Percutaneous transluminal angioplasty involving internal mammary artery grafts

Surgical Challenges of Familial Hypercholesterolemia

A 21-year-old patient with familial hypercholesterolemia presented with angina caused by ostial stenosis of the left internal mammary artery and severe calcific aortic stenosis with small aortic root 9 years after coronary revascularization. The ostium of the left internal mammary artery was enlarged using a saphenous vein patch through a left supraclavicular incision, which improved left ventricular function. Successful aortic valve replacement with posterior aortic root enlargement was subsequently performed. The surgical management of this condition is discussed briefly.

Rapid diagnostics and treatment of early complications after CABG surgery: a life saver

Early graft failure after CABG surgery may lead to severe adverse events and death. Because the cause of the graft failure can vary, rapid diagnostic management is mandatory in order to address these complications appropriately. In the present 2 cases, patients who underwent CABG procedures showed typical electrocardiograms and serology of a perioperative myocardial ischemia shortly after surgery. In the first case, a rapidly performed coronary angiogram revealed a torqued right CABG, which was detorqued and, in order to avoid further torsion, fixated to the pericardium in a redo procedure. In the second case, the patient underwent a revascularization by means of percutaneous coronary intervention with stent implantation for severe stenosis due to a localized dissection of the vein graft, diagnosed on coronary angiogram. The further postoperative course of both patients was smooth and both could be discharged on day 8 and 11 after initial surgery, respectively.

Distal anastomotic lesions after coronary artery bypass surgery: incidence, pathogenesis, and treatment approach

Distal anastomotic lesions are the most common reason for venous and arterial graft failure. Redo coronary artery bypass surgery carries a higher risk for mortality and non-fatal myocardial infarction. Many operators therefore consider percutaneous coronary intervention as a good alternative for relieving angina symptoms in this subset of patients with anastomotic lesions. However, the best percutaneous method for treating these lesions is still controversial. Here we review reported data on the incidence, pathogenesis, and treatment of distal anastomotic lesions in both venous and arterial bypass grafts.

Resistance of the Internal Mammary Artery to Restenosis: A Histomorphologic Study of Various Porcine Arteries

BACKGROUND/AIMS

Restenosis after percutaneous transluminal angioplasty (PTA) of the internal mammary artery (IMA) grafts is much less pronounced than in other arteries and venous grafts. The aim of the study was to test whether various arteries respond differently to dilatation.

METHODS

PTA of the IMA, carotid, renal and circumflex coronary (RCx) arteries was performed in 9 pigs (balloon to artery ratio of 1:1.5). After 8 weeks, angiography was repeated and vessels prepared for histological analysis. Immunohistochemical staining was done to examine proliferative activity (Ki67) and to identify the vasa vasorum of the adventitia (F VIII-RA).

RESULTS

The intima-media ratio after PTA was lowest in the IMA (0.06), followed by the carotid (0.27) and renal arteries (0.49) and the RCx (0.69). Proliferation of the intima was seen at 287 degrees of the vessel circumference in the RCx, at 286 degrees in the renal and at 166 degrees in the carotid artery. No proliferative activity was seen in the IMA. The intima-adventitia ratio was lower in the IMA than in the RCx and renal arteries (p < 0.05).

CONCLUSION

Intima proliferation after PTA varies between the different vessels, with best results seen in the IMA. There are differences in remodeling after PTA between muscular, muscular/elastic and elastic arteries.

Successful angioplasty and stenting of bilateral internal mammary artery grafts from the left radial approach. Case report and review of the literature

We describe a case of successful percutaneous transluminal coronary angioplasty and stenting from the left radial approach in a patient with effort angina due to two tight stenoses at the distal anastomosis site of the internal mammary artery grafts. The left radial approach has several advantages compared with the conventional femoral approach: a lower rate of vascular complications and an easier vascular access to the left internal mammary artery graft. The distance from the access site to the origin of the artery is shorter and involves less angulation than the femoral approach. The radial approach is not only safe but it enables faster patient mobilisation and seems also useful in reducing management costs with a hospital stay that can be reduced to 6 h in low-risk cases.

