Treatment for LMCA ostial stenosis using a bifurcation technique with a retrograde approach

A 69‐year‐old man who underwent coronary artery bypass surgery in February 2008. The surgery included grafting of the left internal thoracic artery (LITA) to the diagonal branch (D1) and a saphenous vein graft (SVG) to the left circumflex artery (LCX) due to ostial stenosis of the left main coronary artery (LMCA). The patient presented with recurring effort chest pain 18 months later. Coronary CT revealed that the LITA‐D1 graft was patent, the SVG‐LCX graft was occluded, and there was severe ostial stenosis of the LMCA. Coronary angiography was performed in August 2009, but a 5‐Fr diagnostic catheter could not be engaged due to the severe ostial stenosis. Percutaneous coronary intervention (PCI) was performed 5 days later with an attempt to cross the lesion with a guidewire using a retrograde approach through the LITA‐D1 graft. However, the guidewire could not be crossed using a conventional technique due to the extreme angulation of the LITA‐D1 anastomosis. Therefore, we attempted to use a reversed guidewire technique. After crossing the LMCA ostial lesion the retrograde wire was snared through antegradely for insertion of the guiding catheter via the right brachial artery. We were able to engage the guiding catheter in the left coronary artery and implant the stent successfully using the antegrade approach. © 2009 Wiley‐Liss, Inc.     

10 plus-years follow-up after patch angioplasty of the left main coronary artery

In ostial or proximal left main coronary artery (LMCA) obstruction, re-establishment of normal antegrade flow via the main trunk may be preferable to distal bypass grafting. The objective of this study was to assess the effectiveness of patch plasty of the left main (LM) trunk of the coronary artery for more than 10 years. Direct widening of the LMCA was recommended to patients with ostial, proximal, or midpoint stenosis of the main trunk. Group I of 16 patients had isolated LM obstruction with no distal disease, and Group II of 15 patients had, in addition, right coronary obstruction. The mean age was 60.9 years (age group, 47 to 83 years). Nineteen patients underwent this operation through an anterior transverse aortotomy. No endarterectomies were performed. In Group II, in addition, a single saphenous vein bypass graft was placed in the right coronary artery. There were no operative deaths. Follow-up period extends from 10 to 18 years (mean 11.2). Eight patients had angiography from 3 to 9 years after surgery and all show adequate LM trunk caliber. Noncardiac deaths occured in five patients (26.3%) at 2 months, and 1, 4, 6, and 7 years after surgery. Two women with isolated ostial stenosis diagnosed as a spasm have not shown progression of coronary disease 7 to 9 years after the operation. Widening of the LMCA should be considered in selective cases, only when ostial, proximal, or midportion stenosis of the main vessel exist, even if a right coronary bypass graft is required.     

Coronary Ostial Stenosis after Aortic Valve Replacement: Successful Treatment of 2 Patients with Drug-Eluting Stents

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.Key words: Angioplasty, transluminal, percutaneous coronary; aortic valve/surgery; cardiac surgical procedures/adverse effects; coronary artery disease/etiology/prevention & control; coronary stenosis/diagnosis/etiology/therapy; heart valve prosthesis implantation/adverse effects; iatrogenic disease/prevention & control; perfusion/adverse effects/instrumentation; postoperative complications/therapy; treatment outcomeCoronary ostial stenosis is a rare but potentially serious postoperative sequela of aortic valve replacement (AVR). Ostial stenosis can occur in the left main coronary artery (LMCA) or in the right coronary artery (RCA). The condition, first described by Roberts and Morrow in 1967,¹ is believed to occur after 1% to 5% of AVR procedures.^2–7 No underlying cause has been determined. The clinical symptoms of coronary ostial stenosis are usually severe and can appear from 1 to 6 months postoperatively.^8,9 Although the typical treatment is coronary artery bypass grafting (CABG), patients have been successfully treated by means of percutaneous coronary intervention (PCI).^10–15 Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after AVR, discuss their PCI treatment, and offer our conclusion regarding the feasibility of PCI in the treatment of coronary ostial stenosis.     

