Dynamic kinking of right coronary artery after the button Bentall procedure
- Tomoki Fukui ,
- Nobuyuki Ogasawara and
- Shinji Hasegawa
- Department of Cardiology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
- Correspondence to Dr Tomoki Fukui; tomoki.fukui@gmail.com
Abstract
Postoperative coronary artery complications after Bentall procedures are well recognised but are rare and potentially fatal. There have been only five cases documenting percutaneous coronary intervention (PCI) for right coronary artery (RCA) involvements after button Bentall procedures. We describe a case of postoperative silent myocardial ischaemia in a 72-year-old man who underwent the button Bentall procedure for a right sinus of Valsalva aneurysm. On postoperative day 15, an RCA complication was incidentally detected by follow-up multidetector CT. Coronary angiography showed proximal RCA kinking, which was not an anastomosis but a native coronary artery. The patient underwent a successful PCI with drug-eluting stent implantation. We reviewed six cases consisting of this case and five previous cases treated with PCI. These cases enhance the recognition of potential RCA complications after the button Bentall procedure.
Background
In 1968, Bentall and De Bono described a then-new technique for aortic root and aortic valve replacement using a composite vascular graft with reimplantation of the coronary arteries. The coronary arteries were directly sewn to the vascular graft as end-to-side anastomoses, and the aneurysmal wall was wrapped around the graft.1 Since the original Bentall procedure was first described, several modifications of the surgical technique have reduced the incidences of mortality and operative complications.2–6 In particular, the ‘button technique’, in which a coronary ostium is excised from the aortic wall in a circumferential shape and reimplanted through vascular graft, has remarkably reduced postoperative coronary artery complications such as anastomotic pseudoaneurysm, stenosis and haemorrhage.7–10 Still, a small number of these complications lead to undesirable and fatal outcomes regardless of innovations in the surgical procedure, with limited reports requiring percutaneous coronary intervention (PCI). We herein report a successful case of PCI for right coronary artery (RCA) kinking after the button Bentall procedure.
Case presentation
A 72-year-old man with known hypertension presented with a right sinus of Valsalva aneurysm (SOVA). He reported intermittent chest pain for 1 month and visited a referral hospital, where transthoracic echocardiography (TTE) revealed the right SOVA. In our hospital, TTE and multidetector CT (MDCT) demonstrated a large right SOVA, a bicuspid aortic valve, moderate aortic regurgitation and aortic root dilatation.
A button Bentall procedure was subsequently performed. The aortic root was replaced with a 28 mm prosthetic vascular graft (J graft, Japan Lifeline, Tokyo, Japan). The aortic valve was replaced with a 23 mm bioprosthetic valve (Inspiris Resilia, Edwards Lifesciences, California, USA). Both coronary arteries were reimplanted using the button technique. The ostia of the coronary arteries were wrapped with felt rings. The surgery was successfully completed.
After the operation, the chest symptoms disappeared, and no significant clinical events occurred during the postoperative course. Follow-up MDCT performed on postoperative day (POD) 15 incidentally revealed a focal and severe stenosis of the proximal RCA. Multiplanar reconstruction showed a narrowed vessel diameter without intravascular plaque. The proximal RCA seemed to be extremely bent without external compressive tissues around the lesion site (figure 1). The postoperative ECG did not differ from the preoperative one, and the serum myocardial enzyme levels tested were within the normal range. TTE showed a preserved left ventricular contraction without asynergy. The coronary angiography performed after the TTE showed a focal and severe stenosis of the proximal RCA with coronary slow flow phenomenon (figure 2 and video 1). The stenosis did not improve with a nitroglycerin injection.
The multidetector CT. Multiplanar reformatting image revealed a focal and severe stenosis of proximal right coronary artery (yellow arrow).
Coronary angiography showed a focal and severe stenosis of proximal right coronary artery with coronary slow flow phenomenon.
