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From the Divisions of Cardiology and Cardiovascular Surgery, The
University of Pittsburgh Medical Center, Presbyterian University Hospital,
Pittsburgh, Pa.
Abstract
Background—Angioplasty has become an accepted treatment of
patients with coronary artery disease and is now commonly used
to treat patients with multivessel disease. The major disadvantage of
angioplasty has been restenosis requiring repeat interventions
with resultant loss of initial cost savings. Compared with the right
and the circumflex coronary arteries, the left anterior
descending artery (LAD) has been more adversely affected by
restenosis. Recently, minimally invasive direct
coronary artery bypass (MIDCAB) to the LAD through a small left
anterior thoracotomy using the left internal mammary artery has been
performed in some centers with excellent early results and with reduced
costs compared with standard bypass
surgery.
Methods and Results—We retrospectively reviewed the first 31
consecutive patients treated in our institution with integrated
coronary revascularization (ICR): MIDCAB to
the LAD combined with PTCA of the other diseased vessels in patients
with multivessel disease. Postoperative angiography in 84% of patients
revealed a patent anastomosis and normal flow in the graft and bypassed
vessel. Thirty-eight (97%) of 39 vessels were successfully treated
percutaneously. At a mean follow-up of 7 months, all
patients are currently asymptomatic. There have been 2
adverse clinical events, both related to angioplasty and not to MIDCAB.
The average length of stay at the hospital after MIDCAB was 2.79±1.05
days.
Conclusions—These preliminary results with ICR are encouraging
and suggest that a randomized, prospective clinical trial comparing ICR
with standard coronary artery bypass surgery for the
revascularization of symptomatic
patients with multivessel disease involving the LAD is warranted.
Over the past 2 decades, PTCA has become an accepted and
effective treatment of coronary artery disease. Initially used
in patients with single discrete lesions and subsequently in patients
with complex multivessel disease, PTCA has gained widespread
acceptance because of its relative efficacy in relieving
symptoms, with decreased morbidity and cost compared with
coronary bypass surgery (CABS).1 2 The major
limitation of PTCA has been the problem of restenosis and the
need for repeat procedures.3 Randomized clinical trials
comparing PTCA and CABS, however, have revealed no survival benefit of
CABS at 5-year follow-up.1 In addition, the cost savings
initially achieved by PTCA were largely eroded by 5 years because of
the need for repeat procedures.2 These comparisons were
performed before the use of stents, which have improved long-term
results compared with routine PTCA.4 Furthermore,
deployment of the stent at high pressure with appropriate
antiplatelet regimens rather than aggressive anticoagulation has
improved short-term results.5 This provides an opportunity
to decrease overall costs despite the initial cost of the stent because
of shortened length of stay in the hospital, decreased bleeding and
subsequent blood transfusions, and decreased restenosis.
Surgery, on the other hand, has recently made major technological and
procedural advances with the introduction of minimally invasive direct
coronary artery bypass (MIDCAB) performed through a
small left anterior thoracotomy using the left internal mammary artery
(LIMA) to revascularize the left anterior descending coronary
artery (LAD) territory in a beating heart without
cardiopulmonary bypass.6 The LIMA graft to the LAD
performed in the routine fashion through a midline sternotomy has been
shown to confer survival benefit.7 Compared with routine
CABS, MIDCAB can be performed with decreased resource
utilization8 and with far less morbidity, even in
high-risk patients.9 The MIDCAB operation is currently
limited, however, to revascularization of the LAD
territory, with the circumflex and the right coronary arteries
less accessible, making this surgical approach inappropriate for
providing complete revascularization in patients
with multivessel disease.
We hypothesized that integrated coronary
revascularization (ICR) with MIDCAB to the LAD
combined with PTCA (with stenting when possible) of the other diseased
arteries in patients with multivessel disease could effect optimal
revascularization with equivalent outcomes at
reduced costs. To test this hypothesis, we reviewed the hospital course
and outcomes of the first 31 patients consecutively treated by ICR at
our institution.
