Cutting balloon and stenting of a stenosis at the origin of the left internal thoracic artery

Abstract

Catheterization was performed in a 58-yearold female with chest pain, which exposed a high-grade stenosis of the ostium of the left internal thoracic artery. Bypass had been completed three years earlier. Successful percutaneous intervention was performed utilizing a cutting balloon and a stent. Brief Clinical HistoryA 58-year-old woman underwent coronary artery bypass surgery three years prior to presentation for chest pain. Three native vessels were bypassed (left internal thoracic to left anterior descending, saphenous vein to second obtuse marginal, and saphenous vein to right coronary artery). Additional medical history included an abdominal aortic endarterectomy (eight years before presentation), peripheral arterial disease with intermittent right leg claudication, a remote history of myocardial infarction, hypertension, and type II diabetes mellitus. She was a reformed smoker with a thirty pack-year history having quit six years before presentation.Approximately one week before presentation she was awakened from sleep by retrosternal chest heaviness. Over subsequent days she noticed recurrence of the chest pressure with activity. She eventually sought care at a community hospital and was admitted with unstable angina. Vitals were as follows; BP 146/66, HR 72, RR 20, height 62 inches, weight 71 kg. She was without jugular venous dilatation. No carotid bruit was auscultated. The heart was regular with normal first and second heart sounds. No murmur was noted. Pulmonary and abdominal examinations were normal. Distal pulses in the upper extremities and left lower extremity were normal; however distal pulses were diminished in the right lower extremity in the femoral, posterior tibial, and dorsalis pedis arteries. A resting ECG was obtained in normal sinus rhythm. Laterally, non-specific T wave abnormalities were noted. A dual-isotope adenosine SPECT study was performed. Post-adenosine images exhibited a large, reversible anteroapical defect. Diagnostic and Interventional CatheterizationCoronary angiography was performed via the left common femoral artery using 6F diagnostic catheters (JL4, JR4). The left femoral site was selected due to the patient's history of intermittent claudication on the right. All native coronary vessels were chronically totally occluded. The venous grafts (to OM2 and the RCA) were widely patent. The left internal thoracic graft was sub-selectively injected. A 99% occlusion of the ostium of the internal thoracic vessel was noted ( Figure 1). Semi-selective injections were then performed to avoid catheter damping. Injections of nitroglycerine were done to differentiate spasm from true stenosis, and no changes were observed. The vessel was free of any luminal narrowing distal to the ostium. Additionally, no anastamotic lesion was seen. A left ventriculogram was performed which showed mildly impaired LV systolic function with apical dyskinesis and an overall ejection fraction of 45%.Percutaneous intervention was performed the following day. The left groin was selected because of the dimini...