Coronary Revascularization following Failed Multiple Percutaneous Coronary Intravascular Stents

V. Bharath; Milind Hote

doi:10.25259/JCCC_35_2024

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Case Series

Cardiac Critical Care

8 (

); 223-225

doi:

10.25259/JCCC_35_2024

Coronary Revascularization following Failed Multiple Percutaneous Coronary Intravascular Stents

V. Bharath^1,, Milind Hote¹

1Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

*Corresponding author: V. Bharath, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India. drbharathv@gmail.com

Received: 2024-07-20, Accepted: 2024-09-04, Published: 2024-10-24

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Bharath V, Hote M. Coronary Revascularization following Failed Multiple Percutaneous Coronary Intravascular Stents. J Card Crit Care TSS. 2024;8:223-5. doi: 10.25259/JCCC_35_2024

Abstract

Multiple blocked percutaneous coronary intervention (PCI) stents pose a significant challenge while planning coronary artery bypass grafting (CABG). In most cases, a suitable target site for distal graft anastomosis is difficult to obtain. In this technically challenging case report, we discuss a case of a 40-year-old male presenting with recurrent angina due to blocked multiple PCI stents in the left anterior descending (LAD) vessel. He underwent CABG in which, due to the non-availability of a suitable target site in LAD, the previous stents in LAD had to be excised along with intima and bypass grafting performed by implanting long segment vein patch over the endarterectomized LAD and left internal mammary artery anastomosed over the vein patch. The post-operative course was uneventful. The patient was extubated on post-operative day (POD) 1 and shifted out of the intensive care unit on POD3. He was discharged in stable condition on POD5. In cases where CABG needs to be performed following multiple failed PCI stents, the option of stent excision along with CABG is a safe option with good short-term results.

Keywords

Blocked stents

Coronary artery bypass grafting

Revascularization

Endarterectomy

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INTRODUCTION

Multiple blocked Percutaneous Coronary Intervention (PCI) stents pose a significant challenge while planning Coronary Artery Bypass Grafting (CABG). In most cases, a suitable target site for distal graft anastomosis is difficult to obtain.

CASE REPORT

In this technically challenging case report, we discuss a case of 40-year aged Indian male nonhypertensive, non-diabetic with a smoking history of 10 years. He presented to us with recurrent chest pain for 6 months. He had previously undergone percutaneous coronary intervention (PCI) with multiple stent placements (drug eluting stents) in the left anterior descending (LAD) artery twice, around 6 months and 1 year ago. On evaluation, coronary angiography showed all stents blocked in the LAD vessel due to in-stent restenosis (ISR). Hence, after obtaining informed consent, he was taken up for coronary artery bypass grafting (CABG) surgery.

During the procedure, there was no suitable target site in LAD for grafting. Stents were densely adherent to LAD intima. Hence, it had to be excised along with LAD intima [Figure 1]. Bypass grafting was performed by implanting a long segment vein patch over the endarterectomized LAD [Figure 2], and the left internal mammary artery was anastomosed over the vein patch.

Stent being removed from the left anterior descending along with vessel intima.

Vein patch being sutured over left anterior descending.

Post-operative course was uneventful. The patient was extubated on post-operative day (POD) 1 and shifted out of the intensive care unit on POD3. He was discharged in stable condition on POD 5 with low-dose warfarin therapy along with routine post-CABG medications.

DISCUSSION

Multiple failed PCI stents due to ISR pose a significant challenge during surgical coronary revascularization.^[1] Repeat PCI is not feasible due to previously performed PCI procedures. In such cases, before CABG is contemplated, various techniques like scoring balloon angioplasty can be performed. Furthermore, ablative procedures like excimer laser coronary atherectomy or rotational atherectomy with intravascular lithotripsy can also be considered. Long-term results are also not good with repeat PCI in cases with ISR in multiple stents. Surgical revascularization with CABG remains the ideal choice in such cases.^[2] Few case reports have demonstrated good results with CABG in such case scenarios.^[3,4] During CABG, the majority of the patients would require endarterectomy due to the densely adhered stents on vessel intima.^[5-9] Endarterectomy needs to be performed with utmost care as the posterior wall of coronary artery may be injured in endarterectomy cases.^[5]

CONCLUSION

In cases where CABG needs to be performed following multiple failed PCI stents, the option of stent excision along with CABG is a safe option with good short-term results. Further studies are required for ascertain long-term outcomes.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Financial support and sponsorship

Nil.

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