Catheterization and Cardiovascular Diagnosis 20:8&93 (1990)
Retrograde Coronary Angioplasty of Isolated Arterial Segments Through Saphenous Vein Bypass Grafts Joel K. Kahn, MD, and Geoffrey 0.Hartzler, MD Progression of native coronary artery disease proximal to the placement of saphenous vein grafts may leave arterial segments isolated by stenoses on either side. In 16 patients, we attempted coronary angioplasty in a retrograde direction through saphenous vein grafts to revascularize 17 isolated arterial segments. The retrograde dilatation was successful in 12 of 17 attempts (71%). Failure in 5 attempts was due to severe angulation between the graft insertion site and the retrograde proximal arterial limb. There were no major complications of these procedures. Symptoms and signs of myocardial ischemia were relieved following successful retrograde dilatation. Thus, retrograde dilatation through saphenous vein grafts provides another means of achieving complete revascularization using coronary angioplasty in patients with prior coronary bypass surgery. Key words: coronary artery disease, myocardial ischemia, coronary artery bypass surgery
INTRODUCTION
Serial angiographic studies of patients undergoing coronary artery bypass surgery (CABS) have demonstrated the attrition rate of graft patency with time [I-31 and clinical studies have demonstrated that in a large number of patients angina returns within 5 to 10 years of CABS [4,5]. Although many patients undergo repeat CABS, the operative mortality and long-term results are less encouraging than after initial CABS [6-111. Therefore, percutaneous transluminal coronary angioplasty (PTCA) has grown to play an important role in the treatment of patients with prior CABS [12-161. The importance of complete revascularization of all jeoparized myocardium with CABS for the relief of angina and improved survival has been reported [17-201. Likewise, the goal of PTCA in the patient with prior CABS is complete revascularization. This goal can be compromised, however, by the rapid progression of native coronary arterial disease to total or near total occlusion in segments proximal to the graft insertion [21-241. This may leave arterial branches “isolated” by stenoses on either side without benefit from graft flow [25]. In our efforts to achieve complete revascularization of all jeopardized arterial circulations in patients with prior CABS, we have attempted dilatations of the native coronary artery proximal to the vein graft insertion in a retrograde direction through the vein graft. This report describes our experience with this approach. 0 1990 Wiley-Liss, Inc.
MATERIALS AND METHODS
From August 1985 through September 1989, we attempted retrograde dilatation in 16 patients with prior CABS, representing 1% of patients with prior CABS undergoing PTCA during this period. Overall, 5,700 PTCA procedures were performed during this time period. All patients had the return of chest pain syndromes following CABS characteristic of angina pectoris prompting coronary angiography . Arteriography demonstrated arterial branches that were isolated from flow by total occlusion of the proximal grafted vessel, with additional stenoses proximal to the graft insertion site. Patients were selected for attempted retrograde dilatations because of the considerable size of the isolated branches supplying viable myocardium. Fourteen of the 16 patients had coronary artery stenoses in other arteries or vein grafts that were dilated during the same procedure. Eleven patients underwent pre-procedural exercise treadmill testing that demonstrated evidence of exercise induced ischemia and 5 had unstable angina that precluded exercise testing. The clinical characteristics of these patients are described in Table I. From the Cardiovascular Consultants, Inc., Mid America Heart Institute, St. Luke‘s Hospital, Kansas City, Missouri.
Received November I . 1989; revision accepted January 22, 1990. Address reprint requests to Geoffrey 0. Hartzler, M.D., 4320 Wornall Road, Medical Plaza 11-20, Kansas City, MO 641 11.
