Coronary artery bypass grafting in a patient with severe diffuse lesion and calcification of small-diameter coronary arteries (case report)

• Shiryayev A.A.
• Latypov R.S.
• Vlasova E.E.
• Akhmadov I.I.
• Pashaev. A.A.
• Kurbanov S.K.
• Ganaev K.G.
• Zaikovskii V.Yu.
• Akchurin R.S.

Abstract

Background. Diffuse atherosclerosis of the coronary arteries with the involvement of distal vessels, extensive calcification and a small diameter of the coronary arteries can be the reasons for refusal of invasive treatment of patients with coronary heart disease. The only option of surgical treatment for these patients is coronary artery bypass grafting, but it is associated with technical difficulties in the creation of distal anastomoses and worse long-term survival. Nevertheless, the use of microsurgical techniques makes it possible to successfully treat such patients.

Patients and methods. A 59-year-old male patient with coronary artery disease was hospitalized for elective coronary artery bypass grafting. Coronary angiography revealed a multivessel diffuse lesion with calcification of the coronary arteries. The estimated severity of coronary atherosclerosis according to the Syntax Score amounted to 39 points. Severe three-vessel distal coronary calcification was confirmed by multislice computed tomography.

Results. Using an operating microscope and artificial circulation, we performed autovenous bypass grafting of the diagonal artery, obtuse marginal artery and posterior descending artery according to the method of extended anastomoses (2 cm long) through the atherosclerotic plaque. Due to severe calcification of the anterior descending artery, 4-cm long arteriotomy was performed, followed by prolonged shuntoplasty of the arteriotomic incision of the left internal mammary artery with anterior descending artery in the area of stenosis through the calcified atherosclerotic plaque. The diameter of the target coronary arteries at the site of distal anastomoses was less than 1.5 mm. The postoperative period turned out uneventful with no complications. The patient was discharged on POD 8.

In order to prevent shunt thrombosis, the patient was prescribed to receive dual antiplatelet therapy for 1 year (aspirin and clopidogrel), as well as therapy with statins (atorvastatin 80 mg). The control examination at 12 months revealed no clinical signs of ischemia return. The findings of MSCT bypass angiography confirmed patency of all shunts.

Conclusion. The use of microsurgical techniques, an operating microscope, and coronary reconstructions as shuntoplasty makes it possible to perform coronary artery bypass grafting in severe coronary artery disease with satisfactory clinical outcomes.

Keywords:coronary artery calcification; diffuse coronary artery disease; shuntoplast; endarterectomy

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