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Effects of surgical manipulation on coronary stents: should surgical strategy be altered?
1Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA.
Insights
Open heart surgery can deform or obliterate Palmaz-Schatz stents in coronary arteries. Bypassing previously stented arteries is recommended, even with normal angiographic findings, to prevent stent damage during surgery.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Biomedical Engineering
Background:
- Coronary artery bypass grafting (CABG) is common for patients needing open heart surgery, even after percutaneous transluminal coronary angioplasty (PTCA).
- Increasing use of coronary stents means more patients with stents require open heart operations.
- Sometimes, previously treated coronary arteries are left ungrafted due to patent results, conduit availability, or complex procedures.
Purpose of the Study:
- To investigate the impact of surgical manipulation on Palmaz-Schatz stents during open heart procedures.
- To determine if normal surgical handling causes stent obliteration in epicardial arteries.
Main Methods:
- An experimental model using ten isolated adult pig hearts was developed.
- Stent deployment and surgical manipulation were performed, with direct pressure applied to stented areas.
- Hearts were evaluated using angioscopy, angiography, and stent explantation.
Main Results:
- Heart retraction caused severe deformity in left anterior descending artery stents, mild deformity in circumflex artery stents, and minimal to no deformity in right coronary artery stents.
- Direct pressure on stented epicardial arteries resulted in complete obliteration of all intracoronary stents.
Conclusions:
- Surgical manipulation during open heart operations can significantly deform or obliterate coronary stents.
- Previously stented coronary arteries should be bypassed during surgical revascularization, irrespective of normal angiographic findings.
- This approach mitigates the risk of stent damage from surgical handling.
Background:
Coronary artery bypass grafting is usually indicated for those patients who undergo open heart surgical procedures who have previously undergone percutaneous transluminal coronary angioplasty regardless of the absence of stenosis. Occasionally, however, if the treated artery has remained patent for many years and there is a shortage of conduit material or the patient is undergoing a complex operation, the branch is left ungrafted. With the gaining popularity of coronary stent placement, patients with these devices are undergoing open heart operations with increasing frequency.
Methods:
To determine whether normal surgical manipulation during open heart surgical procedures results in obliteration of the Palmaz-Schatz stents previously deployed in the epicardial arteries, we developed an experimental model using ten isolated adult pig hearts. This allowed us to perform stent deployment and surgical manipulation and to apply direct pressure on the stented areas, with each heart evaluated by angioscopy and angiography and, finally, stent explantation.
Results:
Retraction of the heart resulted in severe deformity of all left anterior descending artery stents, mild deformity of those in the circumflex artery, and mild or no deformity of those in the right coronary artery. However, direct pressure over the stented epicardial arteries (enough to retract the heart) resulted in complete obliteration of every intracoronary stent.
Conclusions:
The findings from this study indicate that once the need for surgical revascularization arises, a previously stented coronary artery should be bypassed even if the angiographic findings are normal, because of the likelihood that manipulation during an open heart operation will result in significant deformity or obliteration of the stent.