Combined Peripheral and Coronary Artery Percutaneous Intervention in Patients with Significant Coronary and Peripheral Vascular

Case Presentations We describe two patients with unstable angina who underwent bilateral common iliac artery stenting immediately before right coronary artery stenting in the same setting in a hybrid procedure followed by review of the literature. Case 1. A 54-year-old male with a past medical history significant for hypertension, tobacco abuse and coronary artery disease with prior angioplasty, presented to an outside institution with resting angina and dynamic ECG changes. His ECG showed marked ST-segment depression in the inferior leads during chest pain episodes which resolved after administration of sublingual nitroglycerin. His cardiac enzymes were unremarkable. The patient also complained of marked bilateral lower extremity claudication occurring with ambulation of less than 50 feet. His femoral and distal pulses were weak bilaterally. The patient subsequently underwent coronary angiography. The operator could not advance a guidewire through the right femoral artery, but a guidewire was successfully advanced via the left femoral artery with some difficulty, and coronary angiography was completed. The patient was found to have an 80% mid-to-distal right coronary lesion with associated haziness (Figure 1). The arterial sheath was removed, and the patient was then transferred to our institution for percutaneous coronary intervention to the right coronary artery. Multiple attempts to advance the wire into the aorta via the right and left femoral arteries were unsuccessful and caused nonocclusive dissection of the right femoral artery. The decision was then made to proceed with aorto-iliac angiography and peripheral vascular intervention prior to coronary angioplasty. Using a micropuncture kit, an angled Glidewire® (Terumo Cardiovascular Corp., Ann Arbor, Michigan) and an angled tapered catheter, we were able to traverse the left common iliac artery stenosis and to advance a guidewire and pigtail catheter via the left femoral artery for angiography. Aorto-iliac angiography revealed 70% ostial stenosis of the right common iliac, 95% ostial stenosis of the left common iliac, and 90% stenosis of the distal right common/proximal external iliac artery (Figure 2). The decision was then made to proceed with bilateral common iliac intervention using stents, thus an Omniflush catheter and angled floppy Glidewire were used to traverse the right iliac stenosis in a retrograde fashion via the left femoral artery. A Microvena 4 mm snare was then utilized via the right femoral sheath and the Glidewire was snared and was pulled through the right femoral sheath. A 65 cm long angled, tapered catheter was then advanced over the wire into the infrarenal aorta. The wire was then exchanged for a 260 cm 0.035 inch Rosen wire, and the 6 Fr sheath was exchanged for a 7 Fr 23 cm Brite-Tip® guide (Cordis Corp., Miami, Florida), advancing above the aortic bifurcation. Next, the 6 Fr sheath in the left femoral artery was exchanged for a 7 Fr long sheath that was positioned into the infrarenal aorta just above the aortic bifurcation. An 8 x 37 mm Express™ balloon-expandable stent (Boston Scientific Corp., Natick, Massachusetts) was then advanced across the right iliac lesion, and a 9 x 25 mm Express balloon-expandable stent was advanced into the left femoral sheath across the left iliac stenosis. The stents were then carefully positioned into the aortic bifurcation and deployed in a simultaneous kissing fashion (Figure 3). Subsequent angiographic views revealed residual stenosis in the right external iliac artery and thus an 8 x 38 mm Wallstent (Boston Scientific) was advanced and deployed across the lesion with excellent angiographic results (Figure 4). Next, we proceeded to perform primary stenting to the RCA. A JR 4 guiding catheter was used for the procedure, and a 180 cm ATW™ wire (Cordis) was utilized to cross the lesion. Next, a Taxus® (Boston Scientific) 3.0 x 24 mm stent was advanced across the lesion and inflated to 16 atmospheres (Figure 5). Final views revealed excellent angiographic results with no significant residual stenosis (Figure 6). The patient was admitted for 23-hour monitoring and was discharged home the next day in stable condition. The patient was seen two months after the procedure and he reported marked improvement in his lower extremity claudication symptoms and resolution of his angina. Case 2. A 63-year-old female with a past medical history significant for tobacco abuse presented to her cardiologist with lifestyle limiting claudication and increasing angina. The patient underwent peripheral and coronary angiography. Coronary angiography was successfully performed despite initial difficulty advancing the guiding catheter. The patient was found to have an 80% mid-right coronary artery stenosis (Figure 7). A 7 Fr Judkins guiding catheter was used to engage the RCA. A 0.014 inch ATW wire was used to cross the lesion. Next, a Taxus 2.5 x 20 mm stent was advanced across the lesion (Figure 8) and deployed to 15 atmospheres with excellent angiographic results (Figure 9). Abdominal aortic and femoral angiography was then performed which revealed an 80% lesion involving the ostium of both iliac arteries extending into the abdominal aorta (Figure 10). Two 7 Fr 23 mm long Pinnacle BriteTip catheters were then inserted into the right and left femoral