Flores-Umanzor Eduardo, Martin-Yuste Victoria, Caldentey Guillem, Vazquez Sara, Jimenez-Britez Gustavo, San Antonio Rodolfo, Cepas-Guillen Pedro, Pujol-Lopez Margarida, Hernández Marco, Sabaté Manel
University of Barcelona, Cardiology Department, Cardiovascular Institute, Barcelona, Spain.
University of Barcelona, Cardiology Department, Cardiovascular Institute, Barcelona, Spain.
Rev Port Cardiol (Engl Ed). 2018 Oct;37(10):865.e1-865.e4. doi: 10.1016/j.repc.2017.03.015. Epub 2018 Oct 21.
Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is an infrequent finding. Revascularization is recommended in the presence of demonstrated viability or ischemia. Coronary artery bypass grafting (CABG) has long been considered the preferred option. Patients with previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains. For these patients, there is no other option for revascularization other than cardiac surgery (requiring resternotomy) or percutaneous coronary intervention (PCI) of the LMCA.
Out of 620 patients with CTO diagnosed in our center, we identified five with previous CABG due to LMCA disease for a retrospective case series. They had occlusion of one graft and progression of the LMCA to CTO. All five underwent PCI. Each patient received a functional classification for angina, myocardial ischemic tests, and a follow-up coronary angiogram during a median follow-up of 63 months. Coronary angiogram showed CTO of the semi-protected LMCA lesions with two CABGs previously performed in all patients, one occluded and the other patent. Three patients had occluded saphenous vein grafts to the circumflex coronary artery, and the rest had left internal mammary artery-left anterior descending artery CABG failure. Ischemia and viability were demonstrated. Surgery was ruled out due to high surgical risk. PCI due to CTO of the LMCA with drug-eluting stents was performed. In a five-year follow-up period, four patients remained asymptomatic and event free. One post-PCI death occurred from non-cardiovascular cause.
PCI due to CTO of the LMCA following CABG can be successful and safe and can provide sustained clinical improvements in selected cases.
左主干冠状动脉（LMCA）慢性完全闭塞（CTO）是一种少见的情况。在证实存在存活心肌或缺血时，建议进行血运重建。冠状动脉旁路移植术（CABG）长期以来一直被视为首选方案。因LMCA疾病曾接受CABG且有一根移植血管闭塞、LMCA进展为CTO的患者构成了一个特殊群体，因为仅剩下一根缺血动脉。对于这些患者，除了心脏手术（需要再次开胸）或对LMCA进行经皮冠状动脉介入治疗（PCI）外，没有其他血运重建选择。
在我们中心诊断为CTO的620例患者中，我们确定了5例因LMCA疾病曾接受CABG的患者进行回顾性病例系列研究。他们有一根移植血管闭塞且LMCA进展为CTO。所有5例患者均接受了PCI。每位患者在中位随访63个月期间接受了心绞痛功能分级、心肌缺血试验以及随访冠状动脉造影。冠状动脉造影显示半保护的LMCA病变CTO，所有患者之前均进行过两次CABG，一根闭塞，另一根通畅。3例患者的大隐静脉移植血管至回旋支冠状动脉闭塞，其余患者的左乳内动脉-左前降支动脉CABG失败。证实存在缺血和存活心肌。由于手术风险高，排除了手术治疗。对LMCA的CTO采用药物洗脱支架进行PCI。在五年随访期内，4例患者无症状且无事件发生。1例PCI术后患者死于非心血管原因。
CABG后因LMCA的CTO进行PCI可以成功且安全，并且在某些选定病例中可提供持续的临床改善。
