Hybrid Coronary Revascularisation in a Patient With Radiation Induced Porcelain Aorta

Abstract

In patients with multivessel coronary artery disease (CAD) involving the left main coronary artery (LMCA), current evidence indicates that coronary artery bypass grafting offers superior long-term survival and lower rates of repeat revascularisation, but an increased risk of short-term stroke when compared to percutaneous coronary intervention (PCI). The favourable outcomes stem from superior long-term patency of the left internal thoracic artery graft (LITA) to the left anterior descending artery (LAD). The superiority of other conduits compared to PCI are less clear. Hybrid coronary revascularisation (HCR) offers an alternative that reduces perioperative risk whilst maximising long-term benefit. We present the case of a 58-year-old male with an 80% stenosis of his LMCA, critical ostial stenosis of his right coronary artery (RCA), and extensive calcification of his aorta due to previous radiotherapy for lymphoma. He also had a previous mechanical aortic valve replacement for radiation induced aortic stenosis. As CT showed his LITA was patent, he underwent HCR, utilising the LITA graft to his LAD via median sternotomy, without the use of cardiopulmonary bypass, and a drug eluting stent to his RCA. Due to his calcified aorta, this approach reduced his risk of perioperative stroke whilst still utilising the superiority of his LITA. His postoperative course was complicated by intrathoracic bleeding, which eventually resolved. He was discharged on postoperative day 23 with no neurological deficit. In conclusion, with the increasing prevalence of high-risk patients with multivessel CAD or LMCA disease, HCR is a valuable alternative, and will be a useful technique in the armamentarium of any heart care centres.