Rescue percutaneous coronary intervention following coronary artery bypass graft--a descriptive analysis of the changing interface between interventional cardiologist and cardiac surgeon

BACKGROUND

Despite decreasing rates of acute and subacute complications of percutaneous coronary intervention (PCI), these procedures are generally only performed in centers where it is possible for failed PCI to be treated by rescue coronary artery bypass graft (CABG). Case reports and case series have documented successful PCI following failed CABG. We sought to confirm this decrease in the need for rescue CABG following failed PCI and to examine trends in the utilization of rescue PCI following failed CABG.

HYPOTHESIS

The interface between interventional cardiologist and cardiac surgeon is characterized by changing practice patterns and resource utilization.

METHODS

We examined the medical records of all patients admitted to the Brigham and Women's Hospital over a 7-year period and identified 169 patients who required both PCI and CABG during the same hospital admission. We describe and compare three predetermined groups of patients defined by the sequence of, and indication for, the relevant myocardial revascularization procedures.

RESULTS

In all, 100 patients required CABG for failed PCI, 46 patients had planned hybrid procedures involving both CABG and PCI, and 23 patients required PCI following failed CABG. There was a decrease in the need for rescue CABG following failed PCI, both in total numbers and as a percentage of total cases (2.5% in 1994 and 0.22% in 1999). There was a simultaneous increase in the utilization of rescue PCI following failed CABG (0% in 1994 and 1.6% in 2000). Hybrid procedures were identified as a source of innovative solutions to a variety of challenging clinical problems.

CONCLUSIONS

Changing patterns of resource utilization should be considered when planning hospital facilities and patient triage, and these patients undergoing percutaneous or surgical revascularization may benefit from close cooperation between the cardiac surgeon and the interventional cardiologist.

An alternative percutaneous interventional approach for post-anastomatic left anterior descending artery stenosis in patients with markedly tortuous LIMA graft

Percutaneous coronary intervention through a tortuous left internal mammary artery (LIMA) graft, especially with redundancy in length is a challenge in spite of availability of different types of coated guidewires and low-profile balloons. Various modifications of the interventional technique are required in order to negotiate the tortuosity of the LIMA graft. We describe an alternative technique that overcomes this problem in patient with a markedly tortuous LIMA graft.

Angioplasty of the internal thoracic artery bypass-graft an alternative to reoperation

BACKGROUND

This review presents an overview of interventional revascularization procedures of the internal thoracic artery after prior implantation as a coronary-artery bypass graft.

METHODS

Our search was concentrated on the MEDLINE-database to identify all articles on internal thoracic artery-graft-angioplasties and reoperation after internal thoracic artery bypass grafting published between 1968 and 2000.

RESULTS

Surgical revascularization and reoperation were reported in five papers including a total of 785 patients. The overall mortality of these patients was 4.2%. The presence of a patent internal thoracic artery-graft at the time of reoperation was not a risk factor for higher morbidity and mortality. Revascularization with percutaneous transluminal coronary angioplasty of the internal thoracic artery or the native left anterior descending artery via the internal thoracic artery-graft used as a conduit was performed in 327 patients. The primary success rate was 87%, the angiographically assessed rate of restenosis was 30% and the rate of complications approximately 1%.

CONCLUSIONS

In spite of technical problems the percutaneous transluminal coronary angioplasty in or via internal thoracic artery-graft presents a safe and feasible option to be recognized before a potential reoperation.

