Noninvasive intervention / CABG / hybrid procedure
A 40-year-old expatriate presented with unstable angina. At the age of 31, he had stenting in LAD, obtuse marginal 1, obtuse marginal 2 and RCA. Repeat angiogram showed stent stenosis and progressive disease.
He was taken up for coronary bypass surgery under cardiopulmonary bypass. He had CABG x 5 grafts. He had LIMA anastomosed distal to the stent in LAD and SVG anastomosed to first diagonal, OM1, OM2 and precrux RCA. There was no area in PDA or PLB to do the grafting. There were multiple stents in precrux RCA, PDA and posterolateral right. Long arteriotomy was done in RCA and all the stent with atheromatous material were pulled out distally and proximally. Coronary lumen was washed and grafting done. The patient had a smooth post-op recovery and was discharged on 7th post-op day.
Diffuse coronary artery disease is a well-known fact in young Asian patients. Noninvasive coronary intervention is the treatment of choice in this group of patients. Total arterial grafting is not an easy task in diffuse distal disease. The cardiology team who treated him at the age of 35 did a good job. Later the disease progress and all the stents had progressive atheromatous lesions. Removal of a stent from the coronary is not without morbidity. In this patient, there was no alternative to find out a portion of a coronary artery for grafting. Hence, the stent was removed, cleaned the coronary and grafting done. It is advocated that surgery is possible even if all the coronaries are occupied with blocked stents.