Percutaneous management of ostial stenosis of the left internal mammary artery graft

Percutaneous management of ostial stenosis of the left internal mammary artery graft A 61-year-old man, who had undergone coronary artery bypass surgery 10 years earlier, presented with a non-ST segment elevation myocardial infarction. He was treated with medical therapy and taken to the Cardiac Catheterization Laboratory. A left heart catheterization demonstrated an ostial stenosis in the left internal mammary artery graft, which was felt to be the culprit lesion. This was successfully repaired with a drug eluting stent. This case is presented as an unusual location for a de novo coronary stenosis. The pathophysiology of these lesions is not well understood. stenting for right internal mammary artery and LIMA, it INTRODUCTION remains rare [3, 6, 7]. When performing coronary artery bypass surgery, the left internal mammary artery (LIMA) remains the favored graft for anastomosis to the left anterior descending artery (LAD) [1]. CASE REPORT Lower incidences of atherosclerotic disease as well as better long term patency rates of the left internal mammary artery A 61-year-old male with a history of hypertension, hyperlipid- compared with vein grafts make it the artery of choice [1]. emia, active smoking and coronary artery bypass grafting Interestingly, in the rare case that arteriosclerosis develops in (CABG) 10 years prior was admitted to the hospital with sub- this conduit, it almost always occurs either in the body of the sternal chest pain. In the past, his left heart catheterization vessel or at the distal site of anastomosis. These lesions are had revealed multi-vessel coronary artery disease for which commonly repaired percutaneously [2–4]. However, ostial revascularization was accomplished via a left internal mam- lesions in the internal mammary artery are not well reported mary graft to the LAD artery (LIMA to LAD), saphenous vein and the pathophysiology is not well known. Therefore, man- graft to the obtuse marginal (SVG to OM), and saphenous vein agement becomes more challenging. It has been suggested that graft to the right coronary artery (SVG to RCA). He had not prior catheterization procedures may contribute to vascular experienced angina since the CABG until now. Upon presenta- trauma and subsequent predisposition to stenosis in this area tion for the current admission, his vital signs were significant [5]. While there are case reports of successful angioplasty and for an elevated blood pressure to 203/91, but no signs of cardiac Received: July 21, 2017. Revised: September 24, 2017. Accepted: October 29, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018 22 T. Datta et al. Figure 1: electrocardiogram demonstrating sinus rhythm with left ventricular hypertrophy and a marked repolarization abnormality Figure 2: stenosis at the ostium of the left internal mammary artery (arrow) Figure 3: deployment of stent decompensation. Laboratory findings were significant for a tropo- nin I that peaked at 29.6 (NG/ML). His electrocardiogram demon- with diffuse significant luminal narrowing, the SVG to Ramus strated sinus rhythm with left ventricular hypertrophy and a and OM was patent, there was retrograde filling of distal LCx marked repolarization abnormality (Fig. 1). Based on these find- and the SVG to RCA was occluded. There was no deep engage- ings, he was treated as a non-ST segment elevation myocardial ment of the catheter during the index coronary angiography. infarction with Aspirin (325 mg), Lisinopril (10 mg), Carvedilol Intravascular ultrasound (IVUS) exam of the ostium of LIMA (6.25 mg twice a day), Simvastatin (80 mg), Clopidogrel (600 mg) revealed a bulky plaque in the ostium with minimal diameter and intravenous unfractionated Heparin. He was then taken to of 1mm. A DES was then deployed in the ostium of LIMA (Fig. the catheterization lab the next morning. Coronary angiog- 3) and post-dilated successfully (Fig. 4). Final angiogram raphy revealed an ostial 70% stenosis in the LIMA and a showed no edge dissection, distal embolization or perforation. chronic total occlusion of the LAD after the anastomosis which The rest of his hospital course was uneventful and he was dis- reconstituted via septal collaterals (Fig. 2). The rest of his charged without any complications. Upon follow up 4 months native coronary arteries and grafts were reported as the fol- after discharge, the patient was reported to be free of angina lowing: the left main was occluded, the RCA was small caliber and doing well from the cardiac standpoint. