Successful hybrid treatment with endovascular aorto-iliac revascularization and coronary bypass surgery in a patient with an advanced complex polyvascular disease

Abstract

A 72-year-old Japanese man was admitted to our hospital for effort chest pain and bilateral claudication. He was diagnosed as having severe ischemic heart disease and chronic bilateral aorto-iliac occlusions (Leriche syndrome) by a diagnostic angiography. Manifest collaterals via bilateral internal thoracic arteries (ITA) supplied sufficient blood flow for his lower limbs. We planned a two-stage operation for both the severe coronary artery disease and peripheral artery occlusive disease. He first underwent endovascular therapy (EVT) for bilateral aorto-iliac occlusion. One month later he underwent coronary artery bypass grafting (CABG) that was carried out for three coronary arteries with bilateral ITAs, also known as the internal thoracic artery, and the gastroepiploic artery. His chest symptoms and claudication were completely relieved and he was discharged uneventfully. We hereby suggest that EVT can be a safe, effective, and minimally invasive treatment to enable the patient to undergo CABG with all arterial grafts.

<Learning objective: Patients with polyvascular disease are at a high risk for major vascular events. The priority among the revascularizations should be considered based on the less-invasiveness and better long-term patency. Hybrid treatment of EVT and CABG could be one of the choices among such patients.>

Introduction

Leriche syndrome in patients with complex coronary artery disease deemed them to be unfavorable candidates for surgical treatment. Minimally invasive endovascular angioplasty and percutaneous coronary intervention (PCI) should be considered as an alternative to surgery. Although the usefulness of the latest strategy for complex PCI has been indicated, that of coronary artery bypass grafting (CABG) for some lesion forms and patient backgrounds has also been firmly established. In CABG procedures, the use of the ITAs has been demonstrated to provide better long-term patency and survival rates [1]. However, in Leriche syndrome, the ITA sometimes supplies the collateral blood flow through the inferior epigastric artery (IEA), and cannot be used for a graft conduit for CABG [2], [3]. It was demonstrated that the procedural success rate and long-term patency of endovascular therapy (EVT) was non-inferior to those of surgical bypass surgeries, including the non-anatomical bypass operation in patients with aorto-iliac occlusive disease [4], [5], [6], [7]. It has been thought that the use of the ITA for CABG could be possible once after resolving the iliac artery occlusion by EVT. Here we describe the case of a patient with advanced complex polyvascular disease in whom hybrid treatment with endovascular aorto-iliac revascularization and CABG surgery was successful.

Case report

A 72-year-old man was admitted due to angina pectoris and bilateral claudication. Myocardial perfusion scintigraphy using (Tl-201thallium) showed significant myocardial ischemia, and his ankle-brachial index values had declined to 0.53 (right) and 0.51 (left). It suggested the presence of severe peripheral artery occlusive disease. His history included diabetes mellitus treatment and bilateral carotid stenosis. Contrast-enhanced computed tomography (CT) showed total occlusion of the infra-renal abdominal aorta and bilateral common iliac arteries (Fig. 1A, B), indicating Leriche syndrome. Both femoral arteries were perfused via the IEA from bilateral ITAs (Fig. 1C, D).

Fig. 1.

Contrast-enhancement on computed tomography (CT) (A, right side; B, left side) in the common iliac arteries. Three-dimensional CT angiography (C, D) showing aortobiliac occlusion with collaterals to the lower extremities (arrows).

Catheter-based coronary angiography was carried out, and it revealed that the patient had severe coronary artery disease (CAD) (left main coronary artery stenosis with multivessel coronary artery disease). He had 90% stenosis of the right coronary artery (RCA), 90% stenosis of the left main trunk, 75% stenosis of the left anterior descending artery (LAD), and 90% stenosis of the left circumflex artery (LCX). Both the ITAs and IEAs were good collaterals to the lower extremities. The SYNTAX score of his coronary artery was 40 points from the results of angiography. We diagnosed severe ischemic heart disease and Leriche syndrome.

The anatomy and morphology of his CAD indicated that he was an unfavorable candidate for PCI, and we sent him for CABG. However, due to the risk of limb-threatening ischemia, we could not use the bilateral ITAs for bypass conduits. We planned a two-stage revascularization for both the severe CAD and peripheral artery occlusive disease.

We first administered EVT for the aorto-iliac occlusion to enable the CABG using bilateral ITAs.

EVT for Leriche syndrome

Since a long segment occlusion of aorto-iliac disease seems to be at high risk for vessel perforation, the intravascular ultrasound (IVUS) imaging could be a powerful solution to optimize the route of the guidewire and the device sizing. A bidirectional approach for the occluded segment could also be one of the solutions to enable the safe and successful guidewire-crossing, therefore we made punctures to provide three access sites for this patient, at the bilateral femoral arteries and a left brachial artery.

Along with local anesthesia and oral diazepam, heparin was administered intra-arterially at 5000 IU after the insertion of a 90-cm length 4.5 Fr guiding sheath (Parent Plus45 PTRA, MediKit, Tokyo, Japan) from his left brachial artery. Abdominal aortography was performed using a 4 Fr pigtail catheter and the finding showed the complete occlusion of the terminal abdominal aorta.

After the insertion of 9 Fr sheaths with a balloon catheter-based embolic protection (Optimo Temporary Occlusion Balloon, Tokai Medical Products, Aichi, Japan) to prevent peripheral thrombo-embolism to superficial femoral arteries, we attempted to cross the lesion using a 0.014-inch floppy guidewire and intravascular ultrasound guidance in a bidirectional approach. Several attempts using 0.014 and 0.018-inch stiffer guidewires with parallel wire technique were made but in vain. We then tried the continuous antegrade-retrograde tracking (CART) technique with balloon inflation to create the space for guidewire tracking. Finally, an antegrade, stiff 0.018-inch guidewire was successfully passed through the lesion. After successful guidewire crossing from the terminal aorta to the right femoral artery, the crossed guidewire was externalized to enhance the device’s delivery.

