Treatment of In-Stent Restenosis in a Gastroepiploic Artery Coronary Bypass Graft with Brachytherapy

Since it was first used in 1984 and reported in 1987,1,2 the right gastroepiploic artery (RGEA) has emerged as an effective third or isolated arterial conduit for complete arterial bypass grafting or for use in cases of limited graft numbers or poor quality vein for grafts.3–5 The RGEA can be used as a pedicled or free graft with or without cardiopulmonary bypass.6 The RGEA grafts are superior to vein grafts, with > 95% short-term patency rates and actuarial 5-year patency rates of 80–85%,7–9 with a 5-year survival rate > 92%.5,9 Ischemic events related to pedicled RGEA grafts result from disease progression in the native coronary arteries, or spasm, occlusion or stenosis of the graft, especially at the coronary artery anastomotic site7 that has been successfully treated with percutaneous angioplasty10–12 and/or stenting.13,14 Little is known about the restenosis rate of RGEA grafts. We report a case of percutaneous coronary stenting of an RGEA bypass graft lesion subsequently complicated by in-stent restenosis that was treated with brachytherapy from the left axillary approach. We review the existing published experience with GEA bypass graft coronary interventions. Case Report. A 55-year-old male with premature coronary disease, five previous coronary artery bypass graft (CABG) operations and multiple percutaneous coronary interventions (PCIs) was admitted with accelerating angina of 4 weeks duration. Past medical history was also significant for type 1 diabetes mellitus, hyperlipidemia and peripheral vascular disease, with bilateral iliac and renal stenting in the past. His first CABG occurred at age 36 and his most recent occurred in 1999, at which time he had placement of an RGEA to the native right coronary artery (RCA). In April 2001, he underwent PTCA of the RGEA graft at its anastomosis with the RCA. In May 2002, the patient presented with class III angina and recurrent 90% stenosis at the RGEA graft-RCA anastomosis. Using an 8 French (Fr), renal double-curve 1 guiding catheter from the right femoral approach, the celiac artery was engaged and a 0.014´´ Luge wire (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was advanced through the hepatic and gastroduodenal arteries into the RGEA beyond the lesion. A 2.0 x 12 mm Maverick over-the-wire balloon (Boston Scientific/Scimed, Inc.) was advanced to the lesion with difficulty due to “backing out” of the renal guide catheter and prolapse of the system into the abdominal aorta. Hence, the system was withdrawn. Left brachial access was obtained with a micropuncture set. A 7 Fr, 90 cm shuttle sheath was inserted and advanced over a J-wire to the upper abdominal aorta. A 110 cm, 5 Fr multipurpose diagnostic catheter was advanced through the shuttle sheath and used to engage the celiac artery. A 0.035´´ Glidewire guidewire (Boston Scientific/Scimed, Inc.) was then advanced through the multipurpose catheter into the gastroduodenal artery, and the multipurpose catheter and shuttle sheath were telescoped into the gastroduodenal artery. The multipurpose and Glidewire wires were withdrawn. Prophylactic intra-arterial nitroglycerin was administered. The Luge wire was advanced into the right gastroepiploic artery and then across the lesion. ReoPro was administered. The 2.0 x 12 mm Maverick balloon was used to dilate the lesion, but > 50% residual stenosis remained, largely due to recoil. A 2.75 x 13 mm, over-the-wire Penta stent (Guidant, Santa Clara, California) was advanced and deployed at the lesion. There was haze at the proximal end of the stent, suggesting an edge dissection. Hence, a 2.5 x 13 mm, monorail Pixel stent (Guidant) was advanced and deployed, overlapping the proximal end of the previously placed stent. There was 0% angiographic residual stenosis. The patient developed recurrent class 3/4 angina in August of 2002 while on optimal medical therapy. Echocardiogram showed left ventricular ejection fraction of 40% without significant valvular disease. Coronary angiography revealed proximal chronic total occlusion of the left main and RCA. A saphenous vein graft to the left anterior descending artery was widely patent, with left-to-left collaterals supplying the circumflex marginal branches, which were small and diffusely diseased with multiple intervening occluded segments. A 5 Fr Cobra glide catheter (Boston Scientific/Scimed, Inc.) was advanced over a 0.035´´ Glidewire into the hepatic artery to obtain the diagnostic images of the RGEA bypass graft. There was 80% in-stent restenosis of the GEA graft at the anastomosis with the RCA (Figure 1). The cardiac surgical consultant was willing to operate, but given that it would be a sixth operation, recommended exhausting all reasonable percutaneous methods. The patient also favored repeat percutaneous intervention. The left brachial pulse was diminished on exam. Left upper extremity arteriography showed a 3-cm long, 70–80% left brachial stenosis immediately proximal to the previous