arteries and advanced to the level of the abdominal aorta. The stenotic lesions were pretreated with a PowerFlex® P3 6/4 balloon (Cordis) and were then stented in a kissing fashion using an Express 7 x 37 cm stent in the right iliac artery, and an Express 8 x 37 cm stent in the left iliac artery. The stents were deployed simultaneously to 8 atmospheres (Figure 11) with excellent final angiographic results Figure 12). The patient tolerated the procedure well without complications. He was discharged home the next day and reported resolution of symptoms on follow up. Review Peripheral vascular disease is a common comorbidity in patients with coronary artery disease, and the presence of significant peripheral lesions can complicate vascular access. A combined percutaneous approach can serve as an effective means of therapy in patients with significant symptomatic peripheral and coronary arterial disease. Here we present two cases of combined coronary and peripheral intervention in patients who had severe claudication and angina. In one case, coronary angioplasty was performed following peripheral intervention, and in the second case peripheral intervention was performed first, followed by coronary intervention. These two cases emphasize the feasibility of hybrid percutaneous procedures and demonstrate that they can be safely performed with an excellent outcome. Such combined procedures can save a substantial amount of time and cost, and can serve to improve peripheral access to the coronary arteries while also reducing the risk of limb ischemia from femoral artery access. There are no specific guidelines available to address this hybrid approach. We performed a literature search using PubMed and Google in order to review this topic. Atherosclerosis manifests as a broad spectrum of clinical pathology involving both coronary and non-coronary circulation. Peripheral arterial disease (PAD) is obstruction of blood flow in arteries other than the coronary and intracranial vessels. Although the definition of PAD includes involvement of extracranial carotid, upper limb, visceral and renal arteries, it is the circulation of the lower limbs that is most frequently involved. Atherosclerosis in the lower extremities is more common in elderly individuals and men. Smoking is the most important modifiable risk factor that increases both the risk of development and progression of disease. In diabetics, the prevalence of PAD has been reported to be 1.5 to 6 times higher than in nondiabetics. Hypertension causes a significant increase in the prevalence of PAD. The infrarenal abdominal aorta and the iliac arteries are among the most common sites of involvement. Intermittent claudication is a cardinal symptom of lower extremity PAD, but only a small number of individuals over 60 years of age (2–3% of men and 1–2% of women) have intermittent claudication (IC). Despite a rather low frequency of IC, a higher percentage of the population has PAD as defined by an ankle-brachial index (ABI) 1 Although PAD is progressive in the pathophysiological sense, its natural history and prognosis in the involved lower extremities are relatively benign in most cases. Progression of disease is greatest in patients with multilevel arterial involvement, low ABI, renal failure, diabetes mellitus and heavy tobacco abuse. Despite the rather benign prognosis for the limb, IC is an ominous sign of systemic atherosclerosis with considerable overlap of disease manifested in multiple vascular beds. It is a strong marker of cardiovascular disease; a very strong association exists between PAD and other atherosclerotic disorders such as coronary artery disease (CAD) and cerebrovascular disease.² Percutaneous stenting in many cases has become the gold standard of treatment for PAD. It has the advantage of lower mortality, morbidity and expense, as well as a low procedure-related complication rate compared to surgical revascularization. PAD and coronary artery disease have an important negative impact on each other with respect to treatment options and prognosis. Patients with PAD can present with symptoms of acute coronary syndrome due to concurrent coronary artery disease.³ These patients represent a particularly difficult therapeutic dilemma. Coronary bypass grafting (CABG) in the presence of ACS and PAD carries a substantial risk of morbidity and mortality, and if treated surgically, such patients would have to undergo at least two surgical procedures. In such a clinical situation, percutaneous treatment offers a promising alternative to surgery. Simultaneous peripheral and coronary artery intervention by an experienced operator can be cost effective and an effective treatment that addresses both of the patient’s needs at the same time. Here we review some of the case reports on simultaneous coronary and peripheral artery revascularization by surgery and percutaneous intervention. Most cases that are reported in the literature describe a combination of coronary and peripheral vascular surgery. Suma et al.⁴ presented two patients with both coronary artery disease and leg ischemia who were successfully treated with a combined revascularization procedure. Coronary arteries were bypassed with in situ internal mammary artery grafts, and bilateral femoral arteries were bypassed with expanded polytetrafluoroethylene grafts descended from the ascending aorta through the preperitoneal abdominal wall tunnel. Both patients recovered well and experienced no angina or claudication. Obayashi et al.