[HSF] DES-SVG anastomosis

[Igor Rudez]

Mladen,
Congrats on heroic effort you made! Whenever I encounter stent (BMA or DES,
it's the same BS) I try to get my anastomosis just distal of it, if
possible! What you did, seems to me, under the circumstances, was the only
thing you could possibly do!
I would like to ask you if you measured graft patency, and if so, how it
was?
Thnx,
Igor

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Mladen Kocica
Sent: Wednesday, March 19, 2008 3:47 AM
To: Heart Surgery Forum
Subject: [HSF] DES-SVG anastomosis


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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