Catheter-Based Revascularization of the Hepatic Artery to Treat
Coronary Steal from a Gastroepiploic Artery Bypass Graft

For patients treated with coronary bypass surgery, atherosclerotic peripheral arterial disease may compromise blood flow to more distally located arterial bypass grafts. In most instances, proximal subclavian artery stenosis limits flow to the left internal mammary artery (LIMA) graft, resulting in myocardial ischemia. Although percutaneous revascularization of the subclavian artery to relieve ischemia related to the LIMA graft has been described,1–3 catheter-based revascularization of other peripheral arteries to treat steal phenomena from additional arterial conduits is not well characterized. This report describes successful common hepatic artery angioplasty and stenting to treat ischemic symptoms in a patient with a right gastroepiploic artery (GEA) coronary bypass graft. Case Report. A 53-year-old female with established coronary artery disease, hypercholesterolemia and hypertension was referred for diagnostic cardiac catheterization following an abnormal stress echocardiogram performed to evaluate symptoms of progressive exertional ischemia. Specifically, stress echocardiography demonstrated stress-induced inferior and posterior wall motion abnormalities. Six years previous to the index cardiac catheterization, the patient had undergone coronary bypass surgery that was remarkable for placement of an in situ right GEA graft to the distal right coronary artery (RCA). Diagnostic cardiac catheterization demonstrated normal left ventricular function and patent grafts to the left anterior descending artery (LIMA graft) and distal right coronary artery (GEA graft). However, the common hepatic artery was noted to originate directly from the aorta, separate from the celiac artery (Figure 1). Further, the ostium of the hepatic artery (supplying the right GEA bypass graft via the gastroduodenal branch) was observed to have an approximate 95% stenosis. Two weeks following cardiac catheterization, the patient returned for elective, staged hepatic artery angioplasty and stenting. The patient received preprocedural treatment with 325 mg aspirin and 300 mg clopidogrel. Heparin was administered to achieve an activated clotting time of 235 seconds. Repeat selective common hepatic arteriography (6 French VB-1, Cordis Corporation, Miami Lakes, Florida) via the right common femoral artery confirmed significant ostial narrowing with Thrombolysis in Myocardial Infarction (TIMI) 2 flow (Figure 2). Retrograde flow of contrast from the GEA was observed consistent with the steal phenomenon. Considering the reduced flow to the coronary artery and potential for distal embolization of atherothrombotic debris, the patient was also treated with the glycoprotein IIb/IIIa antagonist eptifibatide (Integrilin, Millennium Pharmaceuticals, Boston, Massachusetts). A 7 Fr renal double curve 1 catheter (Guidant Corporation, Santa Clara, California) was positioned at the ostium of the hepatic artery, enabling the advancement of a 0.014´´ in Spartacore guidewire and pre-dilatation with a 5.0 X 18 mm HighSail coronary angioplasty balloon (Guidant Corporation). Subsequent arteriography demonstrated an approximate 50% residual stenosis with minor longitudinal dissection, and the lesion was therefore successfully stented with a 6.0 X 15 mm Genesis stent (Cordis Corporation) at 10 atmospheres (ATM). Because of an edge dissection distal to the stent, a second 6.0 X 12 mm Genesis stent was placed distally at 8 ATM with minimal stent overlap (Figure 3A). Final arteriography demonstrated a normal angiographic result within the treated segment with TIMI grade 3 antegrade flow in the GEA bypass graft and distal RCA (Figure 3B). Following the procedure, the patient was admitted for overnight observation. Serial cardiac enzymes were negative for myocardial necrosis. Since revascularization, the patient has described no recurrent ischemic symptoms during 6-month clinical follow-up. Discussion. Although use of in situ arterial conduits for coronary bypass grafts have been associated with improved long-term patency and clinical outcomes compared with saphenous vein grafts,4–6 the presence and/or development of atherosclerotic peripheral arterial disease may be an unrecognized cause of graft failure and myocardial ischemia related to coronary steal. As an alternative to surgical bypass, procedural and clinical outcomes for endovascular therapy of subclavian arterial disease proximal to internal mammary artery (IMA) grafts have been described,1–3 yet an understanding of peripheral revascularization to salvage other arterial bypass grafts is incomplete. In this report, successful percutaneous revascularization of the common hepatic artery restored flow to the GEA bypass graft and RCA with resolution of ischemic symptoms. Because use of the GEA for bypass grafting is less frequent than the internal mammary artery, clinical outcomes and long-term patency are less certain. Limited observational studies using GEA bypass grafts have reported long-term patency rates exceeding 95%.7–9 However, while the development of atherosclerotic disease within the hepatic artery and its tributaries is somewhat unpredictable, the presence of atheromatous plaque and calcification in the GEA may be more common than in thoracic internal mammary arteries.10 Successful angioplasty and stenting of the GEA bypass graft anastomotic site has been previously documented,11–14 but prior descriptions of more proximal hepatic artery revascularization to relieve coronary ischemia are unavailable. Unlike direct GEA interventions, which are associated with excessive angulation and vasospasm,11 hepatic artery angioplasty may be less challenging since suitable guide and angioplasty catheters are available. In this particular case, a guide catheter for renal endovascular procedures provided adequate support and lesion visualization. Furthermore, the unique finding of a separate ostium for the hepatic artery (i.e., not originating from the celiac artery) facilitated catheter placement and angioplasty. Although the frequency of this common hepatic artery anatomic variant is not well defined, its occurrence is estimated in only 2% of individuals.15 Conclusion. Percutaneous revascularization of the common hepatic artery leading to a GEA coronary bypass graft is a feasible, less invasive alternative to surgical bypass. Furthermore, such a procedure can be successfully performed using contemporary guide and angioplasty catheters that are designed for coronary and other, more common peripheral arterial procedures. For patients with in situ arterial grafts, these findings should also remind clinicians to consider more proximal peripheral arterial disease as a potential cause of graft failure and myocardial ischemia.

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