Dual antiplatelet therapy was added to the treatment course, and the patient underwent PCI on POD 28. After the engagement of a 6Fr Judkins Right 3.5 guide catheter (Launcher, Medtronic, Minneapolis, Minnesota, USA), we predilated with a 3.0×12 mm compliant balloon (canPass, Japan Lifeline, Tokyo, Japan). Intravenous ultrasound system (IVUS) (OptiCross HD 60 MHz, Boston Scientific, Natick, Massachusetts, USA) revealed a focal severe stenosis, a narrowing external vessel diameter without significant intravascular plaque, and a sudden rotation of imaging at the lesion site, suggestive of coronary artery kinking (figure 3A and video 2). A 4.0×15 mm drug-eluting stent (DES) (Xience Sierra, Abbot Vascular, Tokyo, Japan) was deployed with the support of a 6Fr guiding catheter extension (Guide Liner V.3, Japan Lifeline, Tokyo, Japan). The IVUS performed after the stent deployment revealed that the coronary stent was incompletely expanded at the kinked segment, whereas significant malapposition was not confirmed (figure 3B and video 3). Final angiography showed a slight bending at the kinked segment with good coronary flow (figure 4 and video 4).
(A) Intravenous ultrasound system (IVUS) revealed a focal severe stenosis and narrowing external vessel diameter without significant intravascular plaque. (B) IVUS imaging following the stent implantation. The coronary stent was incompletely expanded at kinked segment, whereas significant malapposition was not confirmed.
Final angiography of right coronary artery showed a little bending at kinked segment with good coronary flow.
Outcome and follow-up
Follow-up MDCT 1 month after PCI demonstrated the coronary stent patency with a little bending (figure 5). No cardiac events occurred during the 7 months of follow-up.
Follow-up multidetector CT scan. Multiplanar reformatting image demonstrated the coronary stent patency with a little bending (yellow arrow).
Discussion
The original Bentall procedure, described in 1968, provided new insights into aortic surgery.1 However, the procedure was associated with a high risk of postoperative complications requiring reinterventions.7 Tsuji et al reported that the original Bentall procedure caused anastomotic stenosis with a prevalence ranging from 5% to 6%.11 In 1991, Kouchoukos et al proposed a button technique and reported that 92% of patients who underwent the button Bentall procedure did not need another operation compared with 71% of patients who underwent the original Bentall procedure within a 5-year period.7 A recent review of the button Bentall procedures described a freedom from reoperation rate of 98.3% at 5 years and 90.8% at 25 years, revealing the excellent short-term and long-term outcomes.12 The button technique has remarkably reduced coronary artery involvements, and it has become the most widely used treatment method for aortic diseases requiring aortic root and aortic valve replacement, such as SOVA, aortic dissection and aneurysm.4 5 9 10 13 Owing to the innovations in the surgical procedure, cardiologists now rarely encounter postoperative coronary artery involvement requiring PCI, which mainly depends on individual cases.14 15 Because of its rarity, it is important to review the previous literature in preparation for possible postoperative complications, which require appropriate recognition and approaches.
In general, coronary artery involvement occurs at the anastomosis between the native coronary artery and the vascular graft including interposed coronary artery graft of Cabrol and Piehler techniques.2 3 The aetiologies are not clearly defined; however, coronary artery involvements are thought to be caused by endothelial inflammation, excessive tension and external compression.14–19 Endothelial inflammation is considered to be associated with suture, the surgical glue or endothelial injury by cardioplegia cannula insertion, and external compression with the haematoma or surgical glue. Regarding excessive tension, surgeons widely recognised that the coronary ostium should be carefully detached and reimplanted to avoid tension or kinking in an operative procedure, especially in dealing with RCA.20 The same care should be taken with the vein graft to RCA and/or left circumflex artery during coronary artery bypass grafting surgery (CABG).21
Importantly, surgery-related complications can occur anytime from the intraoperative to the remote postoperative period. A previous report described that a thrombosed Cabrol graft caused cardiac arrest intraoperatively.22 Another case described that a left main anastomotic stenosis occurred 12 years after a Cabrol operation.23 Intraoperative and early postoperative complications include bleeding, cardiac tamponade and coronary artery involvement of thrombosis, kinking and stenosis, leading to unstable haemodynamics and ventricular dysfunction. In particular, a left main trunk involvement can cause haemodynamic collapse.19 Prediction and prevention of postoperative complications with short-term and long-term observation are crucial, for which routine follow-up examinations should be performed. TTE, cardiac scintigraphy and MDCT are useful less-invasive modalities. In addition, MDCT provides detailed morphological information, which is helpful for revealing the aetiology of coronary diseases, as seen in our case.8 24
Previous reports described the efficacy of PCI and CABG for postoperative coronary artery involvements.9 25 Limited to PCI for RCA complications following the button technique, only five cases in four articles have been reported (table 1).14 19 24 26 Our case is the sixth report and is unique for its asymptomatic presentation, lesion site and aetiology. All five previous cases were symptomatic with angina or myocardial infarction. The earliest case occurred soon after sternotomy closure and the latest case occurred 1 year after operation. Lesion sites were the RCA ostia except for one case with proximal RCA due to a different aetiology. Four cases were treated with DES and one with a bare-metal stent (BMS). However, one case treated with DES and one with BMS resulted in RCA restenosis requiring percutaneous reintervention. In our case, asymptomatic coronary disease was detected by MDCT on POD 15. The lesion site was, uncommonly, a native coronary artery close to the ostial anastomosis. The aetiology of the stenosis appeared to be the excessive tension due to the inadequate mobilisation of the RCA ostium. Proximal RCA kinking is extremely rare, and IVUS findings with sudden rotation of imaging are notable.
