrograde. The anomalous left main artery produces a steal
260
phenomenom from the right coronary artery and produces a large mass of ischemic myocardium. Although a number of surgical ap proaches to correct this condition have been described, ligation of the left main artery and construction of a bypassgraft from the aorta to the left main artery or to the left anterior descending artery have been performed most frequently4 with good relief of symptoms. In our patient this approach led to initial relief of symptomsfollowed by recurrent angina after an interval of 5 years.Angiography revealed a constriction at the anastomosisof the vein graft with the left main coronary artery, pre sumably due to surgical technique or intimal thickening. PTCA appeared to be an attractive alternative to repeat cardiac surgery in this young patient. A large balloon catheter (4.0 mm) was used to accommodatethe dimensionsof the vein graft and the left main stump. We have previously describedsimultaneousinflation of 2 balloon catheters in oversized vein grafts, known as hugging balloons5; however, we believe that the result following single balloon inflations had restored the diameter of the anastomosisto that of the left main stump.
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 65
We expect that the problems experienced by this young patient will be seenmore often in the future as patients with congenital heart disease survive for longer periods because of more aggressivetherapies. Young patients with anomalousorigin of the left coronary arterial system from the right sinusof Valsalva6 provide another population that during follow-up may require PTCA. 1. Dorros G, Cowley MJ, SimpsonJ, Bentivoglio LG. Block PC, BourassaM, Detre K, GosselinAJ, Grunt& AR, Kelsev SF. Kent KM. Mock MB. Mullin SM. Tyler RiC, PArnan EP,‘Stertze.rSH: Williams DO. Percutaneoustransluminal coronary angioplasty: report of complications from the National Heart, Lung and Blood Institute PTCA Registry. Circulation 1983,67:723-730. 2. Perry SB, KeaneJF, Lock JE. Interventional catheterization in pediatric congenitaland acquiredheart disease.Am J Cardiol 1988,61:1096-117G. 3. Bland EF, White PD. Garland J. Congenital anomaliesof the coronary arteries: report of an unusual caseassociatedwith cardiac hypertrophy. Am Hewt J 1933;8:787-792. 4. Moodie DS, Fyfe D, Gill CC, Cook SA, Lytle BW. Tavlor PC. Fitzgerald R. SheldonWC. Anomalousorigin of the leff corona& artery from the pulmonary artery (Bland-White-Garland syndrome) in adult patients:long term follow-up after surgery.Am Heart J 1983:106:381-386. 5. Teirstein PS. Johnson WL Jr. Rutherford BD. Hartzler GO. Hugging balloons~coronary angii plasty of oversizedvesselswith side-by-sideballoons. Cathet Cwdiovasc Diagn 1988:1X52-54. 6. Barth CW III, Roberts WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary artery. JACC 1986;7:366-373.