Patch Angioplasty for Isolated Ostial Stenosis of the Left Main Coronary Artery

Surgical coronary angioplasty of both coronary ostia after chest radiotherapy. Is it good alternative to conventional coronary bypass surgery?

INTRODUCTION

Isolated coronary ostial stenosis of both ostia is a rare, potentially life-threatening condition, occurring in 0.1%-0.2% of patients undergoing coronary angiography.

CASE REPORT

We present a case of a 69-year-old woman with a past medical history of breast cancer, who had been treated with radiotherapy, which most likely caused significant stenosis of both coronary ostia and likely accelerated aortic stenosis. Surgical angioplasty with autopericardium patch reconstruction of the left main coronary artery and right coronary arteries due to proximal stenotic disease was performed instead of venous or arterial bypasses with concomitant aortic valve replacement. The postoperative course was uneventful. There were no cardiovascular events 5 years after operation, and the patient remained free of any symptoms.

CONCLUSIONS

Surgical coronary angioplasty offers an alternative to conventional coronary artery bypass grafting in isolated coronary ostial lesions and is advantageous in restoring more physiological myocardial perfusion, especially in those cases when conduits are suspected to be fibrotic, scarred or stenosed after radiation therapy or if there is the need to preserve conduits for future myocardial revascularisation in young patients.

Robotic totally endoscopic coronary artery bypass for isolated ostial stenosis of the left coronary artery

Isolated ostial stenosis (IOS) is a rare disease that encroaches on aorto-coronary junction of uncertain etiology. All distal coronary vessels present normally. IOS occurs predominantly in premenopausal young women with few risk factors for atherosclerotic disease. Here, we report a 40-year-old woman who had experienced crescendo angina for 4 months. Surgical revascularization was achieved by robotic totally endoscopic coronary artery bypass (TECAB) with left internal thoracic artery (LITA) graft. She resumed her daily tasks without difficulties 1 week after the operation. Postoperative computed tomographic angiography disclosed good opacification of the LITA graft and distal runoff. Robotic TECAB is a potentially feasible alternative for IOS patients, particularly in premenopausal young woman, with obvious benefits of cosmetic appearance and speedy recovery.

Surgical patch angioplasty of the left main coronary artery

Isolated ostial stenosis of the left main coronary artery (LMCA) is rare, occurring in <1% of the patients undergoing coronary angiography. Surgical patch angioplasty (SPA) offers an alternative to conventional coronary artery bypass grafting (CABG) in such cases and is advantageous in restoring more physiological myocardial perfusion, maintaining ostial patency and preserving conduit material. However, a number of early technical failures and high perioperative mortality have limited the generalized uptake of this procedure, and only recently have advances in myocardial protection and novel surgical approaches to the LMCA resulted in a resurgence of the technique. A systematic literature search identified 45 studies incorporating 478 patients undergoing SPA. A variety of patch materials were used, including the pericardium, saphenous vein and internal mammary and pulmonary arteries. Patients were followed up for a mean of 54.4 months. The 30-day mortality was 1.7% and cardiac specific mortality 3.3% at last follow-up. Encouragingly, 92.4% of reported cases (n = 182) showed complete angiographic patency at last follow-up. Our results indicate that SPA may be a viable alternative to CABG in the surgical management of isolated ostial LMCA stenosis. However, no randomized trials have been performed, and it is clear that careful patient selection is essential in minimizing morbidity and mortality in the short- and long-term. Further research is required to allow a direct comparison of SPA to techniques with a more substantial evidence base such as CABG and percutaneous coronary intervention, and to define the optimal patch graft material, elucidating that any beneficial effects arterial patches may have on long-term patency.

Repair of left main coronary ostial stenosis using autologous aortic tissue

BACKGROUND

Patch angioplasty is one of the several surgical options for patients with left main coronary ostial stenosis. It restores native antegrade blood flow in the left main coronary artery (LMCA) and does not leave the patient with graft-dependent retrograde perfusion. Various direct techniques have been described for left coronary ostioplasty. Herein, we described the use of autologous aortic tissue in the surgical treatment of left main coronary ostioplasty, and reported the short- and long-term outcomes of the patients.

METHODS

Between January 2003 and December 2010, 11 patients (nine males and two females) underwent surgical patch angioplasty for LMCA ostial stenosis using autologous aortic tissue as the patch material.

RESULTS

All patients survived the operation, and there were no significant postoperative complications. The follow-up period was 44.09 ± 30.26 months (range, 1-94 months), and no deaths or restenoses were observed during follow-up.

CONCLUSIONS

The use of autologous aortic tissue as an onlay patch for reconstruction of left main coronary ostial stenosis is safe and free of major complications. This tissue is a reasonable material for treating selected types of LCMA patients.

Left main coronary disease treated by direct surgical angioplasty: long-term results

BACKGROUND

Left main coronary artery (LMCA) disease is currently treated by coronary artery bypass grafting or, more recently, by percutaneous coronary intervention. Occasionally, direct surgical patch angioplasty of the LMCA can be proposed as an alternative treatment. The aim of this study was to analyze, on a long-term basis, the safety and efficacy of this technique.

METHODS

This retrospective analysis was obtained from clinical data between April 1995 and December 2008: 91 consecutive patients (67 men, 24 women; mean age: 58+/-10 years) underwent surgical angioplasty of the LMCA with an autologous pericardial patch. Among them, 80 (87.9%) presented an isolated LMCA disease. Mean logistic European system for cardiac operative risk evaluation of this series was 3.9+/-2.9. Concomitant surgical procedures included coronary artery bypass grafting (n=11; 12%), valve procedure (n=5; 5.5%), and carotid endarterectomy (n=1; 1.1%). We analyzed the early and late mortality, major adverse cardiac or cerebral event rate, and repeat revascularization rate.

RESULTS

The mean follow-up was 7.22+/-3.60 years (maximum 13.8 years, minimum 180 days). Perioperative mortality was 1.1%. Five and ten-year global survival was 95+/-4.5% and 80+/-8.3%, respectively. Major adverse cardiac or cerebral event rates at five and ten years were, respectively, 21+/-8.4% and 31+/-9.6%. First repeat postoperative revascularization rate was 12+/-6.8% at five and 17+/-7.8% at ten years (n=10 patients). Among them, repeat target lesion revascularization concerned four patients.

CONCLUSIONS

Similar to other series, our study shows satisfactory long-term outcomes with the surgical patch-plasty of LMCA. This technique can be proposed as an efficient and safe alternative to selected patients, particularly in case of isolated LMCA disease without extended calcification.