access site. Upper extremity arterial Dopplers demonstrated left radial and ulnar pressures of 110 mmHg and 108 mmHg, respectively, that were equivalent to the right upper extremity. Left axillary arterial access was secured with a micropuncture set. A 7 Fr sheath was inserted and a 7 Fr, ACS Multipurpose guide (Guidant Corporation, Santa Clara, California) was used to cannulate the celiac artery (Figure 2). Heparin was administered. A 0.035´´ Glidewire with a 5 Fr, 125 cm, vertebral Glide catheter was advanced through the multipurpose guide to the RGEA and the guide catheter was telescoped over them into the RGEA (Figure 3). Prophylactic intra-arterial nitroglycerin was administered frequently during the procedure. A 0.014´´ Luge wire was advanced across the lesion at the RGEA-RCA anastomosis. PTCA of the in-stent restenosis was performed with a 2.25 x 9 mm NC Rail balloon (Boston Scientific/Scimed, Inc.) to 30% residual followed by a 2.5 x 15 mm Maverick balloon to Discussion. PCI with balloon angioplasty involving an RGEA graft was first reported in 1990. Stenting of an RGEA graft from the femoral approach was first described by Roriz in 1998.13 To our knowledge, this is the first reported case of RGEA stenting via the transbrachial approach and subsequent brachytherapy for in-stent restenosis via the left axillary approach. Reoperation for graft occlusion or stenosis is more technically challenging and is associated with higher complication and mortality rates,15 making PCI a more attractive alternative, especially considering the 83% initial success rate of RGEA angioplasty.10 The experience with GEA graft restenosis has not yet been described. The 6-month restenosis rate of vein grafts is 36% after stenting and 46% after angioplasty.16 The initial experience of treating vein graft restenosis with brachytherapy is encouraging, with a 21% restenosis rate at 6 months and a 70% reduction of target lesion revascularization at 1 year.17 The experience with PCIs of pedicled RGEAs is limited and variable. Angioplasty has been performed via the femoral approach using 6.5 Fr,10 7 Fr10,11 and 8 Fr23 guiding catheters and a 6 Fr diagnostic catheter.18 Sharma described PTCA using a 5 Fr guiding catheter from the left transradial approach.12 Percutaneous stenting of pedicled RGEA grafts has been successfully performed via the femoral approach using a 7 Fr guiding catheter with an over-the-wire system13 and a 6 Fr guiding catheter with a monorail-rapid exchange system.14 Percutaneous intervention on the RGEA graft can pose technical challenges by virtue of its anatomy and the more common occurrence of the stenosis distally at the anastomosis with the coronary artery.10 To intervene on a distal RGEA anastomotic lesion, the guide catheter must engage into the celiac trunk and then advance through the hepatic artery and downward into the gastroduodenal artery, as well as upward into the RGEA (Figure 6). The RGEA graft has an internal diameter of around 2.2 mm,19 giving smaller and less stiff guiding catheters the advantage of deep intubation of the celiac trunk and selective positioning in the gastroduodenal or RGEA closer to the lesion, with better back-up support, especially when the proximal graft is tortuous.12,18 Thus, the ideal system is one that provides a soft and smaller diameter guiding catheter with excellent back-up support for interventional devices with low profile and good trackability.10,12 In celiac, mesenteric, and occasionally renal artery percutaneous interventions, the extreme downward take-off of these vessels often limits the advancement of devices from the femoral approach. As in our case, the brachial and axillary approaches provide more coaxial entry into these vessels, allowing advancement of higher profile and less flexible devices into these territories despite the additional challenges presented by the distal tortuosity of these vessels.12 The RGEA arises from the superior mesenteric artery in 10–20% of patients, providing an even more challenging oblique take-off and greater tortuosity.20 The hepatic, gastroduodenal and gastroepiploic arteries are prone to severe spasm with manipulation. This adds to the challenge of such interventions, especially with deeper intubations and larger guiding catheters, and is usually reversed with the direct intra-arterial administration of nitroglycerin.21–24 The prophylactic use of nitrates or oral calcium-channel blockers is advised to reduce the occurrence of spasm.21 Finally, the development of pseudolesions from the guidewire and catheter shafts may also hamper contrast injections to visualize and guide the intervention (Figure 7). Conclusion. We conclude that gastroepiploic bypass graft stenting and brachytherapy are technically feasible and are facilitated by an upper extremity approach when the celiac artery has an extreme downward take-off from the abdominal aorta. Prior experience with celiac and mesenteric angiography and intervention is helpful in performing this procedure.

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