Multi-Vessel Coronary Artery Disease: Choice of Myocardial Revascularization Strategy
PDF
XML

Keywords

Revascularization
Percutaneous Coronary Intervention
Coronary Artery Bypass Grafting
Fractional Blood Flow Reserve
Acute Myocardial Infarction

How to Cite

Seredyuk, N., Matlakh, A., Vandzhura, Y., Bielinskyi, M., Skakun, O., & Denina, R. (2020). Multi-Vessel Coronary Artery Disease: Choice of Myocardial Revascularization Strategy. Galician Medical Journal, 27(4), E202041. https://doi.org/10.21802/gmj.2020.4.1

Abstract

Multi-vessel coronary artery disease is quite a common state, which is often diagnosed by coronary angiography in patients with both stable coronary artery disease and acute coronary syndromes. Major difficulties in percutaneous coronary intervention include stent thrombosis and the need for antiplatelet therapy (aspirin and a P2Y12 inhibitor). Stent thrombosis leads to the recurrence of myocardial infarction and may occur within the first few hours after percutaneous coronary intervention. The use of dual antiplatelet therapy, especially that combined with low-molecular-weight heparin in the first days after myocardial infarction, poses a risk of bleeding, which often occurs in real clinical practice. Among P2Y12  inhibitors, ticagrelor causes bleeding somewhat more frequently than clopidogrel. A case of multi-vessel coronary artery disease is described in this paper. Coronary angiography revealed right-dominant circulation; occlusion of the proximal and medial segments of the right coronary artery, thrombolysis in myocardial infarction flow grade 0; stenosis of the left main coronary artery (50-60%), thrombolysis in myocardial infarction flow grade 2; diffuse stenosis of the medial and distal segments of the left anterior descending artery, thrombolysis in myocardial infarction flow grade 1; stenosis of the proximal segment of the left circumflex artery (> 75%), thrombolysis in myocardial infarction flow grade 1. The patient underwent percutaneous coronary intervention; the stents were implanted in the infarct-dependent right coronary artery. The clinical course was complicated by early stent thrombosis with subsequent thrombus extraction; a day later melena developed. Bleeding was stopped, the intensity of antithrombotic therapy was reduced: the combination of aspirin and ticagrelor was replaced by the combination of aspirin and clopidogrel. Six weeks after stenting of the infarct-dependent coronary artery, complete myocardial revascularization (hybrid intervention) was performed: coronary artery bypass grafting [the left internal mammary artery → the left anterior descending artery], coronary autogenous bypass grafting [the aorta → the right coronary artery and the aorta → the left circumflex artery]. The role of fractional flow reserve or instantaneous wave-free ratio-controlled complete myocardial revascularization techniques is discussed. The following algorithm for myocardial revascularization was used: percutaneous coronary intervention for the right coronary artery + coronary artery bypass grafting-3: the left internal mammary artery → the left anterior descending artery, the aorta → the left circumflex artery, the aorta → the right coronary artery.

https://doi.org/10.21802/gmj.2020.4.1
PDF
XML

References

Obeid MA, Abdurakhmanov AA, Mashrapov OA, Ganiyev US. The results of surgical revascularization in patients with multi-vessel coronary disease. Inter Collegas [Internet]. 2017 Feb 5;3(4):163-5. Available from: https://doi.org/10.35339/ic.3.4.163-165

Gabrielyan A, Domanskyy T, Beregovoy O. Method of hybrid revascularization of miocard in patients with atherosclerotic damage of coronary vessels. Ukr J Cardiovasc Surg [Internet]. 2018 May 14;25(3):18–21. Available from: https://doi.org/10.30702/ujcvs/18.31/03(018-021)

Demianenko VM, Babliak OD, Babliak DY, Stohov OS, Melnyk EA, Revenko KA, et al. Features of Cardiopulmonary Bypass in Mininvasive Multivessel Coronary Artery Bypass Grafting. Ukr J Cardiovasc Surg [Internet]. 2019 May 22;137(14):18-22. Available from: https://doi.org/10.30702/ujcvs/19.3505/0370018-022

Kozlov KL, Mihajlov SS, Shishkevich AN, Oleksyuk IB, Sedova EV, Rybin EV, et al. Opyt etapnoy gibridnoy revaskulyarizatsiyi patsiyenta pozhilogo vozrasta s generalizovannym aterosklerozom. Klinicheskaya Gerontologiya. 2013;(5):46-8.

Shilov AA, Kochergin NA, Ganyukov VI, Kozyrin KA, Barbarash OL. Immediate results of three methods of surgical myocardial revascularization in multivessel lesion of the coronary bed. Angiol Vasc Surg [Internet]. 2019 May 22;25(3):135. Available from: https://doi.org/10.33529/ANGI02019314

Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J [Internet]. 2019 Jan 7;40(2):87-165. Available from: https://doi.org/10.1093/eurheartj/ehy394

Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3-PRIMULTI): an open-label, randomised controlled trial. Lancet [Internet]. 2015 Aug 7;386(9994):665-71. Available from: https://doi.org/10.1016/S0140-6736(15)60648-1

Fearon WF, Nishi T, De Bruyne B, Boothroyd DB, Barbato E, Tonino P, et al. Clinical Outcomes and Cost-Effectiveness of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease. Circulation [Internet]. 2018 Jan 30;137(5):480-7. Available from: https://doi.org/10.1161/CIRCULATIONAHA.117.031907

Nishi T, Piroth Z, De Bruyne B, Jagic N, Möbius-Winkler S, Kobayashi Y, et al. Fractional Flow Reserve and Quality-of-Life Improvement After Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease. Circulation [Internet]. 2018 Oct 23;138(17):1797-804. Available from: https://doi.org/10.1161/CIRCULATIONAHA.118.035263

Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino PAL, et al. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med [Internet]. 2018 Jul 19;379(3):250-9. Available from: https://doi.org/10.1056/NEJMoa1803538

Ciccarelli G, Barbato E, Toth GG, Gahl B, Xaplanteris P, Fournier S, et al. Angiography Versus Hemodynamics to Predict the Natural History of Coronary Stenoses. Circulation [Internet]. 2018 Apr 3;137(14):1475-85. Available from: https://doi.org/10.1161/CIRCULATIONAHA.117.028782

Khokhlov AV, Shymanko MV, Stan MV. Fractional flow reserve: current status. Card Surg Interv Cardiol [Internet]. 2019 May 22;137(3):5-13. Available from: https://doi.org/10.31928/2305-3127-2019.3.513

Berry C, van ’t Veer M, Witt N, Kala P, Bocek O, Pyxaras SA, et al. VERIFY (VERification of Instantaneous Wave-Free Ratio and Fractional Flow Reserve for the Assessment of Coronary Artery Stenosis Severity in EverydaY Practice). J Am Coll Cardiol [Internet]. 2013 Apr 14;61(13):1421–7. Available from: https://doi.org/10.1016/j.jacc.2012.09.065

Davies JE, Sen S, Dehbi H-M, Al-Lamee R, Petraco R, Nijjer SS, et al. Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI. N Engl J Med [Internet]. 2017 May 11;376(19):1824–34. Available from: https://doi.org/10.1056/NEJMoa1700445

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.