Left main coronary stenosis as a late complication of percutaneous angioplasty:an old problem, but still a problem

Transcription

1 26 Clinical Research Left main coronary stenosis as a late complication of percutaneous angioplasty:an old problem, but still a problem Giuseppe Faggian 1, Gianluca Rigatelli 2, Francesco Santini 1, Giuseppe Petrilli 1, Paolo Cardaioli 2, Loris Roncon 2, Alessandro Mazzucco 1 1. Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy 2. Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy Objective Accelerated left main coronary stenosis (LMCS) is a known potential late complication of coronary artery catheter procedures. The aim of this study was to assess the current occurrence of LMCS as a delayed complication of percutaneous angioplasty (PTCA) of the left coronary branches in our institution. Methods The medical records of patients referred for coronary artery by-pass surgery from the same Cardiology Unit in the January 2003 to December 2006 period and presenting a significant (> 50%) LMCS as a new finding following a PTCA of the left coronary artery branches, were reviewed. Patients with retrospective evidence of any LMCS at previous coronary angiographies preceding the percutaneous procedure were excluded. Results Thirtyseven patients (5 females, mean age 71.1±8.6 years) out of 944 (4%) having undergone a PTCA, fulfilled the inclusion criteria, 19 (51%) after a procedure also involving the LAD coronary artery. Extraback-up guiding catheters were used in most cases. Use of multiple wires or balloons was observed in 3 cases (8%). Rotablator and proximal occlusion device were used in one case respectively (3%). Twenty patients (54%) have had more than one percutaneous coronary intervention on the left coronary branches. The mean time elapsed from the first angioplasty and surgical intervention was 18.1±7.8 months. Conclusions The potential occurrence of LMCS following a percutaneous intervention procedure, especially when complicated and repeated, should not be underestimated in the current era. This evidence may offer the rationale to schedule non-invasive imaging tests to monitor left main coronary patency after the procedure as well as to fuel further research to develop less traumatic materials. (J Geriatr Cardiol 2009; 6:26-30) Key words angioplasty; coronary angiography; surgery; interventional; coronary artery disease Introduction Since the late 1980s, accelerated coronary stenosis related to intimal trauma has been recognized as a potential delayed complication of coronary artery angiography and percutaneous coronary interventions. 1-5 Over the last decade, advances in design and material of guide-wires, catheters and guide-catheters, together with improvements in operators skill leaded to less traumatic and more effective procedures. 6,7 Aim of this retrospective study was to assess the current incidence in our institution of left main coronary stenosis (LMCS) as a delayed complication of percutaneous angioplasty (PTCA) of the left coronary branches, in this emancipated era of percutaneous interventions. Patients and methods We retrospectively reviewed the surgical database of Corresponding author: Gianluca Rigatelli, MD; Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital; Viale tre Martiri, Rovigo 45100, Italy; Fax: ; jackyheart@libero.it the Division of Cardiac Surgery of the University of Verona Medical School relative to the four years period, from January 2003 to December 2006, searching for patients admitted for coronary artery by-pass surgery related to a LMCS (> 50% ) as a new finding occurred after a PTCA of any left coronary artery branches: left anterior descending coronary artery (LAD), circumflex artery (LCx), obtuse marginal artery (OM), diagonal braches (D) or ramus intermedius (RI). Angiographies at the time of first coronary angioplasty and those with evidence of subsequently occurred left main stenosis (>50%) were reviewed by two independent observers. Patients admitted for bypass surgery with left main coronary artery dissection as a result of the percutaneous procedure as well as those with retrospective evidence of any left main stenosis on previous coronary angiography preceding the percutaneous procedure were excluded. Patients referred for surgery as a result of a failed angioplasty were also not included. In order to estimate precisely the incidence of this complication, patients were divided according to the referring centers and those referred from the Interventional Cardiology Unit of the Rovigo General Hospital, in view of the shared data base and representing the largest subgroup,

