Internal mammary revascularization in patients with variant angina and normal coronary arteries

Abstract

Patients with variant angina refractory to medical therapy pose a difficult management problem. In patients with discrete obstructive lesions, coronary revascularization may be helpful. However, it has been widely accepted that coronary revascularization is contraindicated in patients with isolated coronary spasm without evidence of obstructive disease. Here we describe the two patients with life-threatening, medically intractable Prinzmetal's angina and angiographically normal coronary arteries, both of whom underwent coronary-artery-bypass surgery with the internal-mammary-artery (IMA) graft. These operations resulted in rapid, complete remission of coronary spastic attacks in both patients. Postoperative angiography reveals how the IMA graft works during spastic attacks.

Coronary Artery Spasm

“…12 Coronary angioplasty performed in CAS patients produced results similar to those without variant angina. 13 Life-threatening ventricular arrhythmias in CAS were the reason for automatic defibrillator implantation 14 (Table 3).…”

Variations in presentation and various options in management of variant angina

“…Ono et al [55], on the other hand, have reported extremely good clinical results with a pedicled in situ internal mammary artery graft in two patients with intractable variant angina refractory to medical management. Both patients had isolated coronary artery spasm on angiography.…”

“…Atherosclerotic disease affecting large coronary arteries altered their vasomotor tone and reactivity [9,31,[52][53][54][55]. There was an intimate association of spasm with sites of organic stenosis.…”

“…Reported outcome of coronary artery bypass grafting (CABG) have ranged from disappointing [12,30,42,43,193] to gratifying [3,39,43,55,143,194]. These wide variations in results were partly because of the wide spectrum of angiographic findings in this disease ranging from nearly normal to severely stenosed vessels [41].…”

Treatment of Coronary Spastic Angina, Particularly Medically Refractory Coronary Spasm

“…Recent studies have reported new cases of coronary spasm following implantation of a drug-eluting stent (69,70); thus, coronary stents should be selected very carefully for patients with CSA. Furthermore, there are two reported cases of medically refractory CSA without signifi cant coronary stenosis who underwent coronary aorta bypass grafting (CABG) with the internal mammary artery (66). The postoperative course was uneventful, but spasticity remained in the other vessels (20).…”