Left internal mammary artery graft perforation repair using polytetrafluoroethylene-covered stents

Abstract

The increase in the use of the left internal mammary artery (LIMA) as graft of choice to the left anterior descending coronary artery for conventional and minimally invasive coronary artery bypass surgery has led to an increased incidence of LIMA pathologic lesions early after surgery. The lesion, commonly located in the body of the LIMA graft, is usually caused by mechanical injury during harvesting of the vessel. In this context, percutaneous intervention with stent implantation can be complicated by vessel rupture, which usually requires emergency surgical repair. We describe two cases of stent implantation in newly placed LIMA grafts complicated by vessel rupture, which were successfully repaired using polytetrafluoroethylene-covered stents.

Modified dual guide catheter (“ping‐pong”) technique to treat left internal mammary artery graft perforation

“…The perforation was likely due to disrupting the suture. In the previous two reported cases successfully treated with a covered stent, the lesions were in the LIMA body and were also surgically induced with perforation related to traumatizing the surgically‐induced lesion by balloon distention . In the third reported case at the LIMA‐LAD anastomosis, the perforation also occurred in the early postoperative period, but due to its intra‐pericardial position produced cardiac tamponade, and was managed by surgical repair .…”

“…In this circumstance, most perforations are likely contained within an adherent pericardium. In fact, of the three previously reported perforations two occurred in the LIMA body . The lesions were likely due to surgical problems with clinical presentation shortly after bypass surgery.…”

“…The limitation of this approach is that even when exchanging the balloon catheter for the covered stent is rapid, a large amount of blood may be lost through the perforation site during catheter exchange. This point is emphasized in one of the two successfully treated cases who had 1500 ml of blood removed from the pleural space after the covered stent had been deployed . This technical issue has spawned the dual catheter or “ping‐pong” technique.…”

Collagen embolization for the successful treatment of a distal coronary artery perforation

“…The current nonsurgical treatment of a perforated coronary artery involves the use of prolonged balloon inflation including reversal of anticoagulation which in our case failed to seal the perforation. Other reported methods include the use of PTFE‐covered stent and the embolization of microcoils, gelfoam, and polyvinyl alcohol form [4–10]. Since the perforation occurred in a small vessel, the PTFE‐covered stent could not be used.…”

“…The most likely reason for this tendency include advances in technology as well as the improvement in PCI experience. The overall mortality remains quite high (approximately 17%) with different perforation grades [1] having different prognosis despite current treatment strategies including prolong balloon inflation, the implantation of polytetrafluoroethylene (PTFE)‐covered stents, embolization of microcoils, gelfoam and polyvinyl alcohol, and coronary artery bypass surgery [3–9]. In this report, we describe for the first time a CAP that was successfully managed by collagen embolization.…”