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Percutaneous management of ostial stenosis 23 CONFLICT OF INTEREST STATEMENT No conflicts of interest. FUNDING No funding was required. ETHICAL APPROVAL No ethical approval was required. CONSENT We obtained patient informed consent for the presentation of this case. GUARANTOR Tanuka Datta is the guarantor of this article. Figure 4: widely patent lumen after stenting REFERENCES DISCUSSION 1. Cameron AA, Green GE, Brogno DA, Thornton J. Internal Percutaneous repair at the origin of the LIMA remains rarely thoracic artery grafts: 20-year clinical follow-up. J Am Coll reported [3]. The LIMA’s vessel anatomy makes it a good candi- Cardiol 1995;25:188–92. date for bypass grafting. Atheromatous lesions are unusual and 2. Bedogni F, La Vecchia L. Elective stenting of a de novo ostial when compared to saphenous vein grafts, patients who have lesion of the right internal mammary artery. Catheter undergone bypass with the LIMA have improved rates of Cardiovasc Diagn 1998;44:325–7. patency as well as survival [8]. Patency rates of LIMA grafts are 3. Almagor Y, Thomas J, Colombo A. Balloon expandable stent reported near 90–95% 10–15 years after CABG [9]. When implantation of a stenosis at the origin of the left internal mammary artery graft: a case report. Catheter Cardiovasc reported the majority of cases have described lesions that have occurred at sites that are distal rather than proximal. Diagn 1991;24:256–8. Pathogenesis of lesions that develop at the takeoff of the LIMA 4. Hearne SE, Davidson CJ, Zidar JP, Phillips HR, Stack RS, as in our patient is unclear. Mechanical manipulation plays a Sketch MH Jr. Internal mammary artery graft angioplasty: role in more immediate cases of stenosis formation, however acute and long-term outcome. Catheter Cardiovasc Diagn to what degree is not known [2, 10]. 1998;44:153–6. discussion 7-8. There is no data at this time to report the incidences of 5. Tantibhedhyangkul W, Laskey WK. An unusual case of left restenosis of this anatomical site, however ostial lesions are internal mammary artery ostial disease: clarifying role of best managed percutaneously [10]. A DES strategy is often intravascular ultrasound. Catheter Cardiovasc Interv 2002;55: elected in the repair process. This is in part due to the concept 369–72. of elastic recoil that occurs at ostial sites, including the LIMA. 6. Nguyen DQ, Bolman RM 3rd, Park SJ. Reoperative revascu- After balloon dilation, there is both immediate and delayed larization of a left internal mammary artery ostial stenosis. increased elastic recoil caused by the unique muscle layer dis- Ann Thorac Surg 2000;70:963–4. tribution of vessel in ostial regions. Compared to non-ostial 7. Vivekaphirat V, Yellen SF, Foschi A. Percutaneous trans- lesions, this increased recoil can increase the chance of a failed luminal angioplasty of a stenosis at the origin of the left intervention with coronary restenosis. Stents are effective in internal mammary artery graft: a case report. Catheter mitigating this elastic vessel recoil and therefore the interven- Cardiovasc Diagn 1988;15:176–8. tion of choice. The use of IVUS, as done in this case, is done pri- 8. Cron JP, Adolph WL, Alfandari JP, Baud F, Beuzelin JP, marily for optimization of the interventional technique (vessel Bonnemazou A, et al. [Left internal mammary artery. Choice sizing, stent sizing, diameter and length). IVUS can also influ- graft for coronary bypass]. Presse Med 1987;16:427–30. ence post dilation strategy and post-stenting to determine 9. Taggart DP. Current status of arterial grafts for coron- adequacy of stent deployment which includes lesion coverage, ary artery bypass grafting. Ann Cardiothorac Surg 2013;2: stent expansion and apposition as well as any edge injury. 427–30. More research is required to investigate etiology and pre- 10. Sketch MH, Jr., Quigley PJ, Perez JA, Davidson CJ, Muhlestein vention of stenosis at ostial sites. Our case serves to highlight JB, Herndon JE 2nd, et al. Angiographic follow-up after reporting of ostial stenosis of the LIMA as well as exemplify internal mammary artery graft angioplasty. Am J Cardiol successful stenting of this rare anatomical site of occlusion. 1992;70(3):401–3. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Oxford Medical Case Reports Oxford University Press

