Total occlusion at ostial Left internal mammary graft with successful angioplasty and longterm patency result

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1 DOI /s x ASEAN Heart Journal Vol. 22, no. 1, (2014) ISSN: Case Report Total occlusion at ostial Left internal mammary graft with successful angioplasty and longterm patency result Kitigon Vichairuangthum, MD, and Paiboon Chotenopratpat, MD Division of Cardiology, Department of Medicine, BMA Medical College and Vajira Hospital, Bangkok, Thailand The Aurthor(s) This article is published with open access by ASEAN Federation of Cardiology. CASE PRESENTATION The patient is a 62 year old male patient with underlying hypertension, diabetes, dyslipidemia and a history of triple vessel coronary artery disease post CABG (SVG graft to RCA, LIMA graft to LAD) 5 years ago. He smokes and consumes alcoholic drinks but does not have family history of cardiovascular disease. He has crescendo chest pain with unstable angina and near syncope. His EKG showed normal sinus rhythm with no significant ST- T change and no significant rise in cardiac enzymes (Tn T= 0.05 ng/ ml). Echocardiogram showed LVEF 46% with inferior and inferoseptal wall hypokinesia. Exercise stress test was positive with deep ST depression at low work load. Two days later he underwent coronary angiogram which showed patent Left Main coronary artery, total occlusion of proximal LAD, small non dominant LCX, diffuse 70-80% stenosis from proximal to distal RCA. The SVG to RCA graft was occluded. The LIMA to distal LAD is shown at Figure 1. The native RCA was pre dilated with Ryujin balloon (Terumo, Japan) 2.5 x 15 mm at 8, 10,12,15 atm from distal along to proximal part of RCA.and then stented with overlapping Excel stent (JW Medical System, Weihai, China) 3.0 x 28 mm up to 10 atm (distal RCA), Excel stent 3.5 x 28 mm up to 12 atm ( mid RCA) and Xience V stent (Abbott vascular,usa) 4.0 x 23 mm up to 10 atm (proximal RCA). After that, the lesions were post dilated with Hiryu balloon (Terumo,Japan) 4.5 x 10 mm up to 18 mm. The final result was good with TIMI III flow. A day after his discharge, patient experienced recurrent chest pain with NSTEMI (Tn T = 0.35 ng/ml), EKG show Q in II, III, avf,inverted T at lead V1-3. TARGET LESION An Angiogram revealed patent RCA stents. PCI to the CTO proximal LAD CTO lesion was attempted. (Figure 2) An AL1 catheter was engaged to LM. Runthrough NS hypercoat wire (Terumo, Japan) with microcatheter support using the antegrade approach. After multiple attempts we failed to advance the wire to the true lumen of mid part LAD, the strategy was changed to intervene upon LAD via the LIMA graft instead. After an angiogram of LIMA graft with IMA catheter (Medtronic,USA) we also found severe ostial LIMA graft 90-95% stenosis with total occlusion at proximal part of LIMA graft without seeing any flap or dissection area after checking with multiple views (Figure 4). Due to total occlusion of LIMA graft, the flow can t be seen so we used the surgical clip as a hint to advace wire, using Runthrough NS hyper coat wire along the clips to the distal part of the graft. Predilation was done with Ryujin balloon 1.5x 20 mm up to 6 atm at ostial and proximal part of LIMA graft. Xience V 2.75 x 23 mm stent was deployed up to 10 atm at ostial part of LIMA graft (Figure5A). The flow was still at TIMI I. Nitroglycerine 50 mcg intra coronary was given, but the distal flow still poor, so another Xience V 2.5 x 28 mm stent was deployed at proximal part of LIMA graft overlapped with the previous one (Figure 5B). The distal flow did not improve and remained at TIMI I. FINAL RESULT After nitroglycerine 100 mcg intracoronary was given. The final result was acceptable with TIMI II flow at the distal part of LIMA graft (Figure 6), the procedure was terminated with no immediately complication. The patient was discharged 3 days later with stable condition and underwent follow up at OPD with stable clinical. Two years later, he was admitted again with unstable angina. An Angiogram was done and it showed patent ostial LIMA graft stent (Figure 7). There was instent restenosis at the previous RCA stent and it was successfully resolved with PCI with Nobori 3.0 x 14 mm stent. DISCUSSION Although internal mammary artery grafts (IMA) have an excellent record of success and long term patency. 1 The majority of patients requiring intervention for LIMA graft problems have stenosis at the site of insertion into the native coronary artery, which can be treated by angioplasty with a high degree of procedural success. Lesions in the proximal vessel appearing soon after surgery may be caused by Correspondence to: Kitigon Vichairuangthum, MD Division of Cardiology, Department of Medicine, BMA Medical College and Vajira Hospital, Bangkok, Thailand. address neozz15@hotmail.com 116