Retrograde PTCA Through Vein Grafts
89
TABLE I. Characteristics of 16 Patients Undergoing Retrograde Dilatation* Patient Age (years) Sex Prior CABS
M M
7 years 12 years 8 years I year 8 years 15 years 12 years I 1 years 8 years
10
62 57
M M M
6 months 9 years 6 months
I1
61
M
12 13
71 70
M M
15 years 8 years 10 years 1 1 years
14 15 16
72 62 77
M M M
I 2 3
61 62 63
M M F
4 5
63 61
F M
6 7
64 72
8 9
44
10 years
2 years 8 years
Isolated arteries
Vein graft Angle
equipment
Success
Other lesions dilated
Diagonals, septals LAD Septal, diagonal Diagonal Posterior LV, PDA RCA
120 180 60
Micro 11 2.0 Micro I1 2.5 Micro I1 2.5
Septal Diagonals, septals
LAD LAD
180 180
Diagonals. septals Obtuse marginal
LAD LCx
90 180
Diagonal Diagonal Diagonals, septals
LAD LAD LAD
120 I20 I35
No Yes No
LAD, LCx, SVG-RCA LMCA
Posterior LV
RCA
130
Micro 11 2.0, 2.5 .018 HTF Simpson-Robert 3.0 LPS 2.0, Micro 2.0 .014 HTF, HTI SULP 2.0 Micro 2.5 SULP 2.5 .014 HTF ACX 2.0, 2.5 .014 HTI ACX 2.5
Yes Yes
SVG-LCX
Diagonals, septals Diagonals, septals posterior LV Diagonals, septals Diagonals, septals Posterior LV
LAD LAD RCA LAD LAD RCA
I80 I20
,014 HTF, ,014 HTF, .014 HTF, .014 HTF, LPS 2.5 .014 HTF,
No Yes Yes Yes Yes Yes
90 I35 90 180
HTI, HTS SULP 2.5 SULP 2.5 ACX 2.5 ACX 3.0
Yes
No Yes
No Yes Yes
LCx, LAD. RCA, LIMA SVG-RCA, SVG-LAD LMCA, LCX, LAD, SVG-RCA LCx, LAD LCx, SVG-LAD, SVG-RCA LAD, SVG-LAD, SVG-LCx RCA,LAD
LAD, LCx LAD LCx, SVG-LAD, SVG-Diag SVG-RCA
*CABS = coronary artery bypass surgery; PDA = posterior descending artery; LAD = left anterior descending; RCA = right coronary artery; LCx = left circumflex; LV = left ventricular; HTF = high torque floppy; SULP = Simpson Ultra Low Profile; HTI = high torque intermediate; HTS = high torque standard; SVG = saphenous vein graft; LIMA = left internal mammary artery.
ANGIOPLASTY PROTOCOL
descending artery utilizing a saphenous vein graft. Angina pectoris returned 8 weeks Iater. Six months postPatients received 10,000 units of heparin in the cath- operatively he underwent exercise treadmill testing, eterization laboratory. Unless contraindicated, routine which was terminated at 7 minutes for typical angina and pre-medications consisted of 325 mg aspirin three times hypotension. Coronary arteriography demonstrated a daily, dipyridamole 75 mg three times daily, 5 mg iso- widely patent vein graft inserting near the junction of the sorbide dinitrate sublingually, 75 mg lidocaine intrave- mid and distal third of the left anterior descending artery. nously, dextran 500 cc intravenously, and verapamil 5 The continuing segment was small and free of disease. mg intravenously. An additional 5,000 units of heparin The retrograde arterial limb was 90% narrowed by an were given for every hour of the angioplasty procedure. eccentric angled lesion immediately proximal to the graft Following angioplasty , heparin was continued for 12-24 insertion site limiting flow to the mid vessel and diagonal hours. All patients were maintained on 325 mg aspirin and septa1 branches (Fig. 1A). The proximal left anterior three times daily, 75 mg dipyridamole three times daily, descending artery had progressed to complete occlusion and an oral calcium blocker. Prior to hospital discharge, following CABS. A 0.014 inch Hi-Torque Floppy I1 patients underwent symptom limited treadmill exercise guidewire (Advanced Cardiovascular Systems, Santa Clara, CA) was pre-shaped, advanced into the vein graft, testing. Standard angioplasty guides, catheters, and guide- and turned retrograde across the stenosis into the proxiwires were utilized (Table I). Gradual balloon inflations mal left anterior descending vessel. A 2.0 mm ACX were utilized with balloon sizes selected to be compara- (ACS) catheter was advanced over the wire into the leble to the target vessel. A successful retrograde dilatation sion for one inflation for 60 seconds at 8 atmospheres was considered to be reduction to
