Title: Angioplasty With Autologous Pericardium for Bilateral Coronary Ostial Stenosis in Takayasu Disease
Abstract: Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease. Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease. Isolated coronary ostial stenosis is uncommon, with an incidence of 0.07% to 0.09% in patients undergoing angiography, and it may represent a specific disease entity [1Miller G.A. Honey M. El-Sayed H. Isolated coronary ostial stenosis.Cath Cardiovasc Diag. 1986; 12: 30-34Crossref PubMed Scopus (48) Google Scholar, 2Sachithanandan A. Ahmed A. O'Kane H. Bilateral isolated coronary ostial stenosis following mediastinal irradiation.Asian Cardiovasc Thorac Ann. 2004; 12: 78-80Crossref PubMed Scopus (4) Google Scholar]. Syphilitic or Takayasu aortitis is included in this entity. In 1951, Frovig and Loken first reported the coronary artery involvement in Takayasu aortitis [3Frovig A.G. Loken A.C. The syndrome of obliteration of the arterial branches of the aortic arch, due to arteritis; a post-mortem angiographic and pathological study.Acta Psychiatr Neurol Scand. 1951; 26: 313-337Crossref PubMed Google Scholar]. Bilateral coronary ostial stenosis in Takayasu disease is rare, but it has important symptomatic and prognostic implications. A 24-year-old woman had been suffered from worsening chest pain during exercise for 3 months. Positive results compatible with myocardial ischemia were obtained by stress electrocardiogram with the Master two-step test. Preoperative coronary computed tomography and direct coronary angiography revealed isolated critical stenosis of bilateral coronary ostia without any distal coronary artery stenosis (Fig 1) . A preoperative blood test revealed: elevated total protein = 9.3 g/dL; C-reactive protein = 1.8 mg/dL; immunoglobulin (Ig) G = 1,926 mg/dL; IgA = 466 mg/dL; and C3 = 131 mg/dL. All data were compatible with Takayasu disease. A patch angioplasty of the bilateral coronary ostium using glutaraldehyde-treated autologous pericardium was planned. The operation was performed via median sternotomy, with the lower small skin incision being 12 cm long because of cosmetic considerations. Next, autologous pericardium was harvested and treated with 0.6% glutaraldehyde solution for 10 minutes. On the standard cardiopulmonary bypass, the ascending aorta was cross-clamped. Myocardial protection was achieved by both antegrade and retrograde administration of cold blood cardioplegic solution. An aortotomy was placed from the proximal right coronary artery bridging to the left main coronary truncus as shown in Figure 2. Two pieces of glutaraldehyde-treated autologous pericardium were running sutured as patches to enlarge the bilateral coronary ostia also shown in Figure 2. Connecting the two narrowed ostia by a single incision could provide a better view of the coronary ostial lesion and the chance to put in the larger patch appropriately to prevent the restenosis of the lesion. Postoperative coronary computed tomography and direct coronary angiography showed widely patent bilateral coronary ostia (Fig 3) . Two years later, the patient remains asymptomatic with good quality of life without any further intervention. Coronary ostial stenosis is uncommon, with an incidence of 0.13% to 0.80% in patients undergoing coronary angiography, and it is usually associated with atherosclerosis of the coronary arteries elsewhere [1Miller G.A. Honey M. El-Sayed H. Isolated coronary ostial stenosis.Cath Cardiovasc Diag. 1986; 12: 30-34Crossref PubMed Scopus (48) Google Scholar, 3Frovig A.G. Loken A.C. The syndrome of obliteration of the arterial branches of the aortic arch, due to arteritis; a post-mortem angiographic and pathological study.Acta Psychiatr Neurol Scand. 