Abstract
Background
Hybrid revascularization is a less invasive approach to conventional open-chest coronary artery bypass graft surgery for patients with multivessel coronary arterial disease. However, this is infrequently performed because of technical demands, logistical challenges, and concerns for long-term vessel patency.
Case Summary
A 68-year-old man with a history of prostate cancer with bony metastasis presented with accelerated angina. Left heart catheterization revealed multivessel coronary disease. The patient underwent staged hybrid surgical and percutaneous revascularization treatment. Ultimately, the intervention was successful, and the patient had symptomatic relief with successful recovery to baseline function.
Discussion
This case provides insight into the efficacy and application of an individualized hybrid approach in a high-risk patient with comorbidities.
Take-Home Message
Hybrid revascularization is safe and can be considered on an individual basis for patients with complex medical comorbidities.
Key words: cancer, coronary artery bypass, myocardial revascularization
Graphical Abstract
history of presentation
A 68-year-old man with history of metastatic prostate cancer with bone involvement presented to our hospital with accelerating anginal symptoms for weeks requiring frequent nitroglycerin doses.
Take-Home Message
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•
Hybrid revascularization is safe and can be considered on an individual basis for patients with complex medical comorbidities.
Past Medical History
The patient was diagnosed with prostate cancer 6 years before admission that was complicated by bony metastasis including osseous lesions to the spine, sternum, and ribs (Supplemental Figure 1). He was treated with thoracic and lumbar spinal radiation, hormonal therapy, and chemotherapy. His cardiovascular history included hypertension and hyperlipidemia.
Investigations
The patient presented to the hospital for elective catheterization owing to accelerated angina. On presentation to the hospital, patient was afebrile, blood pressure was 189/89 mm Hg, pulse was 65 beats/min, respiration rate was 16 breaths/min, and SpO2 was 98% on room air. Physical examination was unremarkable with normal cardiopulmonary findings. Comprehensive metabolic panel, complete blood count with differential, lipid panel, and hemoglobin A1c levels were obtained. All laboratory values were within the patient's baseline. The electrocardiogram did not show acute ischemic changes (Figure 1). Computed tomography angiography of the chest, abdomen, and pelvis did not reveal acute abnormalities.
Figure 1.
Electrocardiogram on Hospital Admission
Left heart catheterization revealed severe 90% calcified distal left main (LM) trifurcation disease involving the ostium of the left anterior descending artery (LAD), the ramus artery, and the left circumflex artery (Figures 2A to 2C). It also showed severe diffuse calcified right coronary artery disease. A Cardiothoracic surgery was consulted for coronary artery bypass graft (CABG) surgery; however, the patient's known osseus sternal metastatic lesions placed him at a high risk of postoperative sternal healing issues, and he was deemed a prohibitive risk for traditional CABG surgery. Anatomically, the complexity of trifurcation calcified LM disease placed him at high risk of complications with percutaneous coronary intervention (PCI). After several discussions with the heart team, the decision was made to pursue a hybrid revascularization strategy.
Figure 2.
Initial Coronary Angiography
Initial coronary angiography of the left coronary system in anteroposterior caudal view (A), left anterior oblique caudal view (B), and the right coronary artery in left anterior oblique view (C).
Management
The patient was stabilized and eventually discharged on guideline-directed medical therapy for coronary artery disease and antianginal medications. He was subsequently referred to a center with extensive experience with mini-thoracotomy and off-pump left internal mammary artery-to-LAD revascularization and underwent off-pump robotic left internal mammary artery-to-LAD bypass via a left thoracotomy incision (Figure 3). On postoperative day 6 following bypass, he underwent a successful protected PCI of the LM bifurcation into the ramus artery and left circumflex artery using rotational atherectomy and a culotte 2-stent strategy at the same hospital (Figure 4). He had an uneventful postoperative course and was discharged on postoperative day 3 on dual antiplatelet therapy. Three months after the hybrid revascularization, he described a significant improvement in anginal symptoms but continued to have lifestyle-limiting dyspnea on exertion. He subsequently underwent PCI to the right coronary artery at the original referring hospital with lithotripsy and overlapping drug-eluting stents (Figure 5).
Figure 3.
Coronary Angiography of the Left Coronary System After Left Internal Mammary Artery to Left Anterior Descending Artery Bypass to Allow Protected Percutaneous Coronary Intervention
Figure 4.
Final Coronary Angiography After Protected Percutaneous Coronary Intervention to Left Main Bifurcation Into the Ramus Artery and Left Circumflex Artery
Figure 5.
Final Coronary Angiography After Staged Percutaneous Coronary Intervention to Right Coronary Artery
Outcome and Follow-Up
In outpatient follow-up 5 months later, the patient reported no anginal chest pain and had returned to normal daily activities. He continues to follow up with cardiology and oncology.
Discussion
This is the first report to our knowledge of a cancer patient with complex multivessel coronary disease and metastasis to the sternum precluding traditional CABG surgery. Because of his strong indication for revascularization and acceptable oncologic prognosis, the patient was offered a hybrid surgical and percutaneous revascularization approach.
Patients who undergo radiation therapy are at an increased risk of coronary artery disease owing to accelerated atherosclerosis.1 Acute coronary syndromes have been described in cancer patients and are managed preferentially with PCI. Data from the National Cardiovascular Data Registry CathPCI Registry suggests that 10% of PCIs are performed in patients who have a current diagnosis or history of malignancy.1 Importantly, PCI for cancer patients with acute coronary syndrome is a high-risk procedure owing to an increased risk of complications. Active malignancy within 12 months of PCI is considered a major bleeding risk and a strong independent predictor for death within 1 year of the PCI.1,2 Similarly, patients with cancer undergoing CABG surgery had increased bleeding and stroke risk.3 Patients with solid tumors undergoing CABG surgery have a higher 30-day mortality, but a similar long-term survival and recurrence of major adverse cardiovascular events.4
Despite the higher risk of complications and mortality owing to active malignancy, we chose to pursue hybrid coronary revascularization (HCR) owing to the anatomic complexity of the disease. In patients with distal LM bifurcation disease, as in our patient, CABG surgery is usually preferred to improve survival.5 However, patients with clinical frailty and anatomic chest wall abnormalities, such as occur post-radiation, may benefit from PCI. In addition, more recent data suggest noninferiority of PCI compared with CABG for LM disease.6 Thus, shared decision making and individualized planning of revascularization treatment should occur for patients with LM bifurcation disease. In this case, coordination between a center with expertise in minimally invasive off-pump surgery and the initial admitting hospital was required.
HCR is a less invasive approach that may be attractive in high-risk patients.7 Specifically, HCR is found to have lower in-hospital mortality, shorter intubation time, and shorter hospital stays compared with on-pump CABG, although with comparable survival and recurrence of major adverse cardiovascular events.8,9 Importantly, HCR demonstrates equivalent in-hospital mortality to PCI.10 Therefore, after a heart team discussion, HCR should be considered in patients with cancer and metastatic disease.
Conclusions
A 68-year-old patient with metastatic prostate cancer involving the sternum and multivessel complex coronary artery disease underwent a hybrid nonsternotomy revascularization approach. The strategy was successful with a short hospital stay and resulted in significant symptom relief. Our case provides important insights into the safety and success of a patient-centered approach to coronary revascularization.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For a supplemental figure, please see the online version of this paper.
Appendix
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References
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