2 27 were defined as the study population. Patient medical history and procedural data were reviewed, including clinical (cardiovascular risk factors, Canadian Cardiovascular Score class) and angiographic characteristics (lesion/s location and severity) as well as the equipment and techniques used at the time of PTCA. Use of different guide catheters shapes and sizes, use of special techniques such as buddy-wire technique, kissing balloon technique, kissing stent, and utilization of specific devices, such as temporary proximal occlusion devices, and atherectomy devices (rotablator) were recorded. The time elapsed from the first angioplasty and subsequent/s when indicated, and the surgical intervention were also reported. Table 1 Demographical and clinical data Results Thirty-seven patients [32 males (86%), mean age 71.1± 8.6 years] out of 944 (4%) having undergone a PTCA of the left coronary branches at the Interventional Cardiology Unit of the Rovigo General Hospital, developed a LMCS and fulfilled the inclusion criteria. Patient demographics and clinical data are reported in Table 1. All 944 patients were in optimal medical therapy including personalized doses of ACE-inhibitors, beta-blockers of calcium antagonists, antiplatelet drugs, and statins. Nineteen patients out of 37 (51%) had undergone a PTCA involving the LAD coronary artery (Table 2). The guide-catheters used were in most Patients with LMCS Patients without LMCS P value n=37 n=907 Hypertension, n (%) 25 (67) 612/907( 67.4) ns Hypercholesterolemia, n (%) 28 (75) 765/907(83.3) ns Diabetes, n (%) 6 (16) 108/907(11.9) ns Smoking, n (%) 19 (51) 463/907(51.1) ns Previous TIA or stroke, n (%) 5 (13) 98/907(10.8) ns Recent ACS-AMI, n (%) 25 (67) 523/907(57.6) ns Valvular heart disease, n (%) 6 (16) 151/907(16.6) ns EF (%), (±SD) 49± ±12.6 ns CCS class, (±SD) 3.5± ±0.7 ns AMI= acute myocardial infarction; ACS= non ST-elevation acute coronary syndrome; CCS= Canadian Cardiovascular Score; EF= ejection fraction calculated from left ventricle angiography; TIA= transient ischemic attack; SD=standard deviation Table 2 Procedural characteristics of the study groups Patients with LMCS Patients without LMCS P value n=37 n=907 Previous PCI on LAD, n (%) 19/37 (51) 400/907( 44.1) ns Previous PCI on LCx, n (%) 10/37 (27) 355/907(39.1) ns Previous PCI on OM, n (%) 7/37 (19) 289/907(31.8 ) ns Previous PCI on RI, n (%) 2/37 (5) 102/907( 11.2) ns Previous PCI on D, n (%) 2/37 (5) 123/907(13.6) ns Percentage of A lesions, % Percentage of B lesions, % ns Percentage of C lesions, % Multivessel procedure, n (%) 7/37 (19) 210/907(23.1) ns Multiple guide-wire 4/37 (10) 279/907(30.7) ns Rotablator or proximal occlusion device, n (%) 1/37 (2.5) 29/907(3.1) ns Extraback-up guide catheter, n (%) 34/37 (91.8) 792/907( 87.3) ns 6-7F guide catheter, n (%) 26/37 (70.3) 583/907(64.2) ns Procedural time (minutes, ±SD) 103± ± Mean N.of PCI on left branches before 1.54± ±0.60 ns surgery (±SD) PCI= percutaneous coronary intervention; SD= standard deviation. LAD= left anterior descending coronary artery; LCx= circumflex artery; OM= obtuse marginal artery; RI= ramus intermedius; D= diagonal braches

3 28 cases (n=20; 54%) extraback-up catheters such as the Ebu guiding catheter (Medtronic Corp). Left Amplatz (Medtronic Corp, Johnson & Johnson, Boston Scientific Corp.) was used in 6 patients (16%), XB-LAD (Johnson & Johnson) in 8 patients (22%) and Judkins left (Medtronic Corp, Johnson & Johnson, Boston Scientific Corp.) in 3 (8%). The size of the catheters were 7F in one case (3%), 6F in 25 cases (67%) and 5 F in 11 (30%). Use of multiple wires or balloons occurred in 3 cases (8%). Rotablator and proximal occlusion device were used in one case, respectively (3%). Twenty patients (54%) underwent more than one percutaneous coronary intervention on left coronary branches before coronary surgery. The mean time elapsed from the first angioplasty and surgical intervention was 18.1±7.8 months (range, 9 to 27 months). Mean LMCS before cardiac surgery evaluated by quantitative coronary angiography was 79±22% [Ostial LMCS= 24 (65%); Distal LMCS= 13 (35%)]. Coronary angiography in a 72-year-old patient before a PTCA on the LAD and the angiographic control after 9 months are reported in Fig. 1 and 2, respectively. Figure 1 Diagnostic coronary angioraphy in a 72-year-old patient before coronary angioplasty on LAD Twenty-nine patients