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Interact CardioVasc Thorac Surg 2009;9:736-738. doi:10.1510/icvts.2009.210633 © 2009 European Association of Cardio-Thoracic Surgery
Surgical extraction of occluded stents: when stenting becomes a problemDivision of Cardiothoracic Surgery, Department of Surgery, McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada Received 27 April 2009; received in revised form 10 July 2009; accepted 14 July 2009
*Corresponding author. Tel.: +1 (514) 934-1934 ext. 42838; fax: +1 (514) 934-8289.
In this current ‘stent era’, cardiac surgeons are faced with a rapidly increasing number of patients in whom previous percutaneous coronary interventions (PCIs) have been performed before they are finally referred for coronary artery bypass surgery. We herein describe a technique of surgical revascularization in two patients with diffusely diseased left anterior descending arteries (LAD), covered with multiple overlapping stents extending to their distal portion. The pertinent literature is reviewed and the technical steps and clinical presentation are discussed.
Key Words: Coronary disease; Myocardial infarction; Stents
Diffuse coronary artery disease continues to challenge cardiac surgeons, precluding complete revascularization in some patients, while rendering others inoperable. In the era of percutaneous coronary intervention (PCI), surgeons can only expect to confront this problem with increasing frequency with about 20% of patients with previous PCI requiring subsequent coronary artery bypass graft surgery (CABG). We describe an unconventional way to deal with the unusual case of diffusely diseased, ‘full metal jacket’ left anterior descending arteries (LAD) that required surgical intervention to achieve complete revascularization.
Patient 1 is a 73-year-old man with history of hypertension, hyperlipidemia, and diabetes mellitus, who, despite previous stenting of the LAD, continued to complain of worsening angina and was recently admitted with an acute coronary syndrome involving the anterolateral territory. Coronary angiogram revealed the presence of diffuse three-vessel disease, with an ejection fraction of 45%. More importantly, the LAD was diffusely diseased and was covered with multiple overlapping stents extending to its distal portion (Fig. 1). Patient 2 is a 77-year-old man with multiple medical comorbidities who was also referred to our institution for surgical revascularization and aortic valve replacement. In addition to the presence of severe three-vessel disease, his angiogram revealed the presence of completely occluded LAD with a long stent at its distal end.
After establishing cardiopulmonary bypass, cardiac arrest was achieved with antegrade cold blood cardioplegia. After completing the surgical revascularization of the obtuse marginal, diagonal and posterior descending arteries, our attention was then turned to the LAD. As expected from the angiogram, the LAD was extensively diseased with multiple in-stent as well as distal stenoses. Based on the small distal bed, traditional revascularization was considered unfeasible. A long superficial arteriotomy was then made on this diseased artery, extending to its distal portion and exposing the multiple overlapping stents that were carefully dissected from the adventitia and removed (Fig. 2). After tacking the distal intima of the LAD with 8-0 polypropylene sutures, its raw surface was flushed with saline and flaps were removed. Continuous running 7-0 polypropylene suture was then used to reconstruct the LAD by fixing a vein patch inside its lumen. Needles were carefully inserted into the intima, excluding the surrounding plaques. A pedicled internal mammary artery graft was then anastomosed to the vein patch using a continuous 7-0 polypropylene suture. The remainder of the surgery was completed in the same standard manner as any other surgical revascularization and both patients were then weaned from bypass without any problems. They were started on clopidogrel and aspirin and transferred to the floor the next day where they made a normal recovery. They continue to do well and remain in New York Heart Association (NYHA) class I three months after their surgery.
Since the advent of PCI, the number and frequency of PCI procedures are rapidly increasing worldwide. With the recent refinements in percutaneous techniques, aggressive repeated PCI with overlapping stent placement has become more common, affecting up to 30% of patients and have resulted in an increase in the number of high-risk ‘stent loaded’ patients who are referred to cardiac surgeons [1]. This trend will probably continue to increase despite the significant increase in in-hospital mortality and morbidity in patients with previous PCI sessions when undergoing elective CABG [2]. More importantly, an increasing number of patients with a ‘full-metal jacket’ diseased LAD are being referred for CABG, creating a challenging problem to the cardiac surgeon, precluding complete revascularization in some patients, while rendering others inoperable. Interestingly, it has been reported that incomplete revascularization of the LAD remains one of the most important factors influencing long-term mortality and morbidity after surgical revascularization [3]. The significantly worse outcome after surgery may be a consequence of the increased stent load leading to coronary endothelial injury with intimal hyperplasia due to repeated stent lesions [4]. Although some centers reported acceptable clinical outcomes of the ‘full-metal jacket’ approach [1, 4], the risk of restenosis increases with stent length and surgeons continue to be confronted with performing more complex coronary revascularization after PCI failure on diffusely diseased arteries. Perhaps the worse scenario is when confronted with a diffusely diseased LAD with multiple overlapping stents covering all its length. The challenge is then to achieve complete revascularization in such a patient with multiple comorbidities and complex coronary lesions with a greater risk of graft occlusion. Our patients had evidence of diffusely diseased LAD with multiple overlapping stents covering almost all its length. We had to use a variant of the open endarterectomy and vein patch technique and extract the overlapping stents to achieve complete revascularization. Similar to an endarterectomy, the denuded endothelium after stent extraction could, however, enhance myofibrocyte proliferation, and act as a scaffold for new thrombus formation. We believe that the use of clopidogrel and aspirin in this case may help to decrease the risk of graft failure. It is encouraging to note that none of the events associated with acute graft closure, such as ventricular tachycardia or fibrillation, perioperative myocardial infarction or postoperative hemodynamic instability were observed in our patients. In an effort to expand surgical indication to the cohort of patients with diffusely diseased LAD, various techniques, including sequential anastomoses and the creation of more than one bypass to the LAD territory, have been used. In some other situations, other approaches including open endarterectomy combined with different means of complex coronary reconstruction have been utilized simultaneously [3–7]. However, when faced with the unusual situation of multiple overlapping stents covering almost the whole artery, as it was observed in our patients, unconventional techniques are needed to achieve satisfactory outcomes. In both patients, the internal mammary artery anastomosis could not even be inserted distally because of the compromised run-off secondary to the multiple stents inserted distally. We were then forced to extract the stents to allow surgical revascularization of the LAD. In fact, surgical removal of previously inserted stents in a ‘full-metal jacket’ LAD, followed by vein patch and anastomosis to the internal mammary graft has not been previously reported. Although the possibility to use the LIMA graft as an onlay patch is attractive, we believe that the use of a vein patch in the presence of an extensively calcified LAD wall is preferable [5]. Despite the lack of clear evidence, multiple long stents covering the entire length of major epicardial vessels continue to be used around the world with an increasing frequency [1]. As mentioned in a recent guideline update, caution should be exercised before suggesting this strategy, especially when stents are inserted distally because of the inherent limitation of future CABG [8]. In summary, we describe the management of two patients with ‘full-metal jacket’ LAD and multiple overlapping occluded stents extending distally. To the best of our knowledge, this is the first report of surgical stent extraction and revascularization of a diffusely diseased LAD. Although longer follow-up is still needed, we believe that this technique could be a satisfactory and life-saving procedure allowing complete revascularization in the rare case of an occluded LAD covered with multiple overlapping stents, with no adequate distal bed, and when no other traditional revascularization techniques are possible.
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Abstract
1. Introduction