For the next step, we tried to cross an additional guidewire from the left femoral artery using IVUS guidance on the contralateral guidewire. The stiffer 0.018-inch guidewire was successfully crossed through the lesion. We deployed two Epic Vascular stents (8.0/120 mm; Boston Scientific, Freemont, CA, USA) for both lesions simultaneously, followed by balloon angioplasty using a rapid exchange percutaneous transluminal angioplasty (PTA) balloon catheter (4.0/80 mm) under the protection of the inferior mesenteric artery using a 0.014-inch floppy guidewire. Since we recognized under-expansion of the deployed stent by IVUS, we performed an additional balloon angioplasty to optimize the stent expansion by using a larger-diameter of PTA balloon catheter (6.0/80 mm) for bilateral lesions. Subsequently, we added another self-expandable stent for the distal part of the right external iliac artery (SMART Control 6.0/60 mm, Cordis, Bridgewater, NJ, USA). Finally, when we could not get any thrombus or plaque debris from the Optimo catheters, the procedure was completed uneventfully without any obvious signs of distal embolization.

The arterial blood pressure of both femoral arteries was confirmed to be normal, 130/62 mmHg in his left and 123/59 mmHg in his right lower limbs at the end of the procedure.

The elective CABG for multi-vessel CAD

The patient electively underwent CABG (left internal thoracic artery-LAD, right internal thoracic artery-LCX, and right gastro-epiploic artery-RCA) approximately 6 weeks after the EVT. Angiography (Fig. 2) and a postoperative CT scan (Fig. 3A, B) demonstrated patency of the distal aorta and bilateral iliac artery stents. We prescribed dual antiplatelet therapy (DAPT) of aspirin and clopidogrel after EVT. However, since there was the complication of paroxysmal atrial fibrillation after CABG, he was treated with rivaroxaban plus aspirin. Sixteen months have passed since the operation, but he has been well and asymptomatic.

Fig. 2.

Interventional procedure. (A) Preprocedural angiography demonstrated complete occlusion below bilateral renal arteries level with the bilateral external iliac arteries, but showed lower intestinal artery. (B) Angiography by way of the right superior femoral artery showed the false lumen. (C, D) A 4.0/80 mm percutaneous transluminal angioplasty (PTA) balloon catheter was used to expand. (E) A self-expanding stent system was placed simultaneously from both sides to fully cover the lesion. (F) 6.0-mm PTA balloon catheters were used to expand both stents simultaneously. (G) Post-procedural angiography demonstrated successful deployment of the stents. (H) Post-coronary artery bypass grafting angiography showed good patency and stent expansion.

Fig. 3.

Contrast-enhanced computed tomography on postoperative day 4 (A, right side; B, left side) showed good patency and stent expansion from the abdominal aorta to the bilateral lower limb arteries.

Discussion

Leriche syndrome is well known to have a high incidence of co-morbidity with complex coronary heart disease. Inoue et al. reported that 44% of arteriosclerosis obliterans cases were accompanied by ischemic heart disease (IHD), and 73% of Leriche syndrome cases were accompanied by IHD. In that study, compared to patients without the Leriche syndrome, the operative mortality rate of those with it was high [2].

The ITA has been an established and proven conduit for CABG. On the other hand, in Leriche syndrome, the ITAs can generally be a major collateral pathway to the lower limbs [8]. So the use of the ITA for myocardial revascularization in patients with Leriche syndrome may be associated with severe leg ischemia [2], [3]. Some cases have reported that the simultaneous revascularization of the myocardium and the lower limbs was desirable [9]. In the present patient’s case, we conducted a two-stage operation for his severe coronary artery and peripheral artery occlusive diseases. He underwent the EVT first for bilateral aorto-iliac occlusions. One month later, the CABG was carried out for the bilateral ITAs and the gastroepiploic artery. The two-stage procedure was used for the following reasons: (1) acute leg ischemia arising from interruption of the ITA may be severe enough to threaten the lower limbs for good collaterals from ITAs; (2) the patient’s angina symptoms were stable; and (3) his ascending aorta and carotid artery were calcified and showed rich plaques, which were unsuitable for off-pump CABG.

In addition, another remaining issue was that revascularization of the lower limbs should be performed anatomically or non-anatomically. Revascularization by non-anatomical surgery, such as axillo-femoral bypass grafting has been reported to have poor long-term patency. Recent publications have reported that an endovascular strategy utilizing PTA-stent could have favorable outcomes compared to non-anatomical bypass surgery.

Additionally, there might be some advantage of anatomical revascularizations among the usage of percutaneous circulation assistance such as intra-aortic balloon pumping or percutaneous cardiopulmonary support. A recent study reported that EVT could be carried out with a low complication rate and with mid-term durability as favorable as that of bypass surgery in patients with aortic occlusive disease [10].

In this case, we used all arterial grafts, which were expected to provide long-term patency. If elective CABG is possible in patients with Leriche syndrome in whom the ITA can become an important collateral pathway to the lower limbs, we propose that EVT as first line followed by CABG could be safer and less invasive compared to fully-surgical approach even in Leriche syndrome patients. We suggest that the hybrid-staged EVT and CABG could be a choice for Leriche syndrome patients with complex IHD.

Conflicts of interest

The author declares that there is no conflict of interest.