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The proximal LIMA was then stented with a 3.5×15 mm Xience Xpedition (Abbott Vascular, Abbot Park, Ill., USA) drug eluting stent (DES) overlapping with a 3.5×18 mm Xience Xpedition compliant balloon was used to do multiple balloon angioplasties down the stented area. Next, a 3.5×23 mm Xience Xpedition PTCA was performed in the intervening area between the stents between the stented segments as well as at the ostium (Figure-3).
Next, a 3.5×28 mm Promus Premier drug-eluting stent was deployed in the segment between the stents, overlapping the deployed at the ostium of the LIMA that was post dilated with
a 4.0×8 mm Flash Ostial dual balloon system (Access Closure Inc. Santa Clara, Calif., USA) resulting in complete sealing subclavian artery (Figure-4). All wires were removed and (Figure-5).
DISCUSSION
LIMA is the most common arterial graft used for coronary artery bypass graft surgery. Spontaneous as well as angiography induced LIMA dissection has been reported in literature since 4-7 Angioplasty of left internal mammary artery (LIMA) graft is challenging especially
REFERENCES
FIGURE 4
Flash dual balloon angioplasty at the Ostium of LIMA.
when it is done through the femoral approach due to the
sharp angulation between the proximal subclavian artery and the LIMA leading to inadequate guiding catheter support, suboptimal guidewire manipulation and balloon delivery due to relatively long length of the LIMA.6 Additionally, using a large guiding catheter to engage a small LIMA may interfere with subclavian artery.6
Multiple techniques were suggested to provide better support for LIMA interventions and decrease the challenges and potential complications associated with it. This includes the use of a
1. Berger PB, Alderman EL, Nadel A, Schaff HV. Frequency of early occlusion and stenosis in a left internal mammary artery to left anterior descending artery bypass graft after surgery through a median sternotomy on conventional bypass: benchmark for minimally invasive direct coronary artery bypass. Circulation. 1999;100:2353-2358.
2. Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg. 2004;77:93-101.
3. Khan Z, Latif F, Dasari TW. Internal mammary artery graft dissection: a case-based retrospective study and brief review. Tex Heart Inst J. 2014;41:653-656.
4. Farooqi S, Jain AC, O’Keefe M. Catheter-induced left internal mammary artery bypass graft dissection. Cathet Cardiovasc Diagn. 1985;11:597-600.
5. Freeman SP, Liston MJ, Lips DL, Vacek JL. Catheter-induced left internal mammary artery dissection: a report of two cases and review of the literature. J Interv Cardiol. 2004;17:117-121.
6. Hung WC, Guo BF, Wu CJ, Chen CJ, Fang CY. Direct stenting of a transradial left internal mammary artery graft. Chang Gung Med J. 2003;26:925-929.
7. Karabulut A, Tanriverdi S. Acute coronary syndrome secondary to spontaneous dissection of left internal mammary artery by-pass graft nine years after
surgery. Kardiol Pol. 2011;69:970-972.
8. Kuntz RE, Baim DS. Internal mammary angiography: a review of technical issues and newer methods. Cathet Cardiovasc Diagn. 1990;20:10-16.
178 Del Med J | June 2015 | Vol. 87 | No. 6