1951; 26: 313-337Crossref PubMed Google Scholar]. Moreover, the incidence of isolated coronary ostial stenosis had been reported as 0.07% to 0.09% in patients undergoing coronary angiography. Aside from atherosclerosis, the etiologies of this entity include congenital abnormality, syphilitic and Takayasu aortitis, familial hypercholesterolemia, fibromuscular dysplasia, iatrogenic stenosis, and mediastinal radiation [4Barner H.B. Naunheim K.S. Kanter K.R. et al.Coronary ostial stenosis.Eur J Cardiothorac Surg. 1988; 2: 106-112Crossref PubMed Scopus (25) Google Scholar]. Takayasu disease is most commonly found in young Asian women. Its etiology is unknown. Their symptoms become obvious usually during the second or third decade of life. Takayasu disease yields aortitis with its stenosis or the stenosis of a proximal segment of major aortic tributaries resulting from fibrosis [5Ueda H. Morooka S. Ito I. Yamaguchi H. Takeda T. Clinical observation of 52 cases of aortitis syndrome.Jpn Heart J. 1969; 10: 277-288Crossref PubMed Scopus (70) Google Scholar]. Coronary artery involvement had been reported in 9% to 15% of registered cases of Takayasu arteritis [6Lupi-Herrera E. Sanchez-Torres G. Marcushamer J. Mispireta J. Horwitz S. Vela J.E. Takayasu areteritis Clinical study of 107 cases.Am Heart J. 1977; 93: 94-103Abstract Full Text PDF PubMed Scopus (887) Google Scholar]. Angina pectoris is a common complaint in many of these patients; therefore, it is reasonable to suspect Takayasu disease in young Asian women complaining of angina pectoris with inflammatory laboratory data [7Singh S.K. Kumar D. Yadave R.D. Khanna A.R. Sinha S.K. Y graft bypass for bilateral coronary ostial aortoarteritis.Asian Cardiovasc Thorac Ann. 2002; 10: 162-164Crossref PubMed Scopus (3) Google Scholar]. Although coronary artery bypass graft is still considered the standard surgical treatment for the patients with coronary ostial stenosis, surgical patch angioplasty has been advocated as a suitable method of relieving isolated ostial stenosis in the absence of a distal coronary artery lesion. Especially for Takayasu disease, Ohara and colleagues [8Ohara K. Kasegawa T. Ando T. et al.Surgical treatment of coronary artery disease associated with aortitis syndrome.Kyobu Geka. 1986; 39: 423-431PubMed Google Scholar] reported a high incidence of graft failure. Endarterectomy of the proximal coronary arteries was reported by Baily and colleagues [9Bailey C.P. May A. Lemmon W.M. Survival after coronary endarterectomy in man.J Am Med Assoc. 1957; 164: 641-646Crossref PubMed Scopus (189) Google Scholar], but subsequently it was abandoned because of a high operative mortality rate. Some groups reported the efficacy of using the internal thoracic artery or gastroepiploic artery as graft conduits; however, if inflammation extends its origin, both arteries cannot be used as conduits. In the early 1980s, the improved results were obtained by Hitchcock's group with angioplasty of the left main coronary truncus [10Hitchcock J.F. Robies de Medina E.O. Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease.J Thorac Cardiovasc Surg. 1983; 85: 880-884PubMed Google Scholar]. Several successful series of coronary osteoplasty have been reported. Ghosh concluded in his review that patch angioplasty should be the preferred technique in patients with isolated ostial stenosis, because it restores a physiologic antegrade coronary flow [11Ghosh P.K. Coronary ostial reconstruction: technical issues.Ann Thorac Surg. 1991; 51: 673-675Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. In addition to this advantage, it seemed to be easier to make the smaller skin incision with patch angioplasty compared to coronary artery bypass graft surgery. From a cosmetic standpoint, the smaller skin incision can be an important concern, especially for a young female patient as in the present case. In terms of the selection of patch material, we used glutaraldehyde-treated autologous pericardium. This material can be obtained as large as needed; however, the saphenous vein has a limited width as a patch. Because the pulmonary artery can be involved in the inflammatory lesion of Takayasu disease, we suppose it should be avoided to be used as a patch. To prevent restenosis caused by shrinkage of fresh autologous pericardium, we treated autologous pericardium with 0.6% glutaraldehyde solution. It is still an autologous tissue. In conclusion, patch coronary ostial angioplasty using glutaraldehyde-treated autologous pericardium successfully resolved bilateral coronary ostial stenosis secondary to Takayasu disease in a young Japanese woman. The patient is in good health with comfortable daily life with mid-term follow up. We will continue to follow the long-term result of this case.
Publication Year: 2012
Publication Date: 2012-01-28
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']
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Cited By Count: 4
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