Congenital ostial left main coronary artery stenosis associated with a bicuspid aortic valve in a young woman

We describe a 41-year-old woman with no cardiac risk factors, typical exertional angina and an abnormal noninvasive stress test. Coronary angiography demonstrated an ambiguous left main coronary artery (LMCA) stenosis. Intravascular ultrasound (IVUS) demonstrated no atheroma, but the minimum lumen diameter and area of the ostial LMCA were significantly reduced. Transesophageal echocardiography showed normal left ventricular function with a bicuspid aortic valve. Two-vessel coronary artery bypass grafting was subsequently performed. To our knowledge, this is the first IVUS-documented case of a congenital left main coronary artery stenosis associated with a bicuspid aortic valve.     

Left main coronary artery ostial stenosis: Clinical markers,angiographic recognition and distinction from left main disease

Among 1254 patients with coronary artery occlusive disease (CAOD) who underwent cardiac catheterization studies in our laboratory from 1975 through 1977, 114 (9%) had significant (≥50%) stenosis of the left main coronary artery (LMCA). Thirty-four of the 114 (29.8%) had stenosis of the LMCA ostium (2.7% of all CAOD patients). Clinical, hemodynamic, and angiographic data of the 34 patients were analyzed. Unstable angina was more frequent in these patients, most of whom were in functional classes III and IV, than those with other LMCA lesions. Of the 18 who underwent treadmill exercise testing, results were positive in 16 (11 of whom had ST segment depression ≥2 mm Hg), negative in none and indeterminate in two. By avoiding overlapping the coronary ostium with the sinus of Valsalva without significant foreshortening of the LMCA during angiography, LMCA ostial stenosis was recognizable in all patients in the moderate left anterior oblique position only and not in other projections. Coronary arteriography was performed without occurrence of ventricular fibrillation, infarction, or any other morbidity or mortality in the 34, as well as in the entire group of 114 patients with LMCA disease. To ensure a safe procedure, left ventricular filling pressure was monitored constantly via a catheter in the pulmonary artery, and patients experiencing sharp increases following coronary injections were promptly treated with nitroglycerine. Coronary artery bypass, with an average of 3.2 grafts per patient, was performed in 30 patients with a survival of 97% and only one death in a patient who underwent aortic valve replacement and triple bypass. Stenosis of the ostium of the LMCA is not an uncommon lesion in patients with CAOD and should be suspected in all patients whose symptoms are severe. Coronary angiography, performed with adequate precautions, as well as aortocoronary bypass, can be accomplished successfully.     

Angioplasty of the ostium of the left coronary artery using a venous patch]

Isolated critical ostial stenosis of the left main coronary artery (LMCA) without narrowing in the distal parts of coronary vessels is rather rare cause of angina. It was observed in 7 our patients: 5F and 2M aged 42-55 yrs (mean 47.5). Five of them were in unstable condition. In all of them a direct surgical angioplasty of the LMCA was performed. Cardiopulmonary bypass with moderate hypothermia were used in all patients. The LMCA was approached from behind. A curved incision was made into the right lateral aortic wall toward the LMCA. Care was taken to stay away from the commissure between the noncoronary and the left coronary cusp. The posterior aspect of the LMCA was incised across the stenosis and prolonged through bifurcation. A venous onlay patch was used to enlarge not only the LMCA but also the adjacent 2 cm of aortic incision, so as to give the LMCA ostium a funnel shape, which favors a homogeneous blood flow. The mean aortic cross clamping time was 46 min. The patients were easily weaned from cardiopulmonary bypass. The early and late results are good--all patients were discharged from the hospital free of symptoms. In 6 patients a perfect patency of the left main stem was documented during control coronarography. In our opinion direct surgical angioplasty of LMCA is better then the conventional surgical treatment because normal geometry of LMCA ostium and normal blood flow can be restored using this method.     

Impact of ostial stenosis on the Doppler flow profiles in internal thoracic artery graft.

