Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: A feasible option in selected cases (original) (raw)
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European Journal of Cardio-Thoracic Surgery, 1997
Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality. Objecti7e: To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause. Methods: Between 1990Between and 1995Between , 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room. Results: A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n= 59; group 1) or an immediate re-operation (n=12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%). Conclusion: An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography. © 1997 Elsevier Science B.V.
Coronary Artery Bypass Graft Surgery (CABG)
KYAMC Journal
Coronary artery bypass grafting (CABG) is one of the procedure done worldwide with acceptable results and has the highest impact in the history of medicine. Atherosclerotic Plaque formation in the sub-intimal layer is the main pathophysiology which causes ischemia in cardiac muscle & gives symptoms of coronary artery disease (CAD). There are many ways for revascularization but CABG is the mostly performed procedure & still gold standard. Results of percutaneous coronary interventions (PCI) & other novel approach to coronary revascularization is still compared with conventional CABG. Left internal mammary artery is the most durable conduits & should be used for every patients unless contraindicated. In young non-diabetic patient as much possible arterial conduits should be used. In planned operations results are excellent with inhospital mortality <1% with few morbidities like sternal wound infection <3%, renal and neurological complications <7% & <3%.
Percutaneous Intervention of Left Main Coronary Artery Chronic Total Occlusion
Journal of Clinical Case reports and Images
Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is rare on the angiograms; Coronary Artery Bypass Grafting is the standard method of its revascularization. To demonstrate that PCI may in some cases be a safe option for patients with a high-risk surgical category, we report a complex clinical case of revascularization of chronic total occlusion of the LMCA, left anterior descending artery (LAD), and circumflex artery (CX). Methods Recanalization of the occluded LMCA and LAD was performed by utilizing the support-balloon technique, and CTO wires (Miracle 3™ wire, Abbott Vascular; Runthrough® NS Intermediate wire, Terumo); LAD, CX, LMCA, and its bifurcation, were stented with 3 drug-eluting stents (Resolute Integrity DES, Medtronic); the "Culotte Stenting " technique was used for bifurcation stenting, followed by "Kissing Balloon" post-dilatation technique; proximal optimization technique was performed in the LMCA. Results The intervention ende...
Medical Principles and Practice, 1999
Objective: To examine the graft patency and progression of atherosclerosis 8 B 5 years after coronary artery bypass graft (CABG) surgery in symptomatic patients. The relationship of risk factors to the progression of the disease and the possible degree of anginal relief to repeated postbypass surgery, angioplasty or intensified medical treatment were reviewed. Methods: A retrospective review of medical files and coronary arteriographic studies of 122 consecutive patients who were catheterized from January 1, 1993 to December 31, 1996. Results: At 8 B 5 years after CABG, 44.3% of saphenous vein grafts had occluded. For the same period, 89.3% of left internal mammary grafts were patent. Diabetes had a better association with progression of disease in native coronary arteries than grafts. Hypercholesterolemia affected the venous graft more. Hypertension inversely affected graft atherosclerosis and to a lesser extent native artery disease progression. Anginal class improved in 91% of patients having angioplasty. Repeat surgery improved 66% of the patients. Intensified medical intervention helped 50% of the group who were not candidates for other interventions. Conclusion: Symptomatic patients with post-CABG have reasonable prognosis. They should be catheterized early. Based on their coronary anatomy and disease burden in their grafted vessels they could benefit from percutaneous transluminal coronary angioplasty (PTCA), repeat CABG or intensive medical treatment. Amongst the three options, those who could have PTCA had better amelioration of their symptoms.
Journal of Interventional Cardiology, 2007
Background: With continuing technical advances in percutaneous coronary interventions (PCI) for coronary artery disease (CAD), patients undergoing coronary artery bypass surgery (CABG) often have complex coronary anatomy that is not ideal for PCI. Because of the complex anatomy, these patients have a higher risk of early graft occlusion. The feasibility of PCI in the treatment of early graft occlusion is not well established. Methods: A retrospective chart review was performed of patients presenting with recurrent ischemia within three months post-CABG and at one-year follow-up. Results: Forty-six patients with 156 grafts were identified. Three presented with STEMI, 21 with NSTEMI, 21 with unstable angina, and one with congestive heart failure. Sixty-three grafts were occluded or stenosed (>70%). Twenty-seven grafts (43%) in 17 patients were not amenable to PCI. The other 34 grafts (54%) in 23 patients underwent successful PCI. PCI was performed upon native vessels and occluded grafts with equal frequency. Six patients had patent grafts. At one-year follow-up, six of 23 patients in the PCI group were readmitted with ischemia; five vessels (14%) in four patients had restenosed. There were no deaths. In the group with no PCI, 11 of 23 patients were readmitted with ischemia with one death. Conclusion: PCI for early post-CABG occlusion was safely performed in slightly more than half of target vessels. PCI was performed upon native vessels and occluded grafts with equal frequency. After initial PCI success, the clinical target vessel restenosis rate was 14% at one-year follow-up. (J Interven
Journal of Cardiovascular Medicine, 2018
BACKGROUND Treatment of patients with ULMCA (unprotected left main coronary artery disease) with percutaneous coronary intervention (PCI) has been compared with coronary artery bypass graft (CABG), without conclusive results. METHODS All randomized controlled trials (RCTs) and observational studies with multivariate analysis comparing PCI and CABG for ULMCA were included. Major cardiovascular events (MACEs, composite of all-cause death, MI, definite or probable ST, target vessel revascularization and stroke) were the primary end points, whereas its single components were the secondary ones, along with stent thrombosis, graft occlusion and in-hospital death and stroke. Subgroup analyses were performed according to Syntax score. RESULTS Six RCTs (4717 patients) and 20 observational studies with multivariate adjustment (14 597 patients) were included. After 5 (3-5.5) years, MACE rate was higher for PCI [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.07-1.14], without difference in death, whereas more relevant risk of MI was because of observational studies. Coronary stenting increased risk of revascularization (OR 1.52; 95% CI 1.34-1.72). At meta-regression, performance of PCI was improved by use of intra-coronary imaging and worsened by first generation stents, whereas two arterial grafts increased benefit of CABG. For patients with Syntax score less than 22, MACE rates did not differ, whereas for higher values, CABG reduced MACE because of lower risk of revascularization. Incidence of graft occlusion was 3.24% (2.25-4.23), whereas 2.13% (1.28-2.98: all CI 95%) of patients experienced stent thrombosis. CONCLUSION Surgical revascularization reduces risk of revascularization for ULMCA patients, especially for those with Syntax score greater than 22, with a higher risk of in-hospital death. Intra-coronary imaging and use of arterial grafts improved performance of revascularization strategies.
