Successful angioplasty and stenting of bilateral internal mammary artery grafts from the left radial approach. Case report and review of the literature

Vascular Access Site and Outcomes in 58,870 Patients Undergoing Percutaneous Coronary Intervention With a Previous History of Coronary Bypass Surgery: Results From the British Cardiovascular Interventions Society National Database

OBJECTIVES

Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, access site choice and outcomes of patients undergoing PCI with previous coronary artery bypass grafting (CABG) were studied.

BACKGROUND

Given the influence of access site on outcomes, use of radial access in PCI-CABG warrants further investigation.

METHODS

Data were analyzed from 58,870 PCI-CABG procedures performed between 2005 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.

RESULTS

The number of PCI-CABG cases and the percentage of total PCI increased significantly during the study period. Femoral artery (FA) utilization fell from 90.8% in 2005 to 57.6% in 2014 (p < 0.001), with no differences in the rate of change of left versus right radial use. In contemporary study years (2012 to 2014), female sex, acute coronary syndrome presentation, chronic total occlusion intervention, and lower operator volume were independently associated with FA access. Length of stay was shortened in the radial cohort. Unadjusted outcomes including an access site complication (1.10% vs. 0.30%; p < 0.001), blood transfusion (0.20% vs. 0.04%; p < 0.001), major bleeding (1.30% vs. 0.40%; p < 0.001), and in-hospital death (1.10% vs. 0.60%; p = 0.001) were more likely to occur with FA access compared with radial access. After adjustment, although arterial complications, transfusion, and major bleeding remained more common with FA use, short- and longer-term mortality and major adverse cardiac event rates were similar.

CONCLUSIONS

In contemporary practice, FA access remains predominant during PCI-CABG with case complexity associated with it use. FA use was associated with longer length of stay, and higher rates of vascular complications, major bleeding, and transfusion.

Endovascular Management of Symptomatic Spasm of Radial Artery Bypass Graft

OBJECTIVE

To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease.

CLINICAL PRESENTATION

A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging.

TECHNIQUE

The patient underwent a left MCA bypass graft for flow augmentation. She returned with an occluded bypass graft, collateralization of the anterior MCA territory through a spontaneous synangiosis, and a severe perfusion deficit in the posterior MCA territory. She underwent a revision bypass graft procedure with the radial artery from the occipital artery stump to the MCA-M3 branch. She developed repeated symptomatic vasospasm of the radial artery graft postoperatively. After systemic anticoagulation, the graft was accessed through the occipital artery, and intra-arterial verapamil was injected. When this failed to resolve the graft spasm, the radial artery graft was accessed with a 0.14-inch Synchro-2 microwire (Boston Scientific, Natick Massachusetts), and sequential angioplasties were performed using over-the-wire balloons from the proximal to distal anastomosis and in the occipital artery stump. A nitroglycerin patch was applied cutaneously over the graft to relieve the vasospasm.

RESULTS

No complications occurred. Graft patency with robust flow was observed on the 5-month follow-up angiogram.

CONCLUSION

Endovascular techniques can be safely used for salvage of spastic extracranial-intracranial grafts.