Original article
Cardiovascular
Coronary Endarterectomy and Stent Removal in Patients With In-Stent restenosis

https://doi.org/10.1016/j.athoracsur.2004.07.064Get rights and content

Background

In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting.

Methods

Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 ± 9.6 years). The mean number of target vessel interventions was 1.6 ± 0.7. Data were analyzed retrospectively.

Results

The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 ± 1.9 months. The mean number of target vessel interventions was 1.6 ± 0.7. The mean LAD incision length was 57.3 ± 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved.

Conclusions

Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.

Section snippets

Patient Population

Between April 2001 and March 2004, we performed coronary artery bypass surgery on 762 patients. Ninety-eight patients (12.9%) were treated previously with coronary stent implantation by interventional cardiologists. Eleven patients underwent coronary endarterectomy and stent removal before bypass grafting. Patient characteristics are listed in Table 1. The age range was from 43 to 75 years old (mean 64.1 ± 9.6 years). The mean Canadian Cardiovascular Society (CCS) functional class was 2.4 ±

Procedural Data

Of 98 patients who presented with ISR and underwent coronary bypass grafting, 11 whose LAD was diffusely diseased with an involvement of stent underwent stent removal and LAD endarterectomy. Other 87 patients were treated with simple bypass grafting to LAD or sequential bypass grafting to LAD and a diagonal branch because their side branches were not involved with lesions of ISR or their distal targets were suitable for anastomosis. Intraoperative data are listed in Table 2. The stent removal

Comment

Coronary in-stent restenosis remains a significant clinical problem, especially in the setting of diffuse disease [22]. Repeat percutaneous transluminal coronary angioplasty (PTCA) remains the most commonly used technique for ISR, but the rate of recurrence is very high, particularly in patients with diffuse ISR. Besides PTCA, ISR was treated by various other interventional techniques. However, long-term efficacy is unsatisfactory. Revascularization in diffusely diseased vessels may require

References (27)

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