Peculiarities of Interventions in Chronic Coronary Occlusions in Patients with CHD after CABG. State of the Art and Actual Experience
Abstract
Within 10 years after coronary artery bypass grafting (CABG) only 60 % of vein grafts and 90 % of internal mammary artery (IMA) grafts remain patent. Chronic total occlusions (CTO) in patients after CABG suggest more ad-vanced state of atherosclerosis. Although precise mechanism of atherosclerosis in these patients is unknown, several clinical studies reported that atherosclerosis progression occurs more rapidly in grafted than in non-grafted arteries.
These data support the fact that IMA has favorable metabolic effect not only in the bypass, but also in the bypassed artery, which, according to the authors, is defined by NO products.
The frequency of occlusion of initially stenotic arteries in the proximal or distal segment was about 22 % after the application of IMA grafts and on average 48 % after autovenous grafts. According to literature data, in multivariate analysis, bypass interventions are independently associated with higher hospital mortality and perioperative complications. Mortality rate was 2.6 % if the artery recanalization was successful, 5.2% in case of a partial success and 8.2 % in case of failure.
This paper presents the analysis of possible interventional approaches to recanalization of the coronary bed in patients after CABG, discusses actual experience and practical developments. Fifty-two patients underwent recanalization of chron-ic occlusions of the coronary arteries at different times after CABG with a total technical efficiency of 75 %. In 11 patients with СTO, repeated recanalization attempts were made with an efficiency of 54.5 %. The third attempt was effective in two patients. Thus, the secondary efficacy of interventions was about 88 %. An intravascular ultrasound (IVUS) was used in 3.8 % of patients.
One patient died during intervention as a result of collateral rupture at an attempt to perform retrograde approach when a “dry tamponade” occurred that led to cardiogenic shock.
Thus, CTO after CABG have unfavorable characteristics for recanalization and are more technically demanding than occlusion of arteries without prior coronary artery bypass grafting. Retrograde access is much more common here, and the effectiveness of intervention is significantly lower than that in primary patients. Repeated attempts to recapitalize the artery in case of prior unsuccessful attempt may significantly improve the results and were effective in half of the cases.
References
- Alhejily WA, Kong DF, Magnus Ohman E. Retrograde approach to coronary chronic total occlusion via an occluded saphenous bypass graft: a case report. Clin Case Rep. 2013;1(2):54–8. https://doi.org/10.1002/ccr3.23
- Brilakis ES, Rao SV, Banerjee S, Goldman S, Shunk KA, Holmes DR Jr, et al. Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2011;4(8):844–50. https://doi.org/10.1016/j.jcin.2011.03.018
- Brilakis ES, Banerjee S, Lombardi WL. Retrograde recanalization of native coronary artery chronic occlusions via acutely occluded vein grafts. Catheter Cardiovasc Interv. 2010;75(1):109–13. https://doi.org/10.1002/ccd.22196
- Burke AP, Weber DK, Kolodgie FD, Farb A, Taylor AJ, Virmani R. Pathophysiology of calcium deposition in coronary arteries. Herz. 2001;26(4):239–44.
- Touma G, Ramsay D, Weaver J. Chronic total occlusions – Current techniques and future directions. Int J Cardiol Heart Vasc. 2015;7:28–39. https://doi.org/10.1016/j.ijcha.2015.02.002
- Galassi AR, Brilakis ES, Boukhris M, Tomasello SD, Sianos G, Karmpaliotis D, et al. Appropriateness of percutaneous revascularization of coronary chronic total occlusions: An overview. Eur Heart J. 2016 Sep;37(35):2692–700. https://doi.org/10.1093/eurheartj/ehv391
- Michael TT, Mogabgab O, Alomar M, Kotsia A, Christopoulos G, Rangan BV, et al. Long-term outcomes of successful chronic total occlusion percutaneous coronary interventions using the antegrade and retrograde approach. J Interv Cardiol. 2014;27:465–71. https://doi.org/10.1111/joic.12149
- Sakakura K, Nakano M, Otsuka F, Yahagi K, Kutys R, Ladich E, et al. Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft. Eur Heart J. 2014;35(25):1683–93. https://doi.org/10.1093/eurheartj/eht422
- Sekiguchi M, Yamazaki M, Kurabayashi M. Retrograde percutaneous coronary intervention via critically degenerated saphenous vein grafts for chronic total occlusion in native coronary arteries. World Journal of Cardiovascular Diseases. 2013;3(3):261–5. https://doi.org/10.4236/wjcd.2013.33041.
- Sianos G, Werner GS, Galassi AR, Papafaklis MI, Escaned J, Hildick-Smith D, et al. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention. 2012;8(1):139–45. https://doi.org/10.4244/EIJV8I1A21
- Torii S, Masuda N, Ikari Y. Retrograde approach via left internal mammary artery using a 5 Fr guiding catheter. Cardiovasc Interv Ther. 2016 Apr;31(2):156–60. https://doi.org/10.1007/s12928-015-0333-5
- Yang C-F, Chen YM, Chen M-L, Wang, J-H. Successful Revascularization of Chronic Total Occlusion in Native Coronary Arteries through an Occluded Saphenous Bypass Vein Graft: A Retrograde Alternative Approach. Acta Cardiol Sin. 2014;30(5):485–9.
- Azzalini L, Ojeda S, Karatasakis A, Maeremans J, Tanabe M, La Manna A, et al. Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients Who Have Undergone Coronary Artery Bypass Grafting vs Those Who Have Not. Can J Cardiol. 2018 Mar;34(3):310–8. https://doi.org/10.1016/j.cjca.2017.12.016
