[HSF] DES-SVG anastomosis

Wed Mar 19 20:39:24 EDT 2008

Igor, thanks for being so gentle and supportive in your reply. Unfortunately,
we run out of flow-metric sondes, so we do not measure IMA or SVG flow since
few years ago. Bad habbit, I agree. Ex iuvantibus, everything is still OK
(it's now slightly more than 24h, which is - I believe - quite enough for
eventual thrombosis to become aparent. Patient is awake, HD stabile all the
time, extubated this morning and really very happy (without any neurological
reasons to fell so:)
I'm anxious to publish some intraoperative pictures, which I consider my
modest contribution to surgical efforts in surviving cardiological PCI
agression:) I am fed of their uncritical arguments in favour of stents! Maybe
I'm wrong, but I think that we have serious job to do to re-establish the
proper position of our specialty. 

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Igor Rudez
Sent: Wednesday, March 19, 2008 3:17 PM
To: OpenHeart-L at lists.hsforum.com
Subject: RE: [HSF] DES-SVG anastomosis

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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