Drug-eluting stents for the percutaneous treatment of the anastomosis of the left internal mammary graft to left anterior descending artery

Drug-Eluting Stent Restenosis: Modern Approach to a Classic Challenge

In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Immediate and Long-Term Results of Drug-Eluting Stents in Mammary Artery Grafts

Percutaneous intervention of a coronary graft is the treatment of choice when the graft fails. The objective is to report the long-term results of drug-eluting stents (DES) in mammary artery grafts (MAG). Patients who had been treated with DES for MAG in 27 centers were selected. The baseline and procedural clinical data were included prospectively, and the follow-up was performed with the patients, families, and medical records. Two hundred and sixty-eight patients were included: age 65.5 ± 10.1 years, diabetes 47.8%, ejection fraction 55.5 ± 14.9%.

INDICATION

stable angina 28.4%, unstable angina 38.1%, non-ST-elevation myocardial infarction 21.6%, ST-elevation myocardial infarction 5.3%, and heart failure 6.7%; 1.19 ± 0.59 stents/patient were implanted measuring 18.8 ± 8.8 mm in length and 2.68 ± 0.35 mm in diameter. Rapamycin was used in 78 cases (29.1%), paclitaxel in 77 (28.7%), everolimus in 70 (26.1%), zotarolimus in 34 (12.7%), and biolimus in 9 (3.4%). All cases were successful except for 1 in which the patient died 30 minutes after the procedure. There were no other inhospital events. After a follow-up of 41 months (Q25: 23.7 to Q75: 57.8), 24 patients (9%) died of heart-related causes and 20 (7.5%) of noncardiac causes. Repeat revascularization was necessary in 31 cases, and in 1 additional patient, there was total occlusion, which was not treated. These 32 patients represented 11.9% of the total. In conclusion, the implantation of DES in MAG shows very high procedural success and also low long-term event rates.

Left anterior descending artery percutaneous coronary intervention via the left internal mammary artery in a 54-year-old type 1 diabetic woman: a case report

Data on the treatment of left anterior descending artery (LAD) stenosis involving or localized distally to left internal mammary artery anastomosis are scarce and not homogeneous. Both surgery (CABG) and percutaneous interventions (PCI) have been attempted, but the most effective treatment has not yet been established. We report a case of a 54-year-old woman suffering from chronic, stable angina and diabetes type 1 successfully treated with percutaneous angioplasty of LAD via the left internal mammary artery with drug-eluting stent implantation with excellent short-term results.

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.

Endovascular Management of Symptomatic Spasm of Radial Artery Bypass Graft

OBJECTIVE

To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease.

CLINICAL PRESENTATION

A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging.

TECHNIQUE

The patient underwent a left MCA bypass graft for flow augmentation. She returned with an occluded bypass graft, collateralization of the anterior MCA territory through a spontaneous synangiosis, and a severe perfusion deficit in the posterior MCA territory. She underwent a revision bypass graft procedure with the radial artery from the occipital artery stump to the MCA-M3 branch. She developed repeated symptomatic vasospasm of the radial artery graft postoperatively. After systemic anticoagulation, the graft was accessed through the occipital artery, and intra-arterial verapamil was injected. When this failed to resolve the graft spasm, the radial artery graft was accessed with a 0.14-inch Synchro-2 microwire (Boston Scientific, Natick Massachusetts), and sequential angioplasties were performed using over-the-wire balloons from the proximal to distal anastomosis and in the occipital artery stump. A nitroglycerin patch was applied cutaneously over the graft to relieve the vasospasm.

RESULTS

No complications occurred. Graft patency with robust flow was observed on the 5-month follow-up angiogram.

CONCLUSION

Endovascular techniques can be safely used for salvage of spastic extracranial-intracranial grafts.