As ostial stenoses of internal thoracic artery (ITA) grafts rarely occur after coronary artery bypass grafting, little is known about their Doppler flow profile. This report describes changes in the Doppler flow of ITA grafts with ostial stenosis after surgical repair of the stenosis. A 54-year-old male underwent coronary artery bypass grafting (CABG) in which the left ITA was anastomosed to the left anterior descending coronary artery. The follow-up coronary angiography revealed an ostial 90% stenosis of the ITA. The patient underwent elective surgery during which the radial artery was interposed between the left subclavian artery and the ITA. Intraoperative ultrasonography was performed immediately before cut down of the ITA graft and again immediately after completion of all anastomoses. Both diastolic and systolic velocities and the velocity time integral increased more than 2-fold after the repair. Neither the diastolic-to-systolic peak velocity ratio nor the diastolic velocity time integral fraction showed remarkable change. These profiles were different from those reported previously for distal stenosis.     

Coronary ostial stenosis: surgical considerations

To investigate the clinical significance of coronary ostial stenosis, we reviewed eight patients with such lesions, including three with isolated stenosis at the orifice of the coronary artery. There were five male and three female patients, with an average age of 46.25 years (range 32–69 years). Their symptoms consisted mainly of angina (6 patients), with dyspnoea and palpitation being the presenting features in the remaining two patients. All patients underwent preoperative coronary angiography which confirmed stenosis at the level of the orifice with absence of reflux of contrast medium into the sinus of Valsalva as the main features. Delay in the appreciation of stenosis of the orifice of the right coronary artery resulted in the death of two patients, whose diagnosis was confirmed at post mortem examinations. Stenosis of the orifice of the right coronary artery was present in seven patients, with two patients also having stenosis of the orifice of the left coronary artery. The remaining patient had isolated stenosis of the left coronary arterial orifice. Coronary artery bypass grafting was performed in five patients, including two who had patch angioplasty to the right coronary artery. The patient with isolated stenosis of the orifice of the left coronary artery had patch angioplasty only. Follow-up of up to three years in the surviving patients showed good functional results. The ease with which it is possible to miss right coronary ostial stenosis is emphasized and angiographic features are reviewed.     

Sirolimus-eluting stent for in-stent restenosis of left main coronary artery in takayasu arteritis.

A 53-year-old woman with Takayasu arteritis was admitted to hospital because of worsening exertional angina. Coronary angiography revealed 90% ostial stenosis in the left main coronary artery (LMCA), which also involved the bifurcation of the relatively short LMCA. Because the patient refused coronary bypass surgery, she underwent percutaneous coronary intervention (PCI) and the stenosis was successfully dilated. However, the exertional angina recurred a few months later and again after the second PCI. Finally, a sirolimus-eluting stent was deployed in the in-stent restenotic lesion. The patient has been free from angina pectoris for 6 months after the last PCI and follow-up coronary angiography indicated no restenosis in the LMCA.     

IVUS-controlled aorto-ostial directional coronary atherectomy in higher grade stenosis of the central anastomosis of a sequential triple venous bypass

Following coronary artery bypass grafting repeat ischemia mandatory for reintervention occurs in 2 to 30% of cases, depending mainly on graft age. Selection of a suitable strategy for revascularisation--transcatheter angioplasty or reoperation--depends on various parameters including coronary morphology, left ventricular performance, comorbidity and availability of graft material. Catheter-based interventions on saphenous vein bypass grafts are feasible, but lower primary success rates and a higher incidence of restenosis--compared with native coronary arteries--have to be expected. Repeat coronary artery bypass graft operations are associated with a significantly higher perioperative morbidity and mortality, patency rates are lower and late clinical outcome is worse than in primary surgery. We report on a patient who underwent coronary artery bypass grafting 4 years ago revealing a high grade ostial stenosis in a jump-graft supplying RCA, LAD and Cx sequentially, making reintervention necessary. As a prerequisite serial balloon angioplasty of two native vessels was performed prior to ostial intervention. Intravascular-ultrasound guided directional coronary atherectomy was performed with good primary and long-term result. Our case demonstrates that, if all relevant clinical parameters and different therapeutic options are taken into account, complex transcatheter angioplasty procedures are feasible and associated with a reasonable amount of risk, thus avoiding repeat coronary artery bypass graft operations.     