Methods
Patients were selected for ICR if they had an LAD lesion thought
to be less than ideal for percutaneous intervention in
the presence of multivessel disease, with the remaining vessels
amenable to PTCA. In general, PTCA (with stent insertion whenever
possible) was performed first, followed by MIDCAB, except in patients
with unstable angina pectoris or left main coronary disease, in
whom the order was reversed. MIDCAB was performed via a left anterior
thoracotomy, with the LIMA harvested back to its origin. Postoperative
angiography to demonstrate patency of the LIMA anastomosis and flow in
the LAD was performed either at the time of PTCA, at the time of
MIDCAB, or as a separate procedure after MIDCAB. All patients had
routine clinical follow-up and were contacted by a nurse to assess
outcomes and symptoms, which were graded according to the Canadian
cardiovascular classification system.
Results
Between September 1996 and January 1998, 31 patients underwent
ICR. Twenty-six (84%) procedures were done electively and 5 (16%) on
an urgent basis. Five patients (16%) had evidence of acute
nontransmural myocardial infarction within 2 days immediately before
the ICR. Two patients (6%) were on an intra-aortic balloon pump, and 4
(13%) had a history of congestive heart failure. Six (19%) had a
documented ejection fraction <35%. Ten patients (32%) had diffuse
peripheral vascular disease, and 8 (26%) had severe
carotid disease documented by carotid ultrasound. Eighteen patients
(58%) had chronic obstructive pulmonary disease by history or
by pulmonary function testing with a forced expiratory volume
in 1 second of <50% of that predicted. Six patients (19%) had a
history of chronic renal insufficiency with a creatinine
level of
Discussion
The results of this retrospective study of consecutively treated
patients suggest that ICR is a safe and effective therapy, at least in
the short term, for patients with multivessel coronary artery
disease and that it provides an important treatment alternative. Even
patients at high risk, with left main disease, low ejection fraction,
advanced age, and significant comorbidities, were successfully treated
with no mortality and minimal morbidity. It has already been
demonstrated that MIDCAB can be performed with a reduction in cost and
resource use compared with routine CABS.8 A major question
that still remains is whether or not the LIMA-LAD anastomosis as
performed via MIDCAB is as durable and effective as that performed via
midline sternotomy on cardiopulmonary bypass with cardioplegic
arrest. These early results would suggest that in experienced hands,
the LIMA-LAD anastomosis as performed by MIDCAB is as effective as when
performed by the conventional approach. Experience should be
emphasized, because there appears to be a steep learning curve for this
surgery.6
Recent studies1 in patients with multivessel disease have
shown that PTCA is equivalent to CABS in terms of mortality, with
follow-up to 5 years. There is an erosion, however, of the initial cost
savings because of restenosis and the need for
reintervention.2 These trials were performed before the
advent of the routine use of stenting in appropriately sized vessels.
Stenting, although initially expensive owing to the cost of the stent,
may be cost neutral or even cost saving because of diminished
restenosis and the reduced need for repeat procedures. It is
anticipated that the cost of stenting will decrease with the
introduction of more stents into the US market and with improvement in
stent technology and deployment strategies. MIDCAB to the LAD in
vessels not ideally suited for PTCA (eg, long lesions, dense
calcification, and bifurcated lesions) may prove to be superior to PTCA
(even with stenting) because studies have demonstrated the increased
propensity for restenosis in the LAD compared with the
circumflex and right coronary arteries.3 Mariani
and coworkers10 have demonstrated that MIDCAB is
equivalent to PTCA in patients with type C lesions of the LAD in terms
of 1-year survival and major adverse clinical events but that MIDCAB is
superior to PTCA in that it requires significantly fewer
reinterventions. When combined with MIDCAB to the LAD, PTCA of non-LAD
lesions (with stenting when possible) is potentially as effective as
and less costly than routine CABS for the treatment of patients with
multivessel disease. Furthermore, the elimination of
cardiopulmonary bypass, particularly in patients at high risk,
may avoid the significant incidence of neurological sequelae recently
reported with routine CABS.11
Although costs were not directly assessed in this retrospective
analysis of consecutive patients with multivessel disease
treated with ICR, the short lengths of hospital stay and the ability to
perform MIDCAB and PTCA on the same day indicate an opportunity for
cost savings. To maximize the potential for reducing costs, ICR should
ideally be performed with a "team" approach in a single combined
operating room/cardiac catheterization laboratory that
will allow for the seamless performance of MIDCAB immediately
followed by PTCA, or vice versa. This single-room approach must provide
an ideal environment for both the surgeon and the interventional
cardiologist and not compromise the technical ability of either
operator. These preliminary results are encouraging and suggest that a
randomized, prospective clinical trial comparing ICR with standard CABS
for the revascularization of
symptomatic patients with multivessel disease involving the
LAD is warranted.