Results of angioplasty (with or without stent) at the site of a narrowed coronary anastomosis of the left internal mammary artery graft or via the internal mammary artery

During the past 6 years, 50 patients underwent percutaneous transluminal coronary angioplasty (PTCA) of a narrowed coronary anastomosis of a left internal mammary artery (LIMA) graft or PTCA of a left anterior descending coronary artery stenosis via LIMA grafts at the investigators' institution. The success rate was high at 88%. Thirty-four of the 44 successfully treated patients (77%) underwent repeat angiography, which showed restenosis in 14 patients (41%). In cases of stent implantation at the coronary LIMA graft anastomosis angioplasty site, the restenosis rate was 80%, but it was only 14% in cases of pure balloon dilation (p = 0.001). Therefore, in cases of coronary LIMA graft anastomosis, stent implantation should be avoided, because it implicates an excessively high restenosis rate.

Clinical outcomes following stent implantation in internal mammary artery grafts

We evaluated our experience with percutaneous coronary intervention (PCI) of internal mammary artery (IMA) grafts. From the institution's database we identified 288 patients with 311 IMA lesions. Of these, 82 (26.4%) had stents placed during PCI. Angiographic success was 92%. Mortality at 1 month was 1.7%, myocardial infarction (MI) 15.7%, and target lesion revascularization (TLR) 0.4%. Cumulative 1-year event rates were mortality 6.4%, MI 20.4%, and TLR 8.0%. TLR rates were significantly higher in the stented lesions than lesions treated with angioplasty alone (19.2% vs. 4.9%; P = 0.004). The higher TLR rate in stented lesions was most apparent at the anastomotic site (25.0% vs. 4.2%; P = 0.006). Percutaneous revascularization of IMA grafts can be performed safely with high procedural success and excellent short- and long-term results. Stenting, particularly at the anastomotic site, was associated with significantly greater rates of TLR than angioplasty alone.

Percutaneous interventions in radial artery grafts: clinical and angiographic outcomes

In the modern era, radial artery graft is being used with increasing frequency to replace saphenous vein as a conduit for coronary artery bypass surgery. Several reports have shown encouraging early results of radial grafts compared to saphenous grafts. Despite these advantages, radial artery graft failure requiring revascularization does occur. We report on the clinical, angiographic, and technical characteristics and the follow-up results of 22 patients who underwent percutaneous intervention of radial grafts.

Left internal mammary graft stenosis and restenosis following angioplasty and stenting

Coronary bypass grafts using the internal mammary artery usually have an excellent record of success and long term patency. We report a 42 year old man who initially presented with a history of atypical left sided chest pain, who had coronary artery bypass surgery for a severe stenosis in his proximal left anterior descending coronary artery (LAD) and moderate stenosis of his proximal circumflex artery, with his LIMA being grafted to his mid-LAD and a saphenous venous graft to the proximal LAD. He subsequently developed multiple stenoses in the LIMA graft which required coronary augioplasty and stenting, on more than one occasion, in view of very rapid restenosis within the LIMA graft.

Percutaneous revascularization of the internal mammary artery graft: short- and long-term outcomes

OBJECTIVES

We evaluated the short- and long-term clinical outcomes after percutaneous revascularization of the internal mammary artery (IMA) graft.

BACKGROUND

Previous reports in a relatively small number of patients have indicated the safety of balloon angioplasty for the treatment of stenoses in the IMA graft. However, the use of alternative interventional techniques and their long-term results have not yet been evaluated.

METHODS

We analyzed the in-hospital and one-year clinical outcomes of 174 consecutive patients who underwent percutaneous revascularization of 202 lesions located in the IMA graft, by either balloon angioplasty or stenting.

RESULTS

Anastomotic lesions were evident in 128 cases (63%), and they were more commonly treated with balloon angioplasty (116/128, 91%), whereas lesions located at the ostium (n = 16, 8%) were more frequently treated with stents (11/16, 69%). Procedural success was 97% with excellent in-hospital outcome: 0.6% mortality rate, no Q-wave myocardial infarction (MI) and 0.6% rate of urgent bypass surgery. Cumulative one-year rates were: mortality 4.4%, MI 2.9% and target lesion revascularization (TLR) 7.4%.

