[HSF] DES-SVG anastomosis

[Mladen Kocica]

Hi,
 
Has anybody actually saw intracoronary stent intraoperatively? I can't sleep tonight, because I did so yesterday on purpose. Moreover, I've done the atherocut of it. Yet, to have a real nightmare, I sew the graft to the end of it. Enough? Why nightmare? 
The patient received 1 DES on proximal LAD 2 years ago. He stopped Plavix 1 year ago and 6 months ago, he returned with svere angina. Cath revealed 70% and 90% in-stent-stenoses with patent distal LAD. Without any logical reason, he was adviced to continue with pills. Of course, he finally came to us, with no relief. 
I hoped to OPCABG him, according to (bad estimation) still valid cath! As devil never sleeps, I decided to open the pericardium before LIMA harvesting, and I was astonished with LAD appearance. It was petrified on entire lenght. No place to cut. Than comes the crazy part. Open LAD endarterectomy. I got several septals and diagonals free, and at the most proximal point, I met HM the stent, "gazing" at me. A hell of a scene. I read a lot about autopsy findings of severe inflammation arounf this piece of iron, but this was my first eye-to-eye meeting with this kind of reality. If all peri-stent tissues are the same - do not dare to remove stents. Its impossible. Nevertheless, the cavity of it was apparent, as well as neointimal proliferation, occluding its lumen. I started wash-out with cardioplegia and "re-opened" the stent with 1.5mm aterocut. The final act was to "cover the hole" I've made. I sew the SVG heal for the BMS and patched the opened LAD with the rest of the vein. This thing was working!?! Entire procedure uneventfull. ECG normal. Patient stabile in ICU. Ordered heparin with target aPTT 85-100. No bleeding. I intend to continue with aspirin and to switch heparin with OAT, after chest tube removal.
Has anybody did such stupid thing so far. Its been 12 hours since we finished, and everything is still quiet. I do expect that stents would close again, but I can't swear.
So, I am ready. Shoot, please! 
 
 
Mladen J. Kočica, M.D.
Consultant Cardiac Surgeon
Clinic for Cardiac Surgery
Clinical Centre of Serbia
11000 Belgrade
Serbia
Phone: +381(11)3670609
E-mail: kocica at sezampro.yu
URL: www.kocica.org <http://www.kocica.org/> 
CTSNet: www.ctsnet.org/home/mkocica
 
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