Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Dyskeratosis Congenita: A Case Report of a Patient With Coronary Artery Disease

Clinical evidence demonstrates that patients with telomere biology disorders, such as dyskeratosis congenita, are more prone to coronary artery disease. We present the case of a 43-year-old female diagnosed with dyskeratosis congenita with critical cardiovascular disease. She underwent coronary artery bypass graft (CABG) with improvement of her cardiac function. Although this is a rare genetic disease, further studies are warranted to investigate the underlying pathophysiology of cardiovascular disease in patients with dyskeratosis congenita.

Incidental Finding of Thoracic Aortic Dissection in a Patient Post-Coronary Artery Bypass Graft Surgery

Thoracic aortic dissection (TAD) is an uncommon but potentially fatal complication of coronary artery bypass graft (CABG). Most patients present to the emergency room with severe chest pain, shortness of breath, or after a syncopal episode. Asymptomatic patients pose a challenge to diagnosis. The authors present a case of an 82-year-old male, who was found to have an incidental finding of a 5-cm ascending aortic aneurysm with an intimal dissection flap four months after CABG. Extensive workup on possible risk factors such as underlying aortic diseases, genetic conditions, and hypertensive crisis proved noncontributory. Aggressive blood pressure control was achieved, and the patient was observed in the intensive care unit before discharge with follow-up. The purpose of this case report is to alert clinicians of TAD after CABG and highlight the importance of developing a protocol for follow-up and monitoring of patients who have undergone CABG, as complications can be asymptomatic. Early and accurate diagnosis of TAD as a complication of CABG is essential to improving survival rates.

A Complex Left Internal Mammary Artery Intervention

There is a variety of conduits utilized as vascular grafts in coronary artery bypass grafting (CABG). Post-CABG graft rate of failure varies depending on the type of conduit used, with the highest failure rates seen in saphenous vein grafts (SVG). Patency rates of SVG are reported to be about 75% at 12-18 months. Left internal mammary artery (LIMA) grafts have shown higher long-term patency rates when compared to other arterial and venous grafts; however, LIMA occlusions occur, most commonly in the early postoperative period. Percutaneous coronary intervention (PCI) of LIMA graft can be challenging based on the location, the length of the lesion, as well as other factors such as vessel tortuosity. Here we present a case of a complex intervention for osteal and proximal LIMA chronic total occlusion (CTO) in a symptomatic patient. Long stent delivery is usually a challenge in LIMA intervention; however, it was successfully achieved here by placing two overlapping stents. This intervention was also complicated by the tortuosity of the lesion, as well as the difficult cannulation of the left subclavian artery requiring a longer sheath for guide support.

Emergency CABG for a migrated stent in a COVID-19 positive patient

Percutaneous coronary interventions (PCI) have become a standard of treatment worldwide. Despite high safety rates, iatrogenic complications caused by stent dislodgements do exist in 0.21% of cases and most require emergency coronary artery by‐pass grafting (CABG). Here we present a case of a coronavirus disease 2019 positive 40‐year‐old male patient presenting with STEMI due to thrombotic lesions in his left coronary trunk. The patient is taken to PCI and stent placement. Stent dislodgement results in the need for emergency CABG and stent removal. Informed consent and ethics approval were obtained.

Aortic root replacement in a patient with previous coronary artery bypass

Acute type A thoracic aortic dissection is a life-threatening condition that requires rapid diagnosis and prompt surgical intervention. Prior cardiac surgery is recognized as a predisposing risk factor. Here, we report a rare case and successful surgical repair of a late presenting acute type A thoracic aortic dissection four years after a three-vessel coronary artery bypass grafting. Resection of the aortic valve and aneurysmal tissue was required, reconstruction was done with a composite graft, and the native coronary ostia and aorto-saphenous buttons were preserved.

A compact and automated ex vivo vessel culture system for the pulsatile pressure conditioning of human saphenous veins

Saphenous vein (SV) graft disease represents an unresolved problem in coronary artery bypass grafting (CABG). After CABG, a progressive remodelling of the SV wall occurs, possibly leading to occlusion of the lumen, a process termed 'intima hyperplasia' (IH). The investigation of cellular and molecular aspects of IH progression is a primary end-point toward the generation of occlusion-free vessels that may be used as 'life-long' grafts. While animal transplantation models have clarified some of the remodelling factors, the pathology of human SV is far from being understood. This is also due to the lack of devices able to reproduce the altered mechanical load encountered by the SV after CABG. This article describes the design of a novel ex vivo vein culture system (EVCS) capable of replicating the altered pressure pattern experienced by SV after CABG, and reports the results of a preliminary biomechanical conditioning experimental campaign on SV segments. The EVCS applied a CAGB-like pressure (80-120 mmHg) or a venous-like perfusion (3 ml/min, 5 mmHg) conditioning to the SVs, keeping the segments viable in a sterile environment during 7 day culture experiments. After CABG-like pressure conditioning, SVs exhibited a decay of the wall thickness, an enlargement of the luminal perimeter, a rearrangement of the muscle fibres and partial denudation of the endothelium. Considering these preliminary results, the EVCS is a suitable system to study the mechanical attributes of SV graft disease, and its use, combined with a well-designed biological protocol, may be of help in elucidating the cellular and molecular mechanisms involved in SV graft disease.