Bangla Interventional Therapeutics-enhancing education on cardiovascular intervention

PCI of SVG-LAD and SVG-OM graft in a Bangladeshi patient with TVD 7 years after CABG with or without distal protection device

By: Shahabuddin Talukder, MBBS, FCPS, D’card; AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Submitted: 06/07/2012

Operator(s):
Shahabuddin Talukder, MBBS, FCPS, D’card; AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Affiliation(s):
Dept of Invasive and Interventional Cardiology, Apollo Hospitals Dhaka.

Facility/Institution
Apollo Heart Center of Apollo Hospitals Dhaka, Bangladesh

Clinical History
HA, a 72 yrs old Bangladeshi gentleman, admitted for coronary angiogram. He complained of on and off chest pain with shortness of breath. His CAD risk factors were hypertensive, diabetic and Dyslipidemia. He had Coronary artery bypass surgery in 1996. Later on, he had successive PCI to OM in 2003, to LAD-2004 and PCI of SVG-OM in 2007 for the recurrence of chest pain. He was planned for diagnostic Coronary Angiogram for his ongoing angina and previous clinical entity. CAG was done using through femoral approach, which revealed Native TVD with occluded D1 and RCA graft. SVG to LAD and OM has 80-90% proximal lesion in tandem. He was advised for PCI of SVG to LAD and OM carried out. Re-look CAG on 12/9/2011 revealed significant stenosis of SVG-OM anastomosis and PCI of SVG to Native OM done in same setting uneventfully.

Angiography
LM: Normal LAD: Occluded at origin. LCX: Occluded in it’s proximal segment. RCA: Occluded proximally. LIMA-D1: occluded SVG-RCA: Occluded SVG-OM: 90% lesion in tandem in ostio-proximal segment (Fig.1) SVG-LAD: 80-90% tandem lesion in ostio-proximal segment. Stent in distal SVG is fully patent. (Fig.2) Re-look CAG on 12/9/2011 due to recurrence of Angina revealed significant stenosis of SVG-Native OM.(Fig.3)

Procedure
We proceed for PCI via trans-femoral approach. RSVG-LAD was engaged with the guiding catheter JR-3.5(7F). Lesion was crossed with a floppy wire. A spider filter distal protection device was used for the RSVG-LAD graft. Lesion was dilated with 2.0mm x 20 mm balloon . First, in the distal part of RSVG-LAD lesion a 3.5 x 18 mm stent (Cypher) was deployed at 20atm (Fig 4.). Proximal to the stent covering the ostium another Cypher stent of 3.5 x 23 mm was stented at 20ATM (Fig 5). Post dilatation was done with 4.0 x 10 mm balloon at 18-20 ATM. Final cine-angio showed RSVG-LAD was well dilated with TIMI III distal flow (Fig.6). Then, RSVG-OM graft was engaged with the same guide catheter. Floppy guide wire crossed the lesion and dilated with 2.0 x 15 mm balloon at 12 ATM. SVG-OM lesion was stented with a 4.0 x 28 mm Liberte stent at 20 ATM (Fig.7). Final cine-angio showed well dilated SVG-OM with TIMI-III distal flow (Fig 7a). His unstable symptoms resolved immediately after the PCI. He was discharged in a stable haemodynamic. He recovered completely from his primary complaint for which he was admitted and followed up at cardiac OPD regularly. Re-look CAG after 10 months showed significant stenosis of SVG-Native OM (Fig 8) and PCI done uneventfully with a Cypher 2.75 x 13 mm stent deployed at 14ATM. (Fig 9 and Fig 10)

Conclusion(s)/Result(s)
PCI of SVG carries the possible risk of ISR and distal embolization. We have successfully performed PCI of this complex patient. Recurrence of effort angina and SOB, in a post CABG and post PCI patient with occluded LIMA-D1 and SVG to RCA graft and significant lesion in RSVG-LAD and SVG-OM is a challenging case to any interventionist. PCI to RSVG-LAD and SVG-OM with distal protection device prevented any untoward effect of distal embolization. Re-occlusion is not a uncommon phenomena, specially in graft vessels.

Comment(s)/Lesson(s)
As the risk of repeat of CABG is two- four fold higher than that of the initial CABG, PCI as often be considered for the treatment of SVG failure Although most patients with recurrent angina due SVG stenosis can be manage medically, catheterization should be performed at the earliest signs of recurrent ischemia to detect critical graft lesions that can be treated before the irreversible loss of the graft.

Conflict(s) of Interest
None

Figure:1