2 ASEAN Heart Journal Vol. 22, no.1, (2014) kinking of the LIMA during surgical mobilization 2 or occasionally a surgical clip, 3 both of which may be treated by angioplasty. But in this particular case, the patient represented with a long, stenotic segment at the ostium and proximal segment of his LIMA graft, which is unusual. It is known that ostial LIMA is easy to manage with dissection induced by catheter sometimes with delayed presentation but in this case after diagnostic angiogram of LIMA graft, it was discovered that the catheter had accidentally slipped off from ostial LIMA, so the non-selective angiogram was checked before ending the procedure and we did not see any dissection area at osital LIMA (Figure 1 B). At the second procedure we found new lesion at ostial LIMA with total occlusion at proximal part. We did not see any dissection area or intimal flap so we thought that it should be the new lesion at ostial LIMA rather than delayed presentation of diagnostic catheter induced ostial dissection. A previous study of 288 patients treated with IMA PCI found lesions were ostial in 7%, mid-body in 33% and anastomotic in 60%. Treatment with stenting was very successful, with 96% angiographic success compared with 89% (p=0.04) for plain angioplasty. One-year restenosis rates for the three locations were 31%, 5% and 7%, respectively, for the ostial, body and anastamotic segments. 4 During PCI of a lesion in the LIMA graft, the wire can cause pseudoleison. As there was no flow through the LIMA, angiographic assessment of the angioplasty result was difficult. Sharma et al. suggest exchanging the angioplasty wire with a flexible-shaft transit catheter. Once the transit catheter was in place and the wire was removed, the LIMA assumed its normal tortuous contour, thus leading to resolution of the accordion effect of the vessel. Injection of contrast though the guide permitted visualization of the entire LIMA and allowed angiographic assessment of the angioplasty lesion site. 5 PCI of the IMA may be particularly challenging due to its extreme tortouosity, propensity of the IMA ostium to dissect, kink of the IMA on bends and difficulty in visualizing anastomotic lesions.the factor most commonly associated with unsuccessful IMA PCI is tortousity of the IMA. 6,7 The surgical clip can be as a hint like in this case. In this case we showed the view of the excellent long term patency of ostial LIMA grafts stent. CONFLICT OF INTEREST None Figure 1A. index angiogram of LIMA graft to LAD B Figure 1 A. Index angiogram of LIMA graft to LAD. B. non selective injection showing no diagnostic catheter induced dissection of the ostial LIMA graft. 117

3 .. non selective injection showing no diagnostic catheter ASEAN Heart Journal Vol. 22, no.1, (2014) induced dissection of the ostial LIMA graft. Figure 2 Initial coronary angiogram of native left coronary system A. Rt caudal view, B. Lt caudal view. Figure 2 Initial coronary angiogram of native left coronary system A Rt caudal view B Lt caudal view. Figure 3 Failed Attempt PCI of native LAD vessel. Figure 3 Failed Attempt PCI of nativ 118

4 Figure 3 Failed Attempt PCI of nativ ASEAN Heart Journal Vol. 22, no.1, (2014) Figure 3 Failed Attempt PCI of native LAD vessel. Angiogram Angiogram of LIMA.4 Figure Figure 4 Angiogram of LIMA. Figure 4 of LIMA. Figure 5 Attempt PCI of ostial LIMA graft and subsequent stenting A ostial stent B body stent. 119

5 . ASEAN Heart Journal Vol. 22, no.1, (2014) Figure 6 Figure 6 ic Acceptwas TIMI flowgiven. immediately after stenting and NTG ic was given. Figure 6 ic was given. Figure 7 Accept TIMI flow immediately after stenting and NTG ic was given. Figure 7 Two-year follow u 120

6 ASEAN Heart Journal Vol. 22, no.1, (2014) Open Access: This article is distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0) which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. REFERENCES 1. Tector AJ, Schmahl TM, Janson B, et al. The internal mammary artery graft: its longevity after coronary bypass. JAMA 1981;13: Rerkpattanapipat P, Ghassemi R, Ledley GS, et al. Use of stents to treat kinks causing obstruction in a left internal mammary artery graft. Cathet Cardiovasc Intervent 1999;46: Klein AL, Marquis JF, Higginson LA. Percutaneous transluminal angioplasty of a surgically obstructed left internal mammary artery graft. Cathet Cardiovasc Diagn 1988;14: Sharma AK, McGlynn S, Apple S, et al. Clinical outcomes following stent implantation in internal mammary artery grafts. Catheter Cardiovasc Interv 2003;59: Sharma S, Makkar RM. Percutaneous intervention of the LIMA: Tackling the Tortousity JIC 2003; 15: Kugelmass AD, Kim DS, Kuntz R et al, Endoluminal stenting of a subclavian artery stenosis to treat ischemia in the distribution of a patient left IMA graft, Cathet Cardiovasc Diagn 1994: 33: Singh M. Internal Mammary artery stenosis. In: Ellis S, Holmes Jr D (Eds) Strategic approaches in coronary interventions. Lippincott Williams Wilkins, Philadelphia, second edition.pp ,