Footnotes
Reprint requests to Howard A. Cohen, MD, Division of Cardiology, UPMC, Presbyterian University Hospital, S566 Scaife Hall, 200 Lothrop St, Pittsburgh, PA 15213.
Received March 5, 1998;
revision received August 5, 1998;
accepted August 11, 1998.
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retrospectively reviewed the first 31 consecutive patients treated with
integrated coronary revascularization
(ICR): minimally invasive direct coronary artery bypass to the
left anterior descending coronary artery combined with PTCA of
the other diseased vessels in patients with multivessel disease.
Postoperative angiography in 84% of patients revealed a patent
anastomosis and normal flow in the graft and bypassed vessel. PTCA was
successful in 97% of vessels treated. At a mean follow-up of 7 months,
all patients are asymptomatic. These early results are
encouraging and suggest that a randomized, prospective clinical trial
comparing ICR with standard coronary artery bypass surgery for
the revascularization of patients with multivessel
disease involving the left anterior descending coronary artery
is warranted.
© 1998 American Heart Association, Inc.
Brief Rapid Communication
Feasibility of Combined Percutaneous Transluminal Angioplasty and Minimally Invasive Direct Coronary Artery Bypass in Patients With Multivessel Coronary Artery Disease
Key Words: bypass • revascularization • angioplasty
2.0 mg/dL. MIDCAB was performed to the LAD in 30
patients (97%) and to the LAD diagonal in 1 patient (3%). A Y graft
was constructed from the LIMA to the LAD diagonal in 1 patient.
Postoperative angiography performed in 26 patients (84%) revealed
patency of the LIMA anastomosis, with normal flow in the bypass and
grafted vessels in all patients. Single-vessel PTCA was performed in 24
patients (77%) and double-vessel PTCA in 6 (19%). One patient (3%)
had 3-vessel PTCA. The target vessel for PTCA was the left main
coronary artery in 4 patients (13%), the circumflex in 9
(29%), the obtuse marginal in 9 (29%), the ramus intermedius in 2
(6%), the LAD diagonal in 3 (10%), the right coronary artery
in 9 (29%), the right posterior descending in 1 (3%), and the right
posterolateral branch of the right coronary artery in 2 (6%).
Thirty-eight (97%) of 39 vessels were successfully treated
percutaneously, with 1 failure in a chronic total
occlusion. Of the 38 vessels successfully treated, 23 (60%) were
stented, 13 (34%) received balloon angioplasty alone, and 2 (6%) had
rotational atherectomy with adjunctive balloon angioplasty. The average
length of hospital stay from MIDCAB to discharge was 2.79±1.05 days.
ICR was performed on day 0 in 18 patients (58%), day 1 in 3 patients
(10%), and day 2, 3, or 4 in 10 patients (32%). There were 2 major
adverse clinical events. One patient with subacute stent thrombosis
due to failure to take ticlopidine was successfully treated with repeat
PTCA and ultimately CABS because of recurrent symptoms. A second
patient had an acute subendocardial myocardial infarction 3 months
after ICR, with acute occlusion of the proximal right coronary
artery remote from the stent placed in the mid right coronary
artery during the initial procedure. At follow-up at an average of 7
months (range, 1.0 to 13 months), all patients are alive and in
Canadian cardiovascular class I.
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