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(Circulation. 1998;98:1048-1050.)
© 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

Howard A. Cohen, MD; Marco Zenati, MD; A.J. Conrad Smith, MD; Joon S. Lee, MD; Simon Chough, MD; Zubair Jafar, MD; Peter Counihan, MD; Mark Izzo, MD; J.E. Burchenal, MD; Arthur M. Feldman, MD, PhD; ; Bartley Griffith, MD

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.

Key Words: bypass • revascularization • angioplasty

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 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.

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.

References

1. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335:217–225.[Abstract/Free Full Text]
   
2. Hlatky MA, Rogers WJ, Johnstone I, Boothroyd MS, Brooks MM, Pitt B, Reeder G, Ryan T, Smith H, Whitlow P, Wiens R, Mark DB. Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery: Bypass Angioplasty Revascularization Investigation (BARI) Investigators. N Engl J Med. 1997;336:92–99.[Abstract/Free Full Text]
   
3. Leimgruber PP, Roubin GS, Hollman J, Cotsonis GA, Meier B, Douglas JS, King SB Jr, Gruentzig AR. Restenosis after successful coronary angioplasty in patients with single-vessel disease. Circulation. 1986;73:710–717.[Abstract/Free Full Text]
   
4. Serruys PW, deJaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G, Emanuelsson H, Marco J, Legrand V, Materne P, Belardi J, Sigwart U, Colombo A, Goy JJ, Heuvel P, Delcan J, Morel MA. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med. 1994;331:489–495.[Abstract/Free Full Text]
   
5. Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G, Gaglione A, Goldberg SL, Tobis JM. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation. 1995;91:1676–1688.[Abstract/Free Full Text]
   
6. Calafiore AM, Giammarco GD, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Vitolla G, Sciarra A, Fino C, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61:1658–1663.[Abstract/Free Full Text]
   
7. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC, Proudfit WL. Influence of the internal mammary artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986;314:1–6.[Abstract]
   
8. Zenati M, Domit TM, Saul M, Gorcsan J III, Katz WE, Hudson M, Courcoulas AP, Griffith BP. Resource utilization for minimally invasive direct and standard coronary artery bypass. Ann Thorac Surg. 1997;63(suppl):S84–S87.
   
9. Zenati M, Cohen HA, Feldman MD, Chough SH, Courcoulas AP, Smith CA, Lee JS, Izzo M, Counihan PJ, Jafar MZ, Griffith BP. Improved results of minimally invasive coronary artery bypass in Parsonnet very high risk patients. Circulation. 1997;96(suppl I):I-682. Abstract.
   
10. Mariani MA, Boonstra PW, Grandjean JG, Peels JO, Monnink SH, den Heijer P, Crijns HJ. Minimally invasive coronary artery bypass grafting versus coronary angioplasty for isolated type C stenosis of the left anterior descending artery. J Thorac Cardiovasc Surg. 1997;114:434–439.[Abstract/Free Full Text]
    
11. Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A, Marschall K, Graham SH, Ley C. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med. 1996;335:1857–1863.We 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.[Abstract/Free Full Text]
    

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