Emergent Percutaneous Intervention with a Drug-Eluting Stent
of a Cabrol Graft-to-Left Main Anastomosis during a Non-ST-Elevati

There are three classic techniques described for reimplantation of coronary arteries after repair of the ascending thoracic aorta.^1–4 The original Bentall procedure was described in 1968 and is considered the standard technique .⁵ The Cabrol technique utilizes a graft interposed between the aortic root graft and the coronary ostia.⁶ There is one previous report of a percutaneous intervention of a stenotic Cabrol graft-left main anastomosis lesion.⁸ We report the first percutaneous intervention of a stenotic Cabrol graft-left main anastomosis lesion utilizing a drug-eluting stent in a patient with Marfan’s Syndrome with a non-ST-elevation myocardial infarction. Case Report and Procedure A 49-year-old male with known Marfan’s Syndrome and an extensive past history of complicated operations presented to our emergency room with chest pain which was ongoing in spite of aggressive medical therapy. He was an ex-smoker and had no other coronary risk factors. He had undergone a Bentall procedure in 1982 for aortic aneurysm and severe aortic regurgitation. At this time he had a Bjork-Shiley 29 mm single-tilting disk prosthesis implanted. A Bentall procedure essentially involves the complete replacement and exclusion of the ascending aorta with a composite Dacron tube graft which includes an aortic valve prosthesis proximally.⁵ The coronary arteries are then reimplanted onto the sides of aortic tube graft.⁵ He did well until 2002 when he presented with chest pain to our hospital. A computed tomography (CT) scan at that time diagnosed a left posterolateral pseudoaneurysm that was 7 cm in diameter arising from the ascending aorta from the site of left coronary implantation. The patient then underwent a high-risk emergency repeat procedure which included a re-do replacement of the ascending aorta with a 28 mm tube graft, repair of the anterior and left posterolateral sinus of Valsalva and repair of a pseudoaneurysm. He subsequently underwent reimplantation of his right coronary artery using the classic Bentall technique and reimplantation of his left main coronary ostia utilizing a 10 mm Dacron graft (Cabrol graft). A Cabrol graft is a technique involving connection of the native coronary artery ostium to the aortic tube graft (Bentall) in a side-to-side manner by utilizing an interposed 8–10 mm diameter Dacron tube graft of variable length. Although this was extremely high-risk surgery, the patient did well and had a reasonably uneventful recovery. His electrocardiogram (ECG) on arrival demonstrated widespread ST-depressions in the precordial and inferior leads and ST-elevation in aVr, a pattern consistent with left main involvement. Although his initial cardiac enzymes were unremarkable, his second set of cardiac biomarkers demonstrated a CK of 788 and a troponin T of 0.33. His INR was 2.7 on admission. His medications on arrival included metoprolol, digoxin and warfarin. Given his previous presentation in 2002, he underwent an urgent CT aortogram on this occasion, which showed no evidence of dissection or pseudoaneurysm. He was started on aspirin, intravenous heparin, intravenous nitroglycerin and intravenous beta-blockade, with only minimal change in his pain and ECG. He was therefore referred for emergency coronary angiography. Aortic root angiography demonstrated the usual position takeoff for the right coronary artery and a high superolateral takeoff for the Cabrol graft (Figure 1). A standard Judkins right (JR4) diagnostic catheter managed to cannulate the right coronary, which was angiographically unremarkable. Injections of the Cabrol graft confirmed a 90% severe hazy stenosis at the ostium of the left main at the anastomosis with the Cabrol graft (Figures 2 and 3). The patient continued to experience significant chest pain on the table. We obtained vascular access with a 5 Fr sheath via the left femoral artery for balloon pump insertion if emergently required. Surgical consultation was obtained immediately and it was felt that a third procedure with previously-documented heavy scarring, a high INR and in the setting of acute infarction would carry a prohibitive risk. Therefore after detailed discussion with the patient and family, a percutaneous option was chosen. Once again, a JR4 (Judkins right) Viking (Guidant Corp., Indianapolis, Indiana) guiding catheter was used to engage the Cabrol graft. A 0.014 inch Extra-Sport (ACS Hi Torque, Guidant) 300 cm supportive guide wire was passed into the distal LAD. The left main was quite large in caliber, approximately 6.0 mm by QCA. We did not have a 6.0 bare metal stent available at the time. A 5.0 x 16 mm Taxus^® (Boston Scientific Corp., Natick, Massachusetts) drug-eluting stent was carefully placed so as to cover the entire lesion including the anastomosis. This was deployed using a direct stenting method at 22 atmospheres. Mild hypotension did ensue during inflation, however this recovered very quickly and the patient became chest pain free. An optimal angiographic result was obtained with 0% stenosis and TIMI grade 3 flow distally (Figure 4). Intravascular ultrasound was performed to ensure optimal stent deployment and lesion coverage and optimal stent expansion and lesion coverage was confirmed. The patient was treated with a double-bolus and infusion of eptifibatide, and heparin was used as the anticoagulant. He received a loading dose of 600 mg of clopidogrel and will continue this for at least 6 months. The patient was sent back to the referring hospital and remained stable from a cardiac standpoint, and was discharged in good condition. Discussion We report the first patient with Marfan’s syndrome and a Cabrol graft to his left main artery undergo percutaneous coronary intervention with a drug-eluting stent in the face of a non-ST-elevation myocardial infarction and refractory angina with an iatrogenic coagulopathy. Coronary stenosis after a Bentall procedure is uncommon, occurring in less than 2% of patients.⁷ It can, however, be responsible for sudden cardiac death.⁹ Two previous reports of ostial stenting with a Bentall procedure have been described.^10,11 One report of bare-metal stent placement in a left main artery via a Cabrol graft has previously been reported,⁸ however this is the first such procedure in a patient with Marfan’s syndrome. The usual aortic pathology requiring a Bentall or Cabrol procedure include acute aortic dissection, chronic dissection, annulo-aortic ectasia, atherosclerotic aneurysm and bicuspid aortic valve. The early mortality rates for the Cabrol procedure have been reported to be as high as 20% overall, and as high as 41% for aortic dissection.^2,12 Stenosis at a coronary-Cabrol graft anastomosis has been reported in the past, but has usually been managed surgically, likely due to unknown but a high perceived risk of percutaneous coronary intervention in such a situation.^13,14 Given our patient’s very high-risk presentation and lack of surgical options, percutaneous intervention to his ostial left main artery at the anastomosis with the Cabrol graft using a drug-eluting stent proved to be a very viable approach to stabilize him. Challenges in such a case include engaging the graft with appropriate catheters. Intravascular ultrasound interrogation of the post-stent result is important to ensure proper stent apposition, expansion and lesion coverage, and to ensure true ostial coverage. A large drug-eluting stent was chosen to give the patient the best long-term outcome possible with regard to reintervention. We did understand the risks of bleeding with triple therapy (aspirin, clopidogrel and warfarin), however, since the Taxus stent was the largest-diameter stent available at the time, and to avoid undersizing, we opted to deploy a drug-eluting stent after discussion with the patient. We demonstrate that in a situation where surgical risk is high, percutaneous coronary intervention on a left main anastomotic lesion with a Cabrol graft can be a safe and feasible option, even in a high-risk situation. Although long-term data are not available, given the rarity of such lesions, our patient is doing well and remains symptom-free at 3-month follow up, and is being followed on a long-term basis in our congenital cardiac clinic.

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