Circulation. Cardiovascular interventions, 2016
The prevalence of native coronary chronic total occlusions (CTOs) after coronary artery bypass grafts (CABGs) is higher than in non-CABG population. We examined outcomes of CTO percutaneous coronary intervention (PCI) post-CABG versus without CABG. Then, we looked at feasibility and outcomes of retrograde CTO PCI via patent or occluded saphenous vein graft. We compared patient and procedural characteristics of 470 CTO cases treated from January 2010 to December 2015 depending on history of CABG. We assessed major adverse cardiac events, including cardiac death, myocardial infarction, ischemia-driven target-vessel revascularization, or reocclusion 1 year after successful CTO PCI in patients treated before February 2015. Post-CABG patients (175 cases) had a higher J-CTO score (2.5 versus 2.1; P=0.002). In-hospital complications were similar, although the incidence of contrast-induced nephropathy was higher in post-CABG patients (4.6% versus 1%; P=0.01). With multivariable analysis, po...
Coronary artery bypass grafting: yesterday, today & tomorrow
AME Medical Journal, 2020
Despite the changing landscape of treatment of coronary artery disease (CAD), coronary artery bypass grafting (CABG) remains a safe and effective option for treatment of multivessel obstructive CAD. Since its introduction in mid 1960s, CABG has evolved tremendously making it the only evidence-backed standard of care for treatment of CAD with well-established symptomatic and prognostic benefits. Discovery of the cardiopulmonary bypass (CPB) and introduction of myocardial protection strategies made performance of CABG on the beating heart obsolete in the 1970s. Advances in myocardial protection methods, improved CPB techniques and refined anaesthetic management translated into improved outcomes in the 1980s (1). Advances in technology in the 1970s and 1980s were accompanied by enhanced understanding of vascular biology particularly behaviour of the saphenous vein grafts. The pioneering work of FitzGibbon and colleagues brought to the fore phenomenon of early and late vein graft bypass failure (2,3). This reignited interest in use of left internal mammary artery (LIMA) as a bypass conduit. The seminal publications from Cleveland Clinic in the 1980s and 1990s established the status of LIMA as the gold standard for grafting of the left anterior descending (LAD) artery (4) and the superiority of two IMAs over single IMA in improving survival and reducing reoperation rate (5). Additional arterial conduits such as gastroepiploic artery and radial artery have also been used over the years on the premise that they improve long-term outcome (6). However, choice of second best conduit for CABG remains a controversial issue in the current era especially following the publication of the intention-to-treat analysis of Arterial Revascularisation Trial at 10 years (7). Late 1990s and early 2000 saw a boom in percutaneous coronary interventions worldwide. This was accompanied by increasing realisation that conventional CABG despite its safety profile was an invasive procedure. The use of CPB was associated with systemic inflammatory response which along with manipulation and clamping of the ascending aorta increased the morbidity of the procedure (8). Off-pump CABG was rediscovered in late 1990s as a strategy to counteract the invasiveness of conventional on-pump CABG. It remains a highly scrutinised technique with excellent outcomes reported by high-volume centres (9). However, concerns about long-term survival, graft patency and increased repeat revascularization rate remain the Achilles heel of the procedure precluding its universal adoption. Similarly, grafting of isolated LAD with LIMA through a small left anterior thoracotomy termed minimally invasive direct coronary artery bypass (MIDCAB) is a technique that is superior to the state of the art PCI technology but not very popular due to its steep learning curve and technically demanding nature (10). This focused issue of AME Medical Journal is dedicated to providing an overview of CABG covering the various surgical techniques in particular and the evolution of CABG in general. Manuscripts in this focused issue have been contributed by world experts and opinion leaders and are expected to provide an insight to the readers into the past, present and future of CABG.