Early venous coronary bypass graft occlusion in a patient with non-specific aortitis: a case report.

A 58-year-old woman with aortic valve regurgitation and bilateral ostial coronary artery stenosis due to non-specific aortitis is presented. Four months after aortic valve surgery and venous bypass surgery, orificial occlusion or high grade stenosis of the bypass grafts occurred. Repeat coronary arteriography was followed by cardiac arrest and emergency surgery but patient did not survive. The etiology, pathological findings and surgical approach are discussed.     

Acute coronary syndrome due to extrinsic compression of the left main coronary artery in a patient with severe pulmonary hypertension: successful treatment with percutaneous coronary intervention

A patient with severe pulmonary (arterial) hypertension (PH) presented with a non-ST segment elevation myocardial infarction and recurrent angina at rest. Coronary angiography showed severe ostial left main coronary artery (LMCA) stenosis; coronary arteries were otherwise normal. Intravascular ultrasonography (IVUS) showed deformation of the LMCA due to extrinsic compression from a markedly dilated main pulmonary artery, which was confirmed by cardiac computed tomography. The LMCA was successfully stented using a paclitaxel-eluting stent resulting in complete resolution of angina. Extrinsic compression of the LMCA should be considered in patients with severe PH and angina; IVUS may aid in the diagnosis. Percutaneous stent implantation may be the preferred treatment in this high-risk group of patients.     

Coronary angioplasty in patients with previous coronary artery bypass grafting.

Between 1982 and 1990, in 134 patients with prior coronary artery bypass grafting and recurrent angina, repeat coronary angiography and balloon angioplasty of stenoses in grafts or native arteries were attempted. Mean age of grafts was 45.6 months, range three days to twelve years. At the time of angioplasty, 6 patients had one-vessel-disease, 33 had two-vessel-disease, and 95 had three-vessel-disease. A total of 182 lesions were dilated: 55 venous grafts, 3 internal mammary artery grafts, and 124 native vessels. Forty-nine of 55 (89%) venous grafts could be successfully dilated, and in 3 internal mammary artery grafts, a stenosis reduction greater than 50% was achieved. In 65 of 88 (74%) grafted native arteries, dilation success was achieved. Twenty-seven of 36 (75%) patients with prior bypass surgery to other arteries had successful angioplasty of nongrafted native arteries. Three patients underwent emergency bypass surgery after dissection and acute occlusion: one of them died in cardiogenic shock secondary to acute myocardial infarction. The angiographic success rate in grafts was slightly higher than in native arteries (90% vs 74%). These data indicate that percutaneous transluminal coronary angioplasty in patients after bypass surgery is possible at a low risk (3%) and constitutes an effective therapy in symptomatic patients.     

Primary and elective stenting of unprotected isolated left main coronary ostial stenosis in acute coronary syndrome

Direct surgical angioplasty or coronary artery bypass graft has been done in patients who have left main coronary ostial stenosis. Recent reports have demonstrated that stenting of unprotected left main coronary artery stenosis has been attempted as an alternative to bypass surgery in selected patients with normal LV function. We report two patients with isolated left main coronary ostial stenosis who are undergoing primary and elective stenting, respectively. Major cardiac events did not occur during a 3-month follow-up. This study suggests that stenting of isolated left main coronary ostial stenosis in acute coronary syndrome is feasible and results in excellent outcomes.     

Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery

Coronary artery bypass grafting prolongs survival in patients with left main coronary artery stenosis. However, this benefit is denied to patients who refuse the procedure or who are poor surgical candidates due to comorbid conditions. We describe a novel technique for the percutaneous revascularization of stenosis in an unprotected left main coronary artery in high-risk patients. The TandemHeart, a percutaneously inserted left ventricular assist device, was used to provide periprocedural hemodynamic support during angioplasty and stenting of an unprotected left main coronary artery for stenosis in a 70-year-old woman. The device was removed immediately after the procedure, and the patient was discharged from the hospital on the 2nd postprocedural day. The potential advantages of angioplasty with the support of percutaneous left ventricular assist devices in high-risk patients are discussed.     

Multiple extensive coronary artery stenting: does it compromise future surgical revascularization?

