Coronary Artery Bypass Grafting in Patients with Intracoronary Stent Related Complications

Abstract

IntroductionThere has been a change lately in the way we help patients with coronary artery disease. Cardiologists are becoming more aggressive with percutaneous coronary artery interventions. Now multiple, complex, diffuse and smaller coronary vessels are being stented. As a result the surgeons are being referred patients with extensive, diffuse vessels for coronary artery bypass grafting (CABG). Increasing stent insertion is also resulting in more procedure related complications like undeployed or improperly deployed stents. Furthermore complications resulting from the natural progression of coronary artery disease such as stenosis before, within and after the stent are increasing. These are putting forward new set of challenges in front of the surgeon wishing to help the patients with CABG.We present our experience with two different cases. One represents complications due to natural progression of atherosclerosis and the other an example of procedural problems. Case Summary Case 1:A fifty four year old hypertensive, diabetic and dyslipidaemic gentle man was admitted to the coronary care unit (CCU) of our hospital on 26.08.06. He complained of sudden severe compressive chest pain without any radiation and associated with severe sweating for the last one hour. This patient also gave a history of anterior myocardial infarction (MI) in 2003. During that episode he was thrombolysed in another hospital followed by per cutaneous intervention (PCI) to the left anterior descending (LAD) artery in our hospital. Two stents were implanted in tandem at the time. However the patient had lost all documentations from that admission. The patient was stabilized as per established medical management protocols including thrombolysis. Thereafter a repeat coronary angiogram (CAG) was done on 30.08.06. There was also an osteal stenosis of the large diagonal (Fig 1 &2) This showed in stent restenosis along the entire length of the implanted stents. The patient continued to have intermittent chest pain at rest with ECG changes despite maximum medical management. The patient was discussed between the cardiologists and the surgeons and it was decided to graft the distal LAD and the large diagonal with a view to relieve the symptoms. Echo study showed apex dyskinetic, basal and mid portion of anterior septum severely hypokinetic, diastolic dysfunction grade II, Ejection Fraction (EF) 40%. Coronary Artery Bypass Grafting in Patients withThe patient was taken to the operating room (OR) on 07.09.06. Under general anaesthesia the heart was approached via a median sternotomy. The patient was attached to the heart lung machine using routine aortic and two stage single venous cannulation. On bypass the patient was cooled down to 28 degree Celsius, aorta cross clamped and the heart was arrested with antegrade cold blood cardioplegia. On palpating the LAD we found to our horror that the stents extended to cover most of the length of the vessel. The short distal segment that was free of stents lumen not accepting a 1.0 mm metal probe. We realize...