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35 Years Angiographic Follow Up Of Atherosclerotic Cardiovascular Disease Including Redo Cabg, Carotid Artery Stenting & Multiple Interventions To Saphenous Venous Grafts

Case Report | DOI: https://doi.org/10.31579/2690-4861/054

35 Years Angiographic Follow Up Of Atherosclerotic Cardiovascular Disease Including Redo Cabg, Carotid Artery Stenting & Multiple Interventions To Saphenous Venous Grafts

  • Arnab ghosh chaudhury 1*
  • T R Raghu 2
  • C N Manjunath 3

1 Assistant Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore. 

2 Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore. 

3 Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore.

*Corresponding Author: Arnab Ghosh Chaudhury, Assistant Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Sambhram Apartment Ii, Gokulam Main Road, V V Mohalla, Mysore-570002, Karnataka, India.

Citation: A G chaudhury, T R Raghu, C N Manjunath. (2020) 35 Years Angiographic Follow Up Of Atherosclerotic Cardiovascular Disease Including Redo Cabg, Carotid Artery Stenting & Multiple Interventions To Saphenous Venous Grafts. International Journal of Clinical Case Reports and Reviews. 3(5); DOI: 10.31579/2690-4861/054

Copyright: © 2020 Arnab ghosh chaudhury, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 04 September 2020 | Accepted: 19 September 2020 | Published: 25 September 2020

Keywords: coronary angiography; percutaneous coronary interventions; stent

Abstract

Percutaneous coronary intervention (PCI) has got more benefit as compared to redo CABG in terms of morbidity & mortality in patients presented with degenerated CABG grafts. We report a case of post CABG patient treated successfully with multiple PCI to SVG grafts- a 35 years follow up.

Introduction:

CABG is an established form of revascularisation with improved survival. But it has its own demerits including venous graft failure requiring repeat revascularisation. Ideal treatment is controversial for Saphenous Vein Graft (SVG) disease and its long-term success of surgical coronary revascularization is limited by accelerated atherosclerosis and intimal fibrosis of the saphenous vein graft. SVG angioplasty with balloon-expandable or self-expanding stent is an effective alternative treatment option for patients with SVG stenosis [1]. We report the case of a patient post redo CABG with symptomatic SVG disease & carotid artery stenosis treated successfully with Percutaneous Coronary Intervention (PCI) & percutaneous transluminal angioplasty (PTA) to internal carotid artery, respectively.

Case report:

34-years-old male patient presented with anterior wall myocardial infarction (AWMI) in 1982. Coronary angiography (CAG) revealed significant stenosis of left main coronary artery (LMCA) with stenosis of left anterior descending artery (LAD) and left circumflex artery (LCx).  CABG with SVG grafts to LAD & OM were done. Patient eventually developed hypertension in 1992. In 1995 patient presented with effort angina. CAG showed total occlusion of RCA osteoproximally, with patent SVG grafts to LAD & OM. Patient was treated medically with maximal antianginals. In 1998 patient presented with unstable angina.  Repeat CAG showed discrete stenosis in mid SVG to OM graft, with occluded SVG to LAD graft. The SVG lesion was stented using 4mmX22mm MEDICOR stent in August 1998. In view of persistent angina redo CABG was done in September 1998 (repeat SVG to LAD grafts, endarterectomy bypass graft to RCA). Patient developed diabetes mellitus in 2002. Patient presented with right cerebellar infarct in 2004, managed conservatively. In 2005 patient presented with effort angina, CAG (11/05/2005) showed occluded SVG to LAD graft, patent stent in SVG to OM graft with new proximal stenosis in SVG to OM graft and patent SVG to RCA graft. Carotid angiography revealed 80% right internal carotid artery (RICA) stenosis with 70% left internal carotid artery (LICA) stenosis. PTCA with stent to OM graft done with 4mm X 23mm OCCAM AXXIOM stent, PTA with stent to RICA done with 7mm X 40 mm CORDIS PRECISE SMART CONTROL stent. In 2010 patient presented with unstable angina, CAG showed (24/11/2010) new lesion in mid SVG to RCA graft with patent stents in OM graft. PTCA with stent to mid SVG to RCA graft was done using 3.5 mm x 28 mm EXCEL drug eluting stent. In 2016 patient presented with unstable angina. CAG shows (20/10/2016) LMCA disease with native triple vessel disease, patent stent in RICA, occluded LAD graft, patent stents in OM graft, patent stent in mid RCA graft, new onset 90% stenosis in proximal RCA graft (Figure 1). PTCA with stenting done in proximal SVG to RCA graft using 3.5mm X 44mm TETRILIMUS stent. (Figure 2) .

Figure 1: CAG showing proximal significant stenosis (yellow arrow) of SVG to RCA graft with patent stent (white arrow) in mid SVG to RCA graft
Figure2: SVG to RCA graft after PTCA to proximal lesion

Discussion:

Percutaneous management of SVG disease is rapidly changing and continues to be challenging for the interventional cardiologists [2, 3]. Considering the alternative of reoperation which although associated with higher mortality and morbidity and less effective relief of angina, percutaneous treatment of Saphenous Vein Bypass Graft lesion is probably the best treatment using bare metal stents and drug eluting stents [4, 5]. Regarding choice of stent ISAR-CABG trial (2011) shows lesser incidence of target lesion revascularisation with DES than bare metal stent (BMS) without any difference in restenosis rate or mortality. But RRISC trial (2006) demonstrated lower rate of restenosis with BMS. We report the case of a 69-year-old gentleman with redo CABGs and interventions with both BMS and DES in the treatment of Saphenous Vein Bypass Graft disease. Patient is asymptomatic at present, on regular follow up with 4 SVG stents & 1 carotid stent in situ. To conclude, PTCA to occluded SVG grafts is a good alternative to patients with prior history of CABG where redo CABG is difficult to perform.

Acknowledgement:

DR. H S Natraj Shetty, Assistant Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research

DR. B Prabhavathi, Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research

References

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