were scheduled electively for surgical revascularization, whilst 8 (22%) on an emergency basis for refractory angina. In 6 cases IABP was inserted pre-operatively as a precautionary maneuver. All patients survived the operation. Mean number of grafts/patient was 2.8±0.7. At least one internal mammary artery was used in all cases. There were no peri-operative myocardial infarction. One patient was reoperated upon for bleeding (3%). Mean hospital stay was 7.2±1.1 days. Discussion This retrospective study suggests that LMCS as a delayed complication of PTCA still occurs in this emanci- Figure 2 Ostial left main stenosis observed on a 9-month control angiography for unstable angina in the same patient pated era of percutaneous coronary interventions. The advent of thinner catheters, such as the 5F guiding catheters, and of very low profile devices, such as balloon and stent catheter with less than profile, increased the safety and effectiveness of percutaneous coronary procedures allowing to minimize the risk of vascular complications and to engage even more complex lesions. However, our study proves that these advancements have not completely eliminated iatrogenic damages. As suggested by Waller et al.8 in the late 1980s, the development of coronary stenosis proximal to the angioplasty site is multifactorial and may include intimal injury by the guiding catheters or guide wires, use of dilating balloons or a combinations of the previous especially in long-time and complicated interventions with prolonged guidewire and guide-catheter manipulation; retrograde extension of the fibrocellular response of the targeted lesion to an adjacent proximal coronary segment has also been considered. However, not widely appreciated as yet is which components of the PTCA equipment might be more significant in causing endothelial injury. Interestingly enough, LMCS is a well-known rare but severe complication which may follow the use of antegrade cardioplegia administered via direct ostial cannulation in cardiac surgery.9,10 This dismal occurrence may share a common mechanism of injury with what seen after percutaneous procedures. Acute injury after direct cannulation of the coronary ostia may lead to dissection of the LMC artery or intimal damage by mechanical injury. Indeed, most iatrogenic LMCS probably result from direct intimal damage, which induce secondary intimal hyperplasia by proliferation of vascular smooth cells due to the loss of the protective properties of the endothelium, particularly endothelium-derived nitric oxide, on smooth muscle cells proliferation and platelet

4 29 aggregation. Occlusion of the vasa vasorum by compression of the catheter may cause ischemia and necrosis of the intima and lead to secondary fibrotic healing. Rigid catheter may be more prone to cause this complication. Furthermore, genetic predisposition to the development of accelerated atherosclerosis may increase the susceptibility to mechanical injury induced by intracoronary catheters. In our experience, of all patients who received PTCA at the same cardiological unit (Interventional Cardiology Unit of the Rovigo General Hospital, Italy) over 3 years, 4% required surgery within a 9 to 27 months period for a new occurring LMCS. Since all the patients requiring surgery at the mentioned cardiology unit are referred to the Division of Cardiac Surgery of the University of Verona Medical School, and since no deaths occurred in the PTCA population during the study period, the reported incidence may well represent the actual occurrence of LMCS post PTCA, at least for the considered interventional cardiology unit experience. In our study population, 54% of the patients have had more than one PTCA prior to surgery, suggesting, quite intuitively, that the more the number of percutaneous procedure per patient the higher the probability to develop a LMCA stenosis in view of the repeated damage to the left main coronary. Although our study did not reach the statistical power to allow to define the individual impact of each device utilized, still the extraback-up catheters such as EBU or Left Amplatz shapes seem likely to cause a more severe damage to the left main ostium than catheter with smoother shape such as the XB-LAD, XB-LCx, or Left Judkins. Similarly, the use of multiple guidewire or kissing stent and kissing balloon appear likely to cause greater injury damage to the distal left main than simple techniques utilizing single wire and balloon. Atherectomy devices such as cutting balloons