CONCLUSIONS

Revascularization of the IMA graft can be performed safely, with high procedural success and a low rate of in-hospital complications. Long-term follow-up showed very low TLR rate.

Use of stents to treat kinks causing obstruction in a left internal mammary artery graft

Left internal mammary arteries (LIMA) are used routinely as grafts to the left anterior descending coronary artery (LAD) in selected patients undergoing coronary artery bypass graft (CABG) surgery because of better long-term patency rates. Pathology other than fibrointimal hyperplasia, accelerated atherosclerosis, or thrombus can sometimes cause obstructive lesions in such grafts. This report illustrates a kink in a LIMA graft to the LAD causing an obstructive lesion shortly after surgery and describes the subsequent management of this lesion with intracoronary stents.

Percutaneous transluminal angioplasty of radial artery grafts

The radial artery is being used with increasing frequency to replace the saphenous vein as a coronary artery bypass graft, in the belief that it will provide improved long-term patency. Several centers have confirmed that the early results of surgery using the radial artery seem to be better than those obtained with saphenous grafts. Despite these apparent gains, early failure of the radial artery graft can occur and is frequently associated with symptomatic myocardial ischemia. Percutaneous angioplasty is an alternative to reoperation to treat lesions occurring on radial artery grafts. We report on 4 patients who underwent angioplasty of radial artery grafts.

Elective stenting of a de novo ostial lesion of the right internal mammary artery

Elective stenting for severe stenosis involving the origin of a right internal mammary artery graft was performed in a 60-year-old patient with severe unstable angina 2 yr after surgical revascularization. The procedure had an excellent immediate result which persisted at 6-mo angiographic follow-up. This unusual localization of arterial narrowing will probably be increasingly recognized as the right internal mammary artery becomes a first-choice conduit for right coronary artery bypass.

Internal mammary artery graft angioplasty: acute and long-term outcome

Secondary to the low attrition rate of internal mammary artery grafts, limited data are available on the clinical and angiographic outcome of patients who have undergone balloon angioplasty of an internal mammary artery stenosis. This study examined a consecutive series of 68 patients who underwent balloon angioplasty of an internal mammary artery graft over a 9-year period. Procedural success was achieved in 60 of 68 (88%) patients. The primary reason for procedural failure was extreme vessel tortuosity. There were no major in-hospital complications. Angiographic follow-up was obtained in 78% of the patients with an angiographic restenosis rate of 19%. The overall event-free survival in patients with an initially successful procedure was 92%. In conclusion, internal mammary artery balloon angioplasty has both an excellent initial success rate as well as a low incidence of restenosis and repeat target lesion revascularization.

Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease

Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.

Stent implantation in a left anterior descending coronary artery through an internal mammary artery graft

We describe a case of balloon angioplasty of a totally occluded left anterior descending coronary artery through a tortuous left internal mammary artery graft. Because of early recurrence of the lesion, we implanted a short Palmaz-Schatz stent with good angiographic and clinical results.

Prolonged luminal narrowing of internal mammary artery graft after percutaneous transluminal angioplasty

The authors describe a case with an internal mammary artery (IMA) graft that demonstrated prolonged, but reversible, luminal narrowing persisting > twenty-four hours following percutaneous transluminal angioplasty. Luminal narrowing disappeared spontaneously, however, at the time of follow-up angiography one week after the angioplasty. Since haziness at the dilation site had been shown on preprocedural angiogram, suggestive of intraluminal thrombus, this phenomenon may be attributed to either prolonged vasospasm or distal embolization of the IMA graft.

Initial and subsequent angiographic outcome of percutaneous transluminal angioplasty performed on internal mammary artery grafts

OBJECTIVE

To estimate the initial outcome and incidence of restenosis of angioplasty of internal mammary artery grafts in a retrospective study.