Retrograde Coronary Angioplasty of Isolated Arterial Segments Through Saphenous Vein Bypass Grafts Joel K. Kahn, MD, and Geoffrey 0.Hartzler, MD Progression of native coronary artery disease proximal to the placement of saphenous vein grafts may leave arterial segments isolated by stenoses on either side. In 16 patients, we attempted coronary angioplasty in a retrograde direction through saphenous vein grafts to revascularize 17 isolated arterial segments. The retrograde dilatation was successful in 12 of 17 attempts (71%). Failure in 5 attempts was due to severe angulation between the graft insertion site and the retrograde proximal arterial limb. There were no major complications of these procedures. Symptoms and signs of myocardial ischemia were relieved following successful retrograde dilatation. Thus, retrograde dilatation through saphenous vein grafts provides another means of achieving complete revascularization using coronary angioplasty in patients with prior coronary bypass surgery. Key words: coronary artery disease, myocardial ischemia, coronary artery bypass surgery
INTRODUCTION
Serial angiographic studies of patients undergoing coronary artery bypass surgery (CABS) have demonstrated the attrition rate of graft patency with time [I-31 and clinical studies have demonstrated that in a large number of patients angina returns within 5 to 10 years of CABS [4,5]. Although many patients undergo repeat CABS, the operative mortality and long-term results are less encouraging than after initial CABS [6-111. Therefore, percutaneous transluminal coronary angioplasty (PTCA) has grown to play an important role in the treatment of patients with prior CABS [12-161. The importance of complete revascularization of all jeoparized myocardium with CABS for the relief of angina and improved survival has been reported [17-201. Likewise, the goal of PTCA in the patient with prior CABS is complete revascularization. This goal can be compromised, however, by the rapid progression of native coronary arterial disease to total or near total occlusion in segments proximal to the graft insertion [21-241. This may leave arterial branches “isolated” by stenoses on either side without benefit from graft flow [25]. In our efforts to achieve complete revascularization of all jeopardized arterial circulations in patients with prior CABS, we have attempted dilatations of the native coronary artery proximal to the vein graft insertion in a retrograde direction through the vein graft. This report describes our experience with this approach. 0 1990 Wiley-Liss, Inc.
MATERIALS AND METHODS
From August 1985 through September 1989, we attempted retrograde dilatation in 16 patients with prior CABS, representing 1% of patients with prior CABS undergoing PTCA during this period. Overall, 5,700 PTCA procedures were performed during this time period. All patients had the return of chest pain syndromes following CABS characteristic of angina pectoris prompting coronary angiography . Arteriography demonstrated arterial branches that were isolated from flow by total occlusion of the proximal grafted vessel, with additional stenoses proximal to the graft insertion site. Patients were selected for attempted retrograde dilatations because of the considerable size of the isolated branches supplying viable myocardium. Fourteen of the 16 patients had coronary artery stenoses in other arteries or vein grafts that were dilated during the same procedure. Eleven patients underwent pre-procedural exercise treadmill testing that demonstrated evidence of exercise induced ischemia and 5 had unstable angina that precluded exercise testing. The clinical characteristics of these patients are described in Table I. From the Cardiovascular Consultants, Inc., Mid America Heart Institute, St. Luke‘s Hospital, Kansas City, Missouri.
Received November I . 1989; revision accepted January 22, 1990. Address reprint requests to Geoffrey 0. Hartzler, M.D., 4320 Wornall Road, Medical Plaza 11-20, Kansas City, MO 641 11.