PURPOSE OF REVIEW: In the era of percutaneous coronary intervention, surgeons are confronted with performing coronary artery bypass graft surgery on patients with previous balloon dilatation or stenting. This review evaluates the impact of previous percutaneous coronary intervention on patient survival and choice of optimal myocardial revascularization technique. RECENT FINDINGS: Aggressive atherosclerosis has been remarked in patients complicated with intrastent stenosis. Moreover, bypass grafting with venous grafts has shown an extremely high incidence of graft failure in the restenosis population due to limited nitric oxide (a natural vasodilator) production of venous grafts. The challenge is to achieve complete revascularization in an unfavourable setting (greater co-morbidities, complex coronary lesions) with a greater risk of graft occlusion. SUMMARY: The internal thoracic artery is the optimal graft for myocardial revascularization in patients with and without previous in-stent restenosis. Coronary artery reconstruction by exclusive internal thoracic artery grafting gives superior patency rates and clinical outcomes. It is the most appropriate approach for myocardial revascularization in these patients.     

Two-dimensional echocardiographic analysis of proximal left main coronary artery in humans

The left main coronary artery (LMCA) was evaluated in 100 consecutive patients (88 men and 12 women; mean age 63 years) with anginal syndrome, all in New York Heart Association classes II and III. Each patient underwent two-dimensional echocardiography (2DE) from the parasternal short-axis and apical four-chamber views. Coronary angiography was subsequently performed within 24 hours. The LMCA was directly measured by 2DE and coronary angiography at its widest point. Each echocardiogram was blindly evaluated for LMCA aneurysm or obstruction. Eight patients (8%) were excluded because of inadequate visualization of the LMCA. The mean 2DE measurement was 4.4 +/- 0.9 mm vs 4.2 +/- 0.8 mm on coronary angiography (r = 0.86). Atherosclerotic aneurysms of the LMCA were correctly diagnosed in two patients by 2DE. LMCA stenosis (greater than 50%) was found in 11 patients on coronary angiography; three of them had ostial or proximal lesions, three had middle lesions, and five had distal lesions. 2DE correctly diagnosed all three ostial lesions, two of three middle lesions, but only two of five distal lesions. In four patients, dense echoes in the LMCA caused a false positive diagnosis. It was concluded that: the LMCA can be visualized and correctly measured by 2DE; atherosclerotic aneurysms can be detected; and 2DE is yet unable to screen patients for LMCA lesions; however, 2DE is a promising method for evaluating proximal and especially ostial LMCA stenosis.     

An unusual cause of ischemia after coronary bypass grafting!!

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome.     

Angioplasty of the unprotected left main coronary artery stenosis with standby cardiopulmonary support--a case report

Stenosis of the unprotected left main coronary artery (LMCA) is a classical indication for coronary artery bypass graft surgery (CABG). Percutaneous coronary intervention (PCI) of LMCA may be an alternative to surgical treatment if atherosclerosis of distal segments is very advanced. The periprocedural risk is high, especially if comorbidities are present. However, long-term results remain unclear. The ongoing Syntax trial will clarify whether angioplasty of LMCA with drug-eluting stents can be equivalent to CABG. We present a case of a patient with occluded right coronary artery, severe stenoses of the LMCA, left anterior descending artery and left circumflex artery, and poor left ventricular ejection fraction in whom PCI for stenosis of unprotected LMCA with standby cardiopulmonary support was performed.     

Early ostial vein graft stenosis: management by atherectomy

During the initial perioperative period (1 mo to 1 yr) after saphenous vein coronary grafting, early stenosis and occlusion occurs in 5-8% of grafts due to intimal hyperplasia. We report a patient who developed ostial stenosis within 4 mo of bypass surgery at the aortotomy site of two vein grafts. Balloon angioplasty of the elastic stenoses did not provide significant luminal enlargement, but successful treatment of the lesions was obtained using directional atherectomy. Histological examination demonstrated intimal hyperplasia. Directional atherectomy may be an excellent technique for treatment of elastic ostial vein graft stenoses in lieu of conventional balloon dilatation.