Same-Day Combined Percutaneous Coronary Intervention and Coronary Artery Surgery

Similar myocardial infarction and mortality rates are reported after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease [1]. Long-term patency after internal mammary artery (IMA) bypass has been found to be excellent by several centers [2,3,4]. Using the IMA as conduit of choice [3,4,5] decreases the reoperation rate. In case of severe extensive artery disease, the coronary artery may be reconstructed excluding any atherosclerotic plaques from the reconstructed vessel and preserving long-term patency [6]. Furthermore, the right coronary artery (RCA) is an independent predictor of early saphenous vein aortocoronary bypass occlusion [7]. A ‘hybrid’ procedure combining surgical revascularization of multivessel coronary artery disease with IMA bypass and an additional percutaneous interventional procedure is considered to be an attractive treatment option in some patients [8, 9]. The aim of the present prospective study was to evaluate the feasibility, safety and efficacy of such a hybrid procedure combining initial RCA angioplasty and surgical left coronary artery revascularization using the left and/or right IMA in the following 16 h.Since January 2000, 70 patients (53 male, mean age 68.5 ± 10 years) underwent hybrid revascularization. Over the same period, 850 PCI and 200 CABG were performed per year. The main reason for using a hybrid strategy in all these patients was the urgent need for revascularization between the angiographic diagnosis and treatment of the various coronary network and aortic valve lesions. Thus, all the patients required hospitalization during this period of time. Patients were selected for severe left coronary network lesions (type C, ≥90% or distal part of left main artery) associated with critical but PCI-accessible right coronary stenosis. The type of surgical revascularization varied, as the surgeon could tailor the left network revascularization technique to the patient and lesions, the right coronary being stabilized by PCI.Patient characteristics are summarized in table 1. Fifty-five patients (79%) had three-vessel disease, including 25 patients presenting left main coronary artery stenosis. In patients suffering from unstable angina, left coronary network lesions underlay the instability and were systematically associated with type A or B threatening right coronary stenosis.Mean left ventricular ejection fraction was 62 ± 9%. Except in 3 patients with aortic valve stenosis, the left coronary artery coronary artery disease was diffuse and extensive, unsuitable for PCI (≥90% on type C quantitative angiography of the modified AHA/ACC lesion), or involved the distal common left trunk. Right coronary stenoses, on the other hand, were all accessible to PCI.All patients were informed of the original procedure being proposed to ensure complete revascularization; none refused, on the contrary, there was a clear tendency in favor of the proposed procedure.PCI was performed using a 6F right guiding catheter and a transfemoral arterial approach. A bolus of 30 IU/kg heparin was administered intra-arterially. Patients were maintained on aspirin ahead of the procedure. Stents were deployed with or without predilation, at 12–16 atm. The target lesion was the proximal RCA in 13 patients (19%), the mid-RCA in 54 (78%) and the distal RCA in 13 (19%). Thirteen patients presented 2 RCA lesions. Mean stent diameter was 3.5 ± 0.5 mm. The sheath was removed at the end of the procedure, using the Angioseal device (St. Jude Medical, Minnetonka, Minn., USA). Ticlopidine 250 mg was prescribed at the end of PCI and 500 mg at the end of surgery; this was replaced by clopidogrel at 75 mg per day for 1 month thereafter.Surgical revascularization was performed a mean of 16 ± 2 h following PCI. The numbers and types of anastomoses are summarized in table 2. All procedures were performed without partial aortic clamping, as no venous grafts were used.Coronary artery reconstruction was performed in 16 patients (50%) in case of diffusely diseased left anterior descending artery. This technique has been described previously [6]. Mean coronary artery reconstruction length was 3.6 ± 1.7 cm.Myocardial protection was achieved by continuous retrograde warm blood cardioplegia. Mean cardiopulmonary bypass time was 120 ± 40 min. Six cases (8%) were managed off-pump.The safety and efficacy of our hybrid procedure were assessed postoperatively and on midterm clinical follow-up. The postoperative criteria were: peroperative mortality, myocardial infarction rate, use of inotropic drugs, reexploration for bleeding, postoperative bleeding, transfusion and in-hospital stay. The clinical follow-up noted a recurrence of cardiac events. The patients were followed up by the referring cardiologist and contacted by us 3 years postoperatively.Data are expressed as means ± standard deviation for continuous variables and as percentages for categorical variables.PCI of the RCA was successful in 69 patients. One stent was used in 57 patients (81%) and 2 on 2 different target lesions in 13 patients (19%). Subacute stent thrombosis occurred in 1 patient 8 h after PCI and PCI was repeated successfully; creatine kinase elevation was twice the upper normal limit and CABG was performed 5 weeks later after verification of RCA patency.CABG was performed on the same day in 69 patients (98%). The patients remained in the surgical intensive care unit for a mean of 2 ± 0.5 days and were all extubated within 3 ± 0.55 h after intervention. Inotropic drugs were required for 4 patients (6%). No cases of stroke, perioperative renal failure or sternal wound infection occurred.There were 3 major adverse clinical events, including 1 death. One patient showed subacute stent