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Ann Thorac Surg 1995;60:65-66
© 1995 The Society of Thoracic Surgeons
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Introduction |
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 Top Introduction |
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DR CARY W. AKINS (Boston, MA): Doctor Craver and colleagues at Emory are to be congratulated for once again bringing cardiac surgeons up to date on the surgery for complications of newer techniques of invasive cardiology, in this case, the intracoronary stent. I also thank Dr Craver for supplying me with a copy of the manuscript before the meeting. The presentation describes excellent operative and long-term survival after coronary grafting for failed stent procedures between 1987 and 1994 in 68 patients, of whom 53 required emergency grafting.
The intracoronary stent may be the first adjunct to angioplasty that actually decreases the incidence of restenosis as seen in the documented results of the Stress Stent Trial in which restenosis fell from about 40% to about 30%. These results have led to an increasing utilization of stents for broader applications in many centers, and thus the current report is very timely. I have several questions for Dr Craver.
You noted that 56 of the 68 patients received a Gianturco-Roubin stent. At Massachusetts General Hospital, our interventional cardiology group, led by Drs Palacios, Gold, and Leinbach, has documented a requirement for very high levels of anticoagulation with that particular stent; they tried to achieve an international normalized ratio of 4.0. In fact, the high thrombotic potential of that stent has led us to operate on some patients almost prophylactically if the angiographic result is not perfect. Dr Craver, do you think that some of your late stent problems could be related to the thrombogenicity of that stent? In addition, have your interventional cardiologists altered their approach to this stent?
My next question relates to the Q-wave infarction rate of 21%. In the 1982 report from the Emory group concerning surgical results for revascularization after failed angioplasty, you made a strong case for an intervention that we at Massachusetts General firmly supported, namely, the insertion of an intraaortic balloon pump for patients in unstable condition; in your current series, only 16 patients, or 24%, received a balloon pump. Have you changed your earlier opinion about the efficacy of balloon pumping to reverse ischemia preoperatively? Also, do you think that more frequent use of the balloon pump might have yielded a lower infarction rate and might also have made it easier for you to harvest the mammary artery because the patient would have been in more stable condition during anesthesia?
My last question is, what do you do with your anticoagulation protocol after the operation? When a vein graft is put in, most of us use just aspirin, but if a stent is in place, we have a higher requirement for crystalline warfarin sodium anticoagulation. Do you now use combination therapy, or do you not worry about late thrombosis of the stent?
DR PETER C. PAIROLERO (Rochester, MN): Doctor Craver, thank you for an excellent presentation. You have demonstrated very nicely what happens after the patient is transferred to your care, but it also is of interest to know how many total patients at Emory had these stents placed and how many patients had complications that you were not called on to see. Also, were there patients with stent complications whom you saw but did not operate on?
DR CRAVER: I thank both discussants and particularly Dr Akins for his careful, insightful commentary. Restenosis indeed remains a problem with angioplasty. I indicated that stent placement as a prophylactic measure is perhaps where the evolution is taking us or taking stents; this is perhaps good and perhaps bad. When I was trained, Dr Robert Linton put wires in aortic aneurysms to cause them to clot, and I have always been of the opinion that this perhaps was what was going to happen to stented arteries long term. The prophylactic stents at Emory and other places have recently been placed particularly for proximal left anterior descending lesions. Half a Palmaz-Schatz stent is deployed at the time of the original angioplasty in an effort to create a lumen greater than 4.5 mm in diameter. Statistically, if you can achieve and keep that, the effects of later cellular hyperplasia are not as devastating in producing restenosis. We will have to watch.
The Emory cardiologists also have moved to the Palmaz-Schatz stent primarily with virtual abandonment now of the Cook Gianturco stent because of both thrombosis and deployment problems. The Palmaz-Schatz stent is more flexible and more easily deployed in tighter places because of the flexible hinge mechanism in the middle. The Gianturco stent was developed largely by a former cardiology colleague at Emory, Dr Gary Roubin, and that was the reason for its preponderance early in this series.
The Q-wave infarction rate is high. I alluded to the fact that seven of the 14 Q-wave infarctions occurred in the delayed surgical group. This group usually was seen by the cardiologist at a remote interval and with an infarction, and often the balloon pumps were put in after infarction was well established. For the acute surgical group, we still use the balloon pump early and have reduced the perioperative infarction rate to around 14%. We keep the balloon pump available; it is clearly of use in the catheterization laboratory, and trained technicians are always available if an angioplasty is being done.
The anticoagulation regimen we use after this operation is generally just aspirin. We have not thought that having a stent in place above a vein graft is necessarily an indication for continuing warfarin anticoagulation. We did have 1 patient in whom a clot propagated early distally from a proximal left anterior descending stent and occluded a vein graft to the left anterior descending coronary artery. This patient was managed by reoperation, removal of the clot, a new graft, and anticoagulation.
Doctor Pairolero, there were other bleeding complications. The femoral artery complication bleeding rate requiring operation by the vascular surgery service after all coronary artery stenting at Emory is 15%. Cardiac tamponade and other complications occurred at a much lower incidence. However, our cardiologists have patients on regimens of aspirin, dipyridamole, heparin sodium, and probably some kind of dextran type of medication for any angioplasty with a stent.
This article has been cited by other articles:
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  M. Murtra The adventure of cardiac surgery Eur. J. Cardiothorac. Surg., February 1, 2002; 21(2): 167 - 180. [Full Text] [PDF]
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 N. T. Kouchoukos Aortic allografts and pulmonary autografts for replacement of the aortic valve and aortic root Ann. Thorac. Surg., June 1, 1999; 67(6): 1846 - 1848. [Abstract] [Full Text] [PDF]
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