Percutaneous management of ostial stenosis of the left internal mammary artery graft

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Abstract

A 61-year-old man, who had undergone coronary artery bypass surgery 10 years earlier, presented with a non-ST segment elevation myocardial infarction. He was treated with medical therapy and taken to the Cardiac Catheterization Laboratory. A left heart catheterization demonstrated an ostial stenosis in the left internal mammary artery graft, which was felt to be the culprit lesion. This was successfully repaired with a drug eluting stent. This case is presented as an unusual location for a de novo coronary stenosis. The pathophysiology of these lesions is not well understood. stenting for right internal mammary artery and LIMA, it INTRODUCTION remains rare [3, 6, 7]. When performing coronary artery bypass surgery, the left internal mammary artery (LIMA) remains the favored graft for anastomosis to the left anterior descending artery (LAD) [1]. CASE REPORT Lower incidences of atherosclerotic disease as well as better long term patency rates of the left internal mammary artery A 61-year-old male with a history of hypertension, hyperlipid- compared with vein grafts make it the artery of choice [1]. emia, active smoking and coronary artery bypass grafting Interestingly, in the rare case that arteriosclerosis develops in (CABG) 10 years prior was admitted to the hospital with sub- this conduit, it almost always occurs either in the body of the sternal chest pain. In the past, his left heart catheterization vessel or at the distal site of anastomosis. These lesions are had revealed multi-vessel coronary artery disease for which commonly repaired percutaneously [2–4]. However, ostial revascularization was accomplished via a left internal mam- lesions in the internal mammary artery are not well reported mary graft to the LAD artery (LIMA to LAD), saphenous vein and the pathophysiology is not well known. Therefore, man- graft to the obtuse marginal (SVG to OM), and saphenous vein agement becomes more challenging. It has been suggested that graft to the right coronary artery (SVG to RCA). He had not prior catheterization procedures may contribute to vascular experienced angina since the CABG until now. Upon presenta- trauma and subsequent predisposition to stenosis in this area tion for the current admission, his vital signs were significant [5]. While there are case reports of successful angioplasty and for an elevated blood pressure to 203/91, but no signs of cardiac Received: July 21, 2017. Revised: September 24, 2017. Accepted: October 29, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018 22 T. Datta et al. Figure 1: electrocardiogram demonstrating sinus rhythm with left ventricular hypertrophy and a marked repolarization abnormality Figure 2: stenosis at the ostium of the left internal mammary artery (arrow) Figure 3: deployment of stent decompensation. Laboratory findings were significant for a tropo- nin I that peaked at 29.6 (NG/ML). His electrocardiogram demon- with diffuse significant luminal narrowing, the SVG to Ramus strated sinus rhythm with left ventricular hypertrophy and a and OM was patent, there was retrograde filling of distal LCx marked repolarization abnormality (Fig. 1). Based on these find- and the SVG to RCA was occluded. There was no deep engage- ings, he was treated as a non-ST segment elevation myocardial ment of the catheter during the index coronary angiography. infarction with Aspirin (325 mg), Lisinopril (10 mg), Carvedilol Intravascular ultrasound (IVUS) exam of the ostium of LIMA (6.25 mg twice a day), Simvastatin (80 mg), Clopidogrel (600 mg) revealed a bulky plaque in the ostium with minimal diameter and intravenous unfractionated Heparin. He was then taken to of 1mm. A DES was then deployed in the ostium of LIMA (Fig. the catheterization lab the next morning. Coronary angiog- 3) and post-dilated successfully (Fig. 4). Final angiogram raphy revealed an ostial 70% stenosis in the LIMA and a showed no edge dissection, distal embolization or perforation. chronic total occlusion of the LAD after the anastomosis which The rest of his hospital course was uneventful and he was dis- reconstituted via septal collaterals (Fig. 2). The rest of his charged without any complications. Upon follow up 4 months native coronary arteries and grafts were reported as the fol- after discharge, the patient was reported to be free of angina lowing: the left main was occluded, the RCA was small caliber and doing well from the cardiac standpoint. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Percutaneous management of ostial stenosis 23 CONFLICT OF INTEREST STATEMENT No conflicts of interest. FUNDING No funding was required. ETHICAL APPROVAL No ethical approval was required. CONSENT We obtained patient informed consent for the presentation of this case. GUARANTOR Tanuka Datta is the guarantor of this article. Figure 4: widely patent lumen after stenting REFERENCES DISCUSSION 1. Cameron AA, Green GE, Brogno DA, Thornton J. Internal Percutaneous repair at the origin of the LIMA remains rarely thoracic artery grafts: 20-year clinical follow-up. J Am Coll reported [3]. The LIMA’s vessel anatomy makes it a good candi- Cardiol 1995;25:188–92. date for bypass grafting. Atheromatous lesions are unusual and 2. Bedogni F, La Vecchia L. Elective stenting of a de novo ostial when compared to saphenous vein grafts, patients who have lesion of the right internal mammary artery. Catheter undergone bypass with the LIMA have improved rates of Cardiovasc Diagn 1998;44:325–7. patency as well as survival [8]. Patency rates of LIMA grafts are 3. Almagor Y, Thomas J, Colombo A. Balloon expandable stent reported near 90–95% 10–15 years after CABG [9]. When implantation of a stenosis at the origin of the left internal mammary artery graft: a case report. Catheter Cardiovasc reported the majority of cases have described lesions that have occurred at sites that are distal rather than proximal. Diagn 1991;24:256–8. Pathogenesis of lesions that develop at the takeoff of the LIMA 4. Hearne SE, Davidson CJ, Zidar JP, Phillips HR, Stack RS, as in our patient is unclear. Mechanical manipulation plays a Sketch MH Jr. Internal mammary artery graft angioplasty: role in more immediate cases of stenosis formation, however acute and long-term outcome. Catheter Cardiovasc Diagn to what degree is not known [2, 10]. 1998;44:153–6. discussion 7-8. There is no data at this time to report the incidences of 5. Tantibhedhyangkul W, Laskey WK. An unusual case of left restenosis of this anatomical site, however ostial lesions are internal mammary artery ostial disease: clarifying role of best managed percutaneously [10]. A DES strategy is often intravascular ultrasound. Catheter Cardiovasc Interv 2002;55: elected in the repair process. This is in part due to the concept 369–72. of elastic recoil that occurs at ostial sites, including the LIMA. 6. Nguyen DQ, Bolman RM 3rd, Park SJ. Reoperative revascu- After balloon dilation, there is both immediate and delayed larization of a left internal mammary artery ostial stenosis. increased elastic recoil caused by the unique muscle layer dis- Ann Thorac Surg 2000;70:963–4. tribution of vessel in ostial regions. Compared to non-ostial 7. Vivekaphirat V, Yellen SF, Foschi A. Percutaneous trans- lesions, this increased recoil can increase the chance of a failed luminal angioplasty of a stenosis at the origin of the left intervention with coronary restenosis. Stents are effective in internal mammary artery graft: a case report. Catheter mitigating this elastic vessel recoil and therefore the interven- Cardiovasc Diagn 1988;15:176–8. tion of choice. The use of IVUS, as done in this case, is done pri- 8. Cron JP, Adolph WL, Alfandari JP, Baud F, Beuzelin JP, marily for optimization of the interventional technique (vessel Bonnemazou A, et al. [Left internal mammary artery. Choice sizing, stent sizing, diameter and length). IVUS can also influ- graft for coronary bypass]. Presse Med 1987;16:427–30. ence post dilation strategy and post-stenting to determine 9. Taggart DP. Current status of arterial grafts for coron- adequacy of stent deployment which includes lesion coverage, ary artery bypass grafting. Ann Cardiothorac Surg 2013;2: stent expansion and apposition as well as any edge injury. 427–30. More research is required to investigate etiology and pre- 10. Sketch MH, Jr., Quigley PJ, Perez JA, Davidson CJ, Muhlestein vention of stenosis at ostial sites. Our case serves to highlight JB, Herndon JE 2nd, et al. Angiographic follow-up after reporting of ostial stenosis of the LIMA as well as exemplify internal mammary artery graft angioplasty. Am J Cardiol successful stenting of this rare anatomical site of occlusion. 1992;70(3):401–3. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx082/4812534 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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