and rotablators, in view of their stiffness and large size may be particularly dangerous in respect to endothelial layer. Particularly in long-time and complicated PCIs with prolonged guide-wire and guide-catheter manipulation, LM damage should be carefully evaluated with IVUS at the end of the procedure and long-term with noninvasive imaging tools. As previously stated, patients with retrospective evidence of any LMCS on previous coronary angiographies preceding the percutaneous procedure were excluded from the study. Therefore we are unable to comment on the potential impact of PTCA on pre-existing subcritical lesion of the LMC artery. Nevertheless, it is conceivable that the burden of the left main plaque, as well as plaque morphology and instability before any percutaneous coronary intervention might play a fundamental role for the potential further development of a LMCS. 8,11 In this perspective, any left main plaque features should be carefully evaluated before deciding for a percutaneous interventions, taking into account the potential risk of a delayed clinically important complications. This study has several limitations. It is a retrospective observational study based on the assumption that the newly occurred LMCS developed as a consequence of the percutaneous procedures and related to intimal manipulation rather than to natural disease progression; furthermore, the study does not offer any figures on the counterpart represented by all those who underwent an uneventful intervention. It collected a relative small group of patients exposed to different procedures in term of interventional typology and operator expertise, thus limiting the potential for speculation. It also covers a quite limited period of time although representative of the last generation of available materials. Nevertheless, this study suggests that in this emancipated era of percutaneous coronary intervention, even simple procedures may still cause, although infrequently, delayed but potentially life-threatening complications such as severe LMCS, particularly when multiple percutaneous procedures have to be repeated in the same patient. This evidence may offer the rationale to schedule non-invasive imaging tests to monitor left main patency after the procedure, particularly when this had to be repeated in several instances, as well as fuel further research to develop less traumatic materials. The potential occurrence of severe LMCS after repeated PTCA should also be taken into account in the decision-making process about surgical alternatives. References 1. Wilson VE, Bates ER. Subacute bilateral coronary ostial stenoses following cardiac catheterization and PTCA. Cathet Cardiovasc Diagn 1991;23: Mishkel GJ, Marquis JF. Restenosis and accelerated left main coronary artery disease presenting six months after successful percutaneous transluminal coronary angioplasty. Can J Cardiol 1989;5: Wayne VS, Harper RW, Pitt A. Left main coronary artery stenosis after percutaneous transluminal coronary angioplasty. Am J Cardiol 1988;61: Hamad N, Pichard A, Oboler A, Lindsay J Jr. Left main coronary artery stenosis as a late complication of percutaneous transluminal coronary angioplasty. Am J Cardiol 1987;60: Bashour TT, Hanna ES, Edgett J,Geiger J. Iatrogenic left main coronary artery stenosis following PTCA or valve replacement. Clin Cardiol 1985;8: Rigatelli Gl, Rigatelli G. Coronary artery angiography in the interventional era: a combination of technological advancements and improved skill. Minerva Cardioangiol 2004;52: Rigatelli GI, Docali G, Rossi P, Rigatelli G. Changes in the way diagnostic coronary arteriography is performed due to the interventional prospect: the clinical impact. Int J Cardiovasc Imag 2004; 20: Waller BF, Pinkerton CA, Foster LN. Morphologic evidence of

5 30 accelerated left main coronary artery stenosis: a late complication of percutaneous transluminal balloon angioplasty of the proximal left anterior descending coronary artery. J Am Coll Cardiol. 1987;9: Pillai JB, Pillay TM, Ahmad J. Coronary ostial stenosis after aortic valve replacement, revisited. Ann Thorac Surg 2004; Winkelmann BR, Ihnken K, Beyersdorf F, et al. Left main coronary artery stenosis after aortic valve replacement: genetic disposition for accelerated arteriosclerosis after injury of the intact human coronary artery? Coron Artery Dis 1993;7: Haraphongse M, Rossall RE. Subacute left main coronary stenosis following percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn. 1987;13:401-4.