METHODS

The study population consisted of 46 patients (48 lesions) who underwent first balloon angioplasty within the internal mammary artery graft. Most (37/48) were at the distal anastomosis. A few (8/48) were in the graft body. Six patients with the evidence of angiographic restenosis underwent a second angioplasty.

RESULTS

The success rate and the restenosis rate of the first angioplasty was 73% and 30% respectively. Of the 34 patients (35 lesions) with a successful first angioplasty, 30 underwent follow up angiography with a restenosis rate of 30% (9/30). A second angioplasty was performed on six of the nine restenotic lesions, with a success rate of 83% and no restenoses. The percent diameter stenosis of the recipient native coronary artery was significantly greater in the restenosis group, at 75 (SD 27)% v 89 (17)%, p < 0.05.

CONCLUSIONS

First angioplasty of 46 patients (48 lesions) within an internal mammary artery graft was performed with a success rate of 73% and a restenosis rate of 30% (follow up rate of 88%). The extent of the stenosis of the recipient native coronary artery may affect the restenosis rate.

Postoperative symptomatic internal thoracic artery stenosis and successful treatment with PTCA

From 1988 to 1992, 4,182 coronary bypass grafting procedures were performed at the University of Ottawa Heart Institute. The left internal thoracic artery (ITA) was used in 2,913 patients, the right ITA in 79, and bilateral ITAs in 61 for a total of 3,053 patients with ITAs. This study assessed patients requiring angioplasty for symptomatic ITA stenosis after operation. A total of 29 patients (0.95%) with a mean age of 55.3 +/- 1.9 years underwent angioplasty for ITA stenosis from 4 days to 34 months after operation (mean, 6.5 +/- 1.6 months). Internal thoracic artery stenosis was identified in 18 patients (62.1%) within 3 months after operation. Angina was present in 26 patients (89.7%), a positive stress test in 8 (27.6%), and myocardial infarction in 1 (3.4%). At angiography, a total of 34 stenotic sites were identified in ITA grafts. Angioplasty was successful (< 50% residual stenosis) in 31 sites (91.2%). Follow-up was available for 28 of 29 patients (96.6%) at 24.6 +/- 2.3 months. Four patients (14.3%) returned with restenosis within 3 months, 2 of whom had successful repeat angioplasty, and 1 required reoperation. Canadian Cardiovascular Society anginal class after angioplasty was less than class II in 84.6% of patients. In conclusion, symptomatic postoperative ITA stenosis is uncommon, occurs most frequently at the site of distal anastomosis, and generally presents within 3 months of operation. It may be safely and effectively treated with angioplasty with a low recurrence rate.

Percutaneous transluminal coronary angioplasty of the left internal thoracic artery graft: a case report in a child

A 9-year-old girl who had undergone previous coronary artery bypass surgery at the age of 3.5 years for stenoses of the left anterior descending and right coronary arteries resulting from Kawasaki disease presented with recurrent exertional angina. Stenosis was found at the anastomosis of the left internal thoracic artery to the left anterior descending artery. Percutaneous transluminal coronary angioplasty was successfully performed. This is the first reported case of percutaneous transluminal coronary angioplasty of an internal thoracic artery graft in a child.

Stenting the distal anastomotic site of the left internal mammary artery graft: a case report

The major problem associated with the long-term patency of the internal mammary artery graft is the early occurrence of stenosis usually at its distal anastomotic site; its management by balloon angioplasty has been associated with a high success rate. We report the case of an unsuccessful balloon angioplasty of an anastomotic stenosis of a left internal mammary artery graft that was successfully managed by stenting with one-half of a Palmaz-Schatz stent.

Balloon recanalisation of a chronically occluded left internal mammary artery graft

A patient in whom balloon recanalisation of a chronically occluded left internal mammary artery graft was successful is described. A Magnum-Magnarail system was used, and a four month follow up showed no restenosis.