Abbreviations
CAD, Coronary artery disease
LAD, Left anterior descending
LDL, Low-density lipoprotein
LIMA, Left internal mammary artery
POBA, Plain old balloon angioplasty
RCA, Right coronary artery
INTRODUCTION
A diffusely diseased coronary artery is defined as a consecutive atherosclerotic lesion in the coronary territory and a challenging clinical problem due to the high risk of recurrence after percutaneous coronary intervention (PCI). It usually occurs in patients with diabetes, hyperlipidemia, chronic kidney disease, connective tissue disease, heart transplantation, and multiple stenting of the coronary arteries.1 Diffusely diseased coronary artery disease (CAD) is a common cause of angina, myocardial infarction, and heart failure, and it is associated with high morbidity and mortality. Several methods of coronary artery bypass surgery have been postulated, including jumping bypass or sequential bypass techniques, long segmental or patch-plasty anastomosis, depending on the quality of the coronary vasculature.2 However, these procedures may also increase operative time and risk of complications. We present a case of a diffusely diseased left anterior descending (LAD) coronary artery that underwent long segmental anastomosis of LAD coronary artery.
CASE REPORT
A 68-year-old man with a history of coronary artery disease after stenting of the LAD was admitted to our department due to chest tightness and exertional dyspnea. Coronary angiography demonstrated significant stenosis, measuring up to 90%, in multiple segmental lesions of the LAD extending from the proximal to the middle portion (Figure 1), in-stent restenosis of the LAD, and total occlusion of the right coronary artery (RCA). Cardiac enzyme levels were within the normal range. Echocardiography revealed decreased left ventricular compliance and hypokinesia of the basal septum (ejection fraction, 50%).
Figure 1.
Coronary angiography demonstrated significant stenosis, measuring up to 90%, in multiple segmental lesions of the left anterior descending artery (LAD) extending from the proximal to the middle portion.
The patient underwent surgery. We harvested the left internal mammary artery (LIMA) and initiated a cardiopulmonary bypass. After cardiac arrest, the middle segment of the LAD was carefully incised to expose the atheromatous core and intact intima. The fit length of the LIMA was designed and anastomosed to the opened LAD (approximately 4 cm) well (Figures 2A and 2B). The RCA was also bypassed by the greater saphenous vein. We closed the sternum with a stainless-steel wire and wound layer by layer. The aortic cross-clamping and cardiopulmonary bypass times were 54 and 91 minutes, respectively. The postoperative flow and pulsatility index in the LIMA to LAD were measured at 87 mL/min and 2.2, respectively. The patient was transferred to the intensive care unit on the day of surgery. Dual antiplatelet therapy was administered, and the patient was weaned from ventilator on postoperative day one. The patient was discharged on postoperative day 16 and had no angina during outpatient department follow-up. The IRB/ERB number is A202215025 (February 22, 2022).
Figure 2.
(A) The middle segment of the left anterior descending (LAD) was incised carefully to exposure the atheromatous core and intact intima. (B) The fit length of the left internal mammary artery (LIMA) was designed and anastomosed to the opened LAD (approximately 4 cm) well.
DISCUSSION
To date, the progression of diffuse atherosclerosis may be reticent in the LAD territory due to long-term myocardial ischemia. Once acute coronary syndrome occurs, aggressive interventions are needed to achieve complete revascularization of the multi-stenotic LAD coronary artery. The jumping bypass technique and sequential bypass technique with LIMA-LAD bypass have been reported to be feasible for severe calcification of the ascending aorta and multiple-lesion LAD coronary artery.3,4 However, for a single multisegmented-stenosis coronary artery, an insufficient area of anastomotic incision might be provided by a jumping bypass or sequential bypass technique for adequate revascularization of the target lesion. Thus, arteriotomy must be extended (more than four centimeters) to obtain an appropriate lumen size and anastomosis area. Long-segmental reconstruction of the LAD coronary artery was developed and used for revascularization of segmental lesions without requiring second graft.5 The procedure for long segmental reconstruction of the LAD coronary artery was as follows: LAD arteriotomy was performed in the middle portion of the LAD coronary artery and then extended proximally and distally. The proximal severe stenosis was not bypassed to avoid competition flow. Moreover, the LAD incision must be extended as much as possible to the relatively healthy segment distally. The atheromatous plaque was then removed. Then, a matched-length LIMA conduit was attached and sutured to the LAD incision site using 7-0 or 8-0 polypropylene. Patients who underwent long segmental reconstruction of LAD coronary artery had no new electrocardiographic changes postoperatively, postoperative myocardial infarction, or hospital readmission rate.5 Extensive endarterectomy plays an important role based on conduit feasibility and arteriotomy location. Patients undergoing coronary artery endarterectomy benefit from actual survival and were free from death or cardiac events.6 However, aggressive endarterectomy might also induce endothelial injury and trigger a coagulation cascade, leading to postoperative myocardial infarction.7 Higher mid-term LIMA graft failure was observed in patients who underwent concomitant LAD endarterectomy with long segmental reconstruction.8 Nonetheless, the benefits of long segmental reconstruction of LAD with concomitant endarterectomy remain controversial. Favorable early- and mid-term angiographic patency rates were noted in patients who underwent concomitant LAD endarterectomy with long segmental reconstruction. It has also been suggested to occur in severely calcified coronary branches. Due to diffuse atheromatous plaques and calcification, endarterectomy might be an option for complete revascularization.9 Further research is needed to elucidate the long-term angiographic patency rates and major cardiovascular adverse events associated with concomitant LAD endarterectomy with long segmental reconstruction.
Minimally invasive bypass surgery combined with percutaneous transluminal coronary angiography is also an option to revascularize all areas of the coronary arteries and conglomerate the advantages of both procedures, including excellent long-term cardiac-event-free survival, short length of hospitalization, and fast recovery.10
Diffusely diseased CAD is a difficult and challenging clinical problem that needs a inclusive method to diagnosis and management. Advances in noninvasive imaging techniques and invasive diagnostic procedures have upgraded our capability to diagnose patients with diffusely diseased CAD. The best treatment strategy for diffusely diseased CAD remains controversial, but medical therapy, PCI, and coronary artery bypass graft all have significant roles in the management of this disease. A multidisciplinary approach, involving cardiologists, cardiac surgeons, and other healthcare professionals, is important for the management of patients with diffusely diseased CAD.
NEW KNOWLEDGE GAINED
As a prevalent cardiovascular disease, diffusely diseased coronary artery is an important issue for interventional cardiologists and surgeons. Advanced surgical techniques such as long-segment anastomosis are required for complete revascularization. However, the long-term outcomes should be evaluated in future research.
DECLARATION OF CONFLICT OF INTEREST
The authors declare no conflict of interest.
DISCLOSURE STATEMENT
The authors disclose no financial support.
FUNDING STATEMENT
There is no funding in our research.
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