Surgical removal of stent from multiply stented vessel: problem with choice of place for anasthomosis — one year follow-up

Abstract

Since the advent of percutaneous coronary intervention there have been increasing numbers of patients with so-called 'full metal jacket' coronary arteries disease. This is creating a challenging problem for the cardiac surgeon. A 73 year-old woman after the implantation of two metal stents to the left anterior descending artery (LAD) and four to the right coronary artery (RCA), with ejection fraction of 28%, significant mitral and tricuspid insufficiency, and high systolic pulmonary pressure, was admitted to our department with unstable angina and with symptoms of pulmonary oedema. Coronary angiogram revealed restenosis in all stents. She agreed to a coronary artery bypass graft (CABG) with mitral and tricuspid valve reconstruction. The RCA was opened just above the postero-lateral branch. Due to lack of space, the metal stent was removed and saphenous bypass graft performed.Six months later, control angiography showed a properly working LITA-LAD graft; the stents in the RCA had been occluded above anasthomosis and the venous graft to RCA had been stenosed. Percutaneous cardiac intervention was performed and the metal stent was implanted with good early effect. After a further six months, coronarography revealed in stent stenosis in the place of venous anasthomosis. The patient was qualified for conservative treatment. Long term results after such procedures are hard to predict;we believe patients should be qualified earlier for CABG and that doctors should avoid implanting too many stents into one artery.

Early Outcomes of Using Skeletonized Left Internal Mammary Artery (LIMA) for Sequential Grafting of Multiple Left Anterior Descending Artery Lesions

“…In addition, in some areas especially larger plaques, the surgeon have to insert the needle in LAD artery farther than the vessel free edge or even in some cases from the vessel base [30] . This caused a great volume of suture material being lodged in anastomosis area and leads to accelerated vessel occlusion.…”

Aortic valve replacement in patients with protruding coronary artery stents

“…During the surgery, one may try to remove the protruding stents in case they compromise the procedure. Although successful removal of stents from the coronary ostia has been reported previously [2], pulling the stent out of the coronary artery is likely to cause damage to the intima, and result in significant stenosis or even occlusion of the coronary artery. Therefore, we should keep stents intact whenever possible.…”

Coronary endarterectomy to facilitate bypass surgery for patients with extensive stenting of the left anterior descending artery

“…Procedural full metal jacket (FMJ) results in an increasing number of high-risk ‘stent-loaded’ patients who are referred to cardiac surgeon and complete revascularization cannot be achieved with the conventional technique 1 , 2 . The following report describes the technique used to allow en-block long-segment stent removal by coronary endarterectomy (CE) and left anterior descending (LAD) repair with left internal thoracic artery (LITA) graft.…”