thrombosis on the 6th day after PCI due to failure to take ticlopidine, but was successfully treated with a second PCI. A second patient had major bleeding due to treatment by clopidogrel, requiring packed platelet transfusion; the consequent contraindication for clopidogrel led to subacute stent thrombosis, which was successfully treated by repeated PCI on day 7. In these 2 cases, creatine kinase elevation was less than twice the upper normal limit. The third patient had a severe pulmonary infection resulting in renal failure and death on day 7. Transfusion of 3 ± 1 packed red blood cells was necessary in 12 patients (17%), a rate not significantly different from that found with CABG alone [10]. There was no severe bleeding leading to the use of more than 5 packed red blood cells or surgery.After a mean follow-up of 33 months (range: 2–70 months), all 68 patients were free from angina and major cardiac events at the time of writing.A combination of PCI and CABG to treat multivessel coronary artery disease has been reported previously [8, 9, 11]. The present pilot study sought to assess the safety and feasibility of a same-day implementation of this approach in the treatment of severe two- or three-vessel coronary artery disease.Some multivessel disease patients may not be ideally suited for PCI (long lesions, dense calcifications, distal left main artery trifurcation or other bifurcations). The extremely high patency rate of a left IMA bypass to the left anterior descending artery is no longer questionable: it is a major factor in the long-term favorable results of surgery, and the most important independent predictor of long-term survival [5].Surgical treatment of the RCA in multivessel disease classically involves venous bypass. Many studies have shown that about 10% of venous bypasses are occluded at the time of discharge [12, 13] and 19–27% at 1 year of follow-up, with <50% remaining patent at 5 years [13, 14]. The RCA is an independent predictor of early saphenous vein aortocoronary bypass occlusion [7]. Therefore, PCI with stenting seems preferable to venous grafting. In the present study, patients showed threatening but nondiffuse RCA stenosis, <16 mm in length and >2.5 mm in diameter. That is, these lesions were perfectly accessible to bare-metal stenting, which accounts for the absence of clinical restenosis in our data. The advent of coated stents may enable more complex right coronary stenoses to be managed in this way.Hybrid strategy remains a subject of debate. The present study concerns PCI with stenting and IMA CABG within an interval of 16 hours. Currently, some authors tend to perform CABG of the left anterior descending artery first, followed by PCI several days later [8, 9, 15]. Left IMA to left anterior descending artery graft patency is then verified. PCI after same-day CABG affords several advantages: antiplatelet agents can be administered, the patient is already sedated and, assuming the left coronary artery to be responsible for unstable angina, more stable. First-step PCI, on the other hand, avoids dilated lesion destabilizing during left coronary network surgery, notably preventing peroperative or immediate postoperative right ventricle infarction. Surgical aortic clamping time is shortened, because there is no need for RCA graft anastomosis. Lateral aortic clamping for proximal aortic anastomosis of the graft is avoided. This is particularly valuable in the case of off-pump surgery, as the risk of postoperative stroke is reduced when the aorta is not surgically manipulated [16].PCI with stenting does not delay IMA CABG when treatment with aspirin and ticlopidine is used. Before the CLASSICS study was published [17], the combination of 500 mg ticlopidine and aspirin was the reference antithrombotic therapy after coronary stenting. Full antiplatelet treatment takes a few days, because of the delayed onset of ticlopidine action. On the other hand, clopidogrel (a new platelet ADP receptor antagonist) shows faster onset, particularly with a loading dose of 300 mg. In our strategy, the effect of ticlopidine was poor when IMA CABG was performed the next day; with a combined loading dose of aspirin and clopidogrel, on the other hand, the antiplatelet effect kicks in during the first day, increasing the rate of CABG bleeding [18], which accounts for the bleeding observed in the only patient of our series who received clopidogrel instead of ticlopidine.As we mentioned earlier, the major reason for our strategy was the urgent need for revascularization between the angiographic diagnosis and treatment of the various coronary network and aortic valve lesions in these unstable patients. Thus patients underwent concomitant treatment of multiple vessels during the same hospitalization. The good results in the present series are to be noted in the case of complete revascularization in patients with multivessel coronary artery disease, compared to results reported for surgery or PCI alone [19,20,21]. Compared to other hybrid revascularization series involving right coronary stenting [22,23,24], our follow-up results were very satisfactory. We did not perform mini-sternotomy, as this precludes coronary reconstruction. Eight percent of the patients were managed off-pump.Hybrid procedures combine the most successful applications of surgical and interventional techniques in patients with diffuse extensive multivessel coronary artery disease. The sequence of PCI followed by CABG in the next 16 h allows better left coronary artery revascularization by extending the benefit of coronary artery reconstruction, with the RCA already treated by PCI. With this hybrid procedure, PCI and IMA coronary grafting are not competitive but complementary, especially in the case of complex left coronary artery lesions.