Asian Cardiovasc Thorac Ann 2002;10:162-164
© 2002 Asia Publishing EXchange Pte Ltd
"Y" Graft Bypass for Bilateral Coronary Ostial Aortoarteritis
Sushil K Singh, MCh,
Deepak Kumar, MD1,
Ram D Yadave, DM2,
Asha R Khanna, DM2,
Subhash K Sinha, MCh
Department of Cardiothoracic and Vascular Surgery
1 Department of Cardiac Anaesthesia
2 Department of Cardiology Batra Hospital and Medical Research Centre New Delhi, India
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Subhash K Sinha, MCh Tel: 91 11 608 6951 Fax: 91 11 608 7661 email: sksinha{at}del3.vsnl.net.inDepartment of Cardiothoracic and Vascular Surgery, Batra Hospital and Medical Research Centre, Mehrauli Badarpur Road, 1 Tughlakabad Institutional Area, New Delhi 110062, India.
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ABSTRACT
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A case of bilateral coronary ostial aortoarteritis, which presented with angina pectoris, is reported. Emergency total arterial revascularization was performed using the bilateral mammary artery and radial artery, and the radial artery was hanged "Y" on the left internal mammary artery. The patient was discharged on low-dose steroid. He was asymptomatic at 1-year follow-up.
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INTRODUCTION
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Savory in 1856 and Kussmaul in 1872 reported the earliest cases of nonspecific arteritis of unknown origin affecting the aorta and its branches. In 1908, Takayasu reported a case of a young woman with a peculiar wreath-like arteriovenous anastomosis around the papillae in the ocular fundi. Takayasu's arteritis is a disease of unknown etiology that predominantly affects the aortic arch and the proximal portion of its major branches, as well as the pulmonary arteries, in young Asian women.1 Frovig and Loken first reported in 1951 coronary artery (CA) involvement in Takayasu's arteritis, which includes stenosis or obstruction, aneurysm, dilation and kinking, and coronary steal syndrome caused by fistula formation. The lesions are found predominantly in the ostia or the proximal parts of the CAs.2
This report describes a patient who presented, as the first symptom of Takayasu's arteritis, angina pectoris resulting from bilateral coronary ostial stenosis. He was treated successfully by total arterial coronary revascularization using a Y graft.
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CASE REPORT
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A 33-year-old male, a chronic smoker for the last 15 years, was admitted with severe chest pain and shortness of breath, which had started an hour earlier. He had on and off chest pain for the last 6 months, which usually lasted 5 to 10 minutes, but never sought medical advice. He had no history of any serious illnesses, including diabetes and hypertension, nor a family history of coronary artery disease. Physical examination revealed a pulse rate of 126 beats•min-1 and blood pressure of 96/64 mm Hg. His peripheral pulse in all 4 limbs was palpable and symmetric. His optic fundi were normal. There was no cardiac enlargement, and heart sounds were normal. Routine hematological examination including Wasserman reaction and VDRL (Venereal Disease Research Laboratory) test was normal, but the erythrocyte sedimentation rate, C-reactive protein level, and leukocyte count were increased. Electrocardiography showed sinus tachycardia and ST segment depression in leads I, II, III, aVL, aVF, and V2 to V6. Selective coronary angiography demonstrated severe narrowing of both the right and left coronary ostia but not in the remaining coronary vessels (Figures 1 and 2
). Thoracic aortography showed that the thoracic and abdominal aortae, as well as the renal and carotid arteries, were normal.
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Figure 1. Selective left coronary angiogram showing critical narrowing of the ostium of the left main coronary artery.
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Figure 2. Selective right coronary angiogram showing critical narrowing of the ostium of the right coronary artery.
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The ascending aorta was found to be the site of inflammatory reaction with severe ostial stenosis of both the right and left CAs resulting from proliferation of the aortic intima. Coronary artery bypass grafting was performed, where the left internal mammary artery (IMA) was anastomosed to the left anterior descending artery, the right IMA to the right CA, and the left radial artery (RA) to the obtuse marginal artery. The proximal end of the RA was anastomosed to the left IMA as a Y graft. Histopathological examination of aortic tissue showed nonspecific aortoarteritis with degenerative changes (Figure 3). The patient was discharged on low-dose steroid, which was stopped after 3 months. Stress test performed after 3 months was negative. At 1-year follow-up, the patient was asymptomatic.
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Figure 3. Histologic section of the ascending aorta showing lymphocytic infiltration of the aortic wall (hematoxylin and eosin stain, original magnification x400).
