Case Report
T H E R O L E O F S U R G E R Y I N I A T R O G E N I C D I S S E C T I O N D U R I N G I N - S T E N T R E S T E N O S I S T R E A T M E N T A l i C i v e l e k , M . D . * / T e k i n Y ı l d ı r ı m , M . D . * * / S e r d a r A k g ü n , M . D . * S e l i m İ s b i r , M . D . * / S i n a n A r s a n , M . D . * * * D e p a r t m e n t o f C a ıd io t h o r a c ic S u rg e ry , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is t a n b u l, T u rk e y . * * D e p a r t m e n t o t C a ıd io t h o r a c ic S u rg e ry , S c h o o l o f M e d ic in e , M a lte p e U n iv e rs ity , Is t a n b u l, T u rk e y . A B S T R A C TIn-stent re ste n o sis (IS R ) rem ains a challenging problem , and its optimal m anagem ent is still
u n kn o w n. Although redilatation has
predom inantly been used, unusual complication such a s coronary artery dissection may occur. T h is report d e s c rib e s s u c c e s s fu l su rg ical treatm ent of a se ve re coronary artey dissection in the left anterior descend ing coronary artery after attempting exim er la se r angioplasty for in-stent resten o sis.
K e y W o r d s : In-stent resten o sis, Coronary artery d issectio n , Su rg ical treatm ent.
I N T R O D U C T I O N
In tra co ro n a ry a rte ry ste nt p la ce m e n t is an effective treatm ent for patients with coronary artery d ise a se (1). H ow ever, angiographic and clinical re ste n o sis after stenting develops in 15% to 5 4 % of the c a s e s and constitutes a major limitation to the e ffe ctive n e ss of this technique (1 ,2 ). Optim al treatm ent of in-stent resteno sis
h a s not been d eterm ined so far. Balloon angioplasty, repeat stenting, directional coronary atherectom y, exim er laser angioplasty or high fre q u e n cy rotablation a re co n sid e re d as therapeutic options of choice at present (3). S e ve re coronary artery dissection is a rare but se rio u s com plication of th e se p e rcu tan e o u s interventions for the treatm ent of in-stent resten o sis (IS R ) (4). Here, we present a c a se of se ve re coronary artery dissection during exim er lase r angioplasty for the treatm et of IS R and su cc e ssfu l surgical treatment by long segm ent internal m am m ary artery b yp ass graft.
C A S E R E P O R T
A 37-year-old man w a s adm itted due to exertio nal ang in a for one m onth. C a rd ia c cath e te rizatio n d em o n strated n e arly a total occlusion of proximal left anterior descending (LA D ) coronary artery. S te n o sis w a s dilated by 2 .5 x 1 2 mm Jo m e d flex ste nt (JO M E D In tern ation al, H elsin g b o rg , G e rm a n y ) s u c c e s s fu lly . But his sym p to m s recurred 2 m onths after intraco ro n ary stent p lacem ent. Coronary angiography w a s repeated and 80%
Correspondence to: Ali Civelek, M.D, - Department ot Cardiothoracic Surgery, Marmara University Hospital, Aitunizade 81190, Istanbul, Turkey,
e mail address: alicivelek@turk.net
(Accepted 26 May, 2002)
Marmara Medical Journal 2002;15(3):183-185
AU Civelek, et al
stenosis in the stent w as detected. Exim er laser percutenous translum inal coronary angioplasty (P T C A ) w as planned to treat IS R . But during exim e r la se r ang io p lasty, se v e re co ro nary dissection developed (Fig 1). Guidew ire went forward to the ap e x in the fa lse lumen accidentally. Due to the extend of dissection and inability to move the guidewire back into the true lum en, the patient w a s referred for urgent surgery. During the operation, bluish hemorrhage and fresh thrombus w a s noted between intima and media of mid-distal LA D coronary artery. A large arteriotomy to the LA D up to the apex w as performed. Dissection w a s extended to the apex of the heart and there w ere three different fenestrations in the intima. A long segm ent
F i g . l s Beginnig point of dissection. Dissection extends to the apex of the LAD coronary artery.
F i g .2 : Postoperative angiogram shows good flow in both the internal mammary artery and the LAD coronary artery.
Internal m am m ary artery anastom osis to the LAD coronary stenting w as performed incorporating true and false lumina together a s patchplasty to reestablish flow in the true lum en. He w as d isch arg ed on the sixth post-operative day without any problem. A follow-up angiogram one month post-operatively dem onstrated good flow in the LAD coronary artery (Fig 2).
D I S C U S S I O N
IS R h as becom e a sig n ifican t problem for interventional card io lo g ists. Due to different pathogenic c a u se s it rem ains unclear w hether a uniform therap eutic regim en is appropriate. S e ve ral studies have shown variable results using balloon angioplasty alone, repeat stenting, directional athe recto m y, e xim e r la se r angioplasty, and, more recently, intracoronary radiation therapy (5-9). But it is still unclear which one, if any, will provide the most favorable outcome.
Redilatation has predominantly been used for the treatment of in-stent restenosis. H ow ever, in long and diffuse restenotic stents it is reported to be poor, and recurrent restenosis is likely (10). Any intervention has diverse complication such as coronary artery dissection, distal em bolisation, sm all perforation depending on the type of procedure (11). Cardiologists planned to perform exim er laser angioplasty to treat IS R in this c a se . But at the beginning of the procedure se vere iatrogenic co ro n ary d isse ctio n developed probably b ecau se of the nature of restenotic plaque. Postangioplasty dissections have been associated with acute ve sse l closure and are frequent ca u se for re-stent deploym ent, but se v e re d isse c tio n s can no t be m anaged interventionally. B e c a u se of the multiple intimai fenestrations, the guidewire may not go forward back into the true lumen which is essential to perform reintervention, a s in this ca se .
Surgery is generally accepted a s the last choice for the treatm ent of IS R . But patients who underwent coronary artery b yp ass graft ( C A B G ) surgery for the treatment of IS R had significantly better outcom es than those who underwent p ercu tan eo u s interventions (1 2 ). R e su lts of su rg ery for co m plication s of p e rcu tan e o u s interventions are also good. In this c a se quality of