Retrograde PTCA Through Vein Grafts
89
TABLE I. Characteristics of 16 Patients Undergoing Retrograde Dilatation* Patient Age (years) Sex Prior CABS
M M
7 years 12 years 8 years I year 8 years 15 years 12 years I 1 years 8 years
10
62 57
M M M
6 months 9 years 6 months
I1
61
M
12 13
71 70
M M
15 years 8 years 10 years 1 1 years
14 15 16
72 62 77
M M M
I 2 3
61 62 63
M M F
4 5
63 61
F M
6 7
64 72
8 9
44
10 years
2 years 8 years
Isolated arteries
Vein graft Angle
equipment
Success
Other lesions dilated
Diagonals, septals LAD Septal, diagonal Diagonal Posterior LV, PDA RCA
120 180 60
Micro 11 2.0 Micro I1 2.5 Micro I1 2.5
Septal Diagonals, septals
LAD LAD
180 180
Diagonals. septals Obtuse marginal
LAD LCx
90 180
Diagonal Diagonal Diagonals, septals
LAD LAD LAD
120 I20 I35
No Yes No
LAD, LCx, SVG-RCA LMCA
Posterior LV
RCA
130
Micro 11 2.0, 2.5 .018 HTF Simpson-Robert 3.0 LPS 2.0, Micro 2.0 .014 HTF, HTI SULP 2.0 Micro 2.5 SULP 2.5 .014 HTF ACX 2.0, 2.5 .014 HTI ACX 2.5
Yes Yes
SVG-LCX
Diagonals, septals Diagonals, septals posterior LV Diagonals, septals Diagonals, septals Posterior LV
LAD LAD RCA LAD LAD RCA
I80 I20
,014 HTF, ,014 HTF, .014 HTF, .014 HTF, LPS 2.5 .014 HTF,
No Yes Yes Yes Yes Yes
90 I35 90 180
HTI, HTS SULP 2.5 SULP 2.5 ACX 2.5 ACX 3.0
Yes
No Yes
No Yes Yes
LCx, LAD. RCA, LIMA SVG-RCA, SVG-LAD LMCA, LCX, LAD, SVG-RCA LCx, LAD LCx, SVG-LAD, SVG-RCA LAD, SVG-LAD, SVG-LCx RCA,LAD
LAD, LCx LAD LCx, SVG-LAD, SVG-Diag SVG-RCA
*CABS = coronary artery bypass surgery; PDA = posterior descending artery; LAD = left anterior descending; RCA = right coronary artery; LCx = left circumflex; LV = left ventricular; HTF = high torque floppy; SULP = Simpson Ultra Low Profile; HTI = high torque intermediate; HTS = high torque standard; SVG = saphenous vein graft; LIMA = left internal mammary artery.
ANGIOPLASTY PROTOCOL
descending artery utilizing a saphenous vein graft. Angina pectoris returned 8 weeks Iater. Six months postPatients received 10,000 units of heparin in the cath- operatively he underwent exercise treadmill testing, eterization laboratory. Unless contraindicated, routine which was terminated at 7 minutes for typical angina and pre-medications consisted of 325 mg aspirin three times hypotension. Coronary arteriography demonstrated a daily, dipyridamole 75 mg three times daily, 5 mg iso- widely patent vein graft inserting near the junction of the sorbide dinitrate sublingually, 75 mg lidocaine intrave- mid and distal third of the left anterior descending artery. nously, dextran 500 cc intravenously, and verapamil 5 The continuing segment was small and free of disease. mg intravenously. An additional 5,000 units of heparin The retrograde arterial limb was 90% narrowed by an were given for every hour of the angioplasty procedure. eccentric angled lesion immediately proximal to the graft Following angioplasty , heparin was continued for 12-24 insertion site limiting flow to the mid vessel and diagonal hours. All patients were maintained on 325 mg aspirin and septa1 branches (Fig. 1A). The proximal left anterior three times daily, 75 mg dipyridamole three times daily, descending artery had progressed to complete occlusion and an oral calcium blocker. Prior to hospital discharge, following CABS. A 0.014 inch Hi-Torque Floppy I1 patients underwent symptom limited treadmill exercise guidewire (Advanced Cardiovascular Systems, Santa Clara, CA) was pre-shaped, advanced into the vein graft, testing. Standard angioplasty guides, catheters, and guide- and turned retrograde across the stenosis into the proxiwires were utilized (Table I). Gradual balloon inflations mal left anterior descending vessel. A 2.0 mm ACX were utilized with balloon sizes selected to be compara- (ACS) catheter was advanced over the wire into the leble to the target vessel. A successful retrograde dilatation sion for one inflation for 60 seconds at 8 atmospheres was considered to be reduction to