⁵ reported a 58-year-old man with angina pectoris and severe intermittent claudication. Angiography showed triple-vessel disease of the coronary arteries and complete obstruction of the bilateral common iliac arteries from their origins. Both femoral arteries were patent by collateral supplies. Combined revascularization of the coronary and femoral arteries was performed. The coronary arteries were bypassed using the left internal thoracic artery, gastroepiploic artery and saphenous vein grafts. Bilateral femoral arteries were bypassed with externally supported Dacron grafts from the ascending aorta through the preperitoneal space. The patient recovered well and postoperative angiography revealed all bypass grafts to be patent. Fabiani et al.⁶ described a technique consisting of an ascending aorta to a bi-femoral graft. This technique allowed combined surgery of the coronary arteries and the lower limbs without opening the peritoneum. Daenens et al.⁷ reported a patient with severe coronary artery disease and leg ischemia which was successfully treated with a combined revascularization procedure. The coronary arteries were bypassed with three vein grafts, and the bilateral femoral arteries were bypassed with a Dacron graft using the ascending aorta as the source of inflow. The patient recovered well and experienced no angina or claudication two years later. Guler⁸ reported a patient suffering from angina pectoris, claudication intermittens and postprandial abdominal pain who underwent coronary and peripheral arteriographic examination; coronary arterial disease and aorto-iliac occlusive disease were diagnosed. Color Doppler ultrasonography revealed superior mesenteric artery stenosis. CABG with the MIDCAB (minimal invasive direct coronary artery bypass) technique was performed, together with aorto-bifemoral graft interposition and graft bypass to the superior mesenteric artery, with considerable success. Matsuzaki et al.⁹ described a 55-year-old man with severe coronary artery disease and aorto-iliac occlusive disease with small aorta syndrome, angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery, with a markedly hypoplastic infrarenal aorta measuring only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the left circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in situ right internal mammary artery graft, an autologous saphenous vein graft and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and femoral arteries to be patent. Although surgery has been the historical mainstay of revascularization therapy for PAD, percutaneous vascular intervention now provides a less invasive and an effective modality for the treatment of atheromatous disease. The preferred mode of revascularization of the aorto-iliac vessels has shifted over the past decade from predominantly surgical to nearly all via the percutaneous route. The rapid expansion of interventional techniques over the past few decades and the introduction of stents has improved the long-term outcome of percutaneous techniques. With constantly improving stent designs, delivery systems and techniques, multivessel stenting has become routine in clinical practice. Simultaneous percutaneous intervention involving coronary and peripheral arteries is feasible, relatively safe and cost effective, but has only rarely been reported in the literature. The only case report combining the iliac artery and coronary intervention that is described in the literature is published by Baruah et al.¹⁰ They reported a patient who underwent percutaneous coronary intervention combined with bilateral iliac and left renal artery angioplasty during the same encounter. Stenting of the coronary and peripheral arteries was performed using direct stenting, and no complications occurred. The patient was discharged two days after the intervention and remained asymptomatic, leading a fully active life at one-year follow up. The combination of coronary intervention and subclavian artery intervention was described by Yaneza et al.¹¹ who presented a case of unstable angina and arterial occlusion of all four extremities treated with subclavian stenting and subsequent percutaneous coronary intervention, with good outcome. Kiesz et al.¹² described a patient who underwent bilateral internal carotid artery stenting and three-vessel percutaneous coronary intervention during the same procedure. No complications occurred. The patient was discharged home one day after the intervention and remained asymptomatic, leading a fully active life. This case elaborates the feasibility of combining carotid and coronary intervention. Conclusion We presented two cases of combined coronary and peripheral intervention performed at our institution with excellent outcomes. Despite the potential time and cost savings of such hybrid procedures, there are few reports in the literature. Given the current trend towards increasingly complex percutaneous interventions, the time is right for the performance of a randomized trial to address the risk and benefits of hybrid procedures. Based on our patient experiences and the limited available literature, we believe that in selected patients, such hybrid procedures are safe and cost effective and should be considered on an individual basis in patients presenting with combined coronary and peripheral vascular disease.

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