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DISCUSSION
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Takayasu's arteritis is a disease of unknown origin that predominantly affects young Asian women and usually has its onset during the second or third decade of life. The disease produces aortitis that may result in stenosis or, less commonly, dilation of the thoracic or abdominal aorta, or both, or the proximal segment of major arteries that arise from the aorta.3 CA involvement has been observed in 9% to 15% of registered cases of Takayasu's arteritis.2 In a review of cases of this disease, most of the patients complained of angina pectoris as the initial symptom, and several patients had CA involvement at the time of operation.4 Therefore, it would be reasonable to suspect Takayasu's arteritis in young Asian women with angina pectoris if laboratory findings suggest an inflammatory background.5 In the majority of cases, the ostia or the proximal major branches of the CAs are believed to be involved. Since most of the symptomatic patients have severe lesions, surgical treatment is mandatory for CA involvement in Takayasu's arteritis, although good palliation has been described using transluminal coronary angioplasty and steroid therapy.6 However, the underlying inflammatory process of the disease makes it very difficult to decide the right time for operation, the operative methods that should be employed, and the correct postoperative management.
The choice of operative procedure for ostial stenosis is controversial.4 Ohara and coworkers7 reported a high incidence of graft failure in patients with Takayasu's arteritis treated by coronary artery bypass grafting of the saphenous vein (50%) compared with patients with other disorders treated by the same method (6%). To avoid failure of the saphenous vein graft resulting from occlusion of the proximal aortic anastomosis, transaortic endarterectomy or angioplasty has been employed as an alternative to bypass surgery,7 although stenosis at the coronary ostium could occur in endarterectomy if the inflammation extends.
Some groups reported that arterial grafts using the IMA and gastroepiploic artery2 were effective in treating ostial lesion in Takayasu's arteritis. But the IMA or the gastroepiploic artery cannot be used as a conduit if inflammation extends to the aortic arch or the descending aorta, respectively. All surgical methods for coronary stenosis have merits and demerits. We grafted the bilateral mammary artery to the left anterior descending and right CAs because inflammation did not extend to any of the branch arteries, and the RA was grafted to the obtuse marginal artery as a support. The proximal end of the RA was hanged "Y" on the left IMA to avoid using the aorta as the proximal anastomotic site.
Perioperative steroid therapy for Takayasu's arteritis is also controversial. Corticosteroids are accepted as an effective therapy in controlling clinical manifestations and inducing remission of the disease. The patency rate of saphenous vein grafts in the study by Ohara's group7 was high in patients who received postoperative steroid therapy (91.7%). Amano and Suzuki6 recommended the use of steroids in patients who are operated in a clinically active stage or who have histologic evidence of inflamma-tion in the aortic wall immediately after operation until the erythrocyte sedimentation rate and C-reactive protein level return to normal or until the clinical condition improves.
Bilateral coronary ostial lesion successfully treated by total arterial revascularization with a Y graft has rarely been described. In a review of 16 cases of coronary arteritis by Cipriano and coworkers,8 all the cases had associated narrowing of other arteries, and all except one of the patients died, underlining the poor prognosis of the disease and the need to treat the stenosis.
To conclude, Takayasu's arteritis may cause bilateral coronary ostial stenosis if the CAs are the initial site of severe arterial narrowing, and angina pectoris may be the first symptom. Total arterial revascularization using a Y graft formed by the IMA and RA is effective in treating the stenosis.
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REFERENCES
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Ueda H, Morooka S, Ito I, Yamaguchi H, Takeda T. Clinical observation of 52 cases of aortitis syndrome. Jpn Heart J
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Endo M, Hashimoto A, Koyanagi H, Sekiguchi M, Hirosawa K, Yasuda H, et al. Coronary angiographic findings and surgical treatment of Takayasu disease [Japanese]. Kokyu To Junkan
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Thomas D, Dubourg O, Bletry O, Kieffer E, Vedel J, Fenoll L, et al. Coronary involvement in Takayasu's disease. Apropos of 3 cases, of which 2 were surgically treated, and review of the literature [French]. Arch Mal Coeur Vaiss
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Amano J, Suzuki A. Coronary artery involvement in Takayasu's arteritis. Collective review and guideline for surgical treatment. J Thorac Cardiovasc Surg
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Ohara K, Kasegawa T, Ando T, Kawazoe K, Kosakai Y, Kaku K, et al. Surgical treatment of coronary artery disease associated with aortitis syndrome [Japanese]. Kyobu Geka
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Cipriano PR, Silverman JF, Perlroth MG, Griepp RB, Wexler L. Coronary arterial narrowing in Takayasu's aortitis. Am J Cardiol
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ABSTRACT
INTRODUCTION