Five previous cases of percutaneous coronary interventions for right coronary artery complications after button Bentall procedures
| Case | Authors | Publishd year | Presentation | Time after operation | Lesion site | Aetiology | Stent | Outcome |
| 1 | Funada et al 26 | 2006 | NSTEMI | 2 months | RCA ostium and LMT ostium | Fibrotic reaction | BMS | RCA restenosis (7 months) |
| 2 | Shenoda et al 24 | 2009 | Angina | 1 year | RCA ostium | Autoimmune response | DES | RCA restenosis (4 months) |
| 3 | Saleem et al 19 | 2018 | VF | Intraoperation | RCA ostium | Dissection | DES | n/a |
| 4 | Adamson et al 14 | 2019 | STEMI | 2 weeks | RCA ostium | External compression | DES | Event free (18 months) |
| 5 | NSTEMI | 4 days | Proximal RCA | Kinking | DES | Event free (2 months) |
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BMS, bare-metal stent; DES, drug-eluting stent; LMT, left main trunk; n/a, not available; NSTEMI, non-ST-elevation myocardial infarction; RCA, right coronary artery; STEMI, ST-elevation myocardial infarction; VF, ventricular fibrillation.
Although PCI is feasible for prompt revascularisation and established management for acute coronary syndrome, the utility of PCI for complications after Bentall procedures remains unclear because of the limited literature. In decision-making for these complications, premanagement anatomical evaluation is essential. There are several modifications of the Bentall procedure where coronary artery derives from an abnormal position in case with combined bypass grafting, Cabrol technique or Piehler technique. Cardiologists and surgeons should consider the lesion characteristic and experience in the surgical procedure when determining case management (PCI or CABG).
Patient’s perspective
I was worried about an intermittent chest pain. I was referred to the hospital, where I was surprised that the doctors recommended me the emergent hospitalisation. After the Bentall procedure, an asymptomatic coronary involvement was surprisingly detected by multidetector CT. I feel relieved to underwent a percutaneous coronary intervention before sudden cardiac events occurred. After the dischargement, I do not realise any chest pain and I am enjoying my life. I hope that my experience would contribute to the medical development.
Learning points
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The button Bentall procedure has achieved excellent short-term and long-term outcomes with a significantly lower incidence of postoperative coronary artery complications.
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Only five cases of percutaneous coronary intervention (PCI) for right coronary artery (RCA) complications following the button technique have been reported. Our case is unique for its asymptomatic presentation, lesion site (proximal RCA) and aetiology (kinking).
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During the button Bentall procedure, the coronary ostium should be carefully detached and reimplanted to avoid tension or kinking. Routine follow-up examinations should be performed to prevent cardiac events.
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Cardiologists and surgeons should consider the lesion characteristic and experience in the surgical procedure when discussing the management (PCI or coronary artery bypass grafting surgery) of postoperative RCA complications.
Footnotes
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Contributors The paper was authored by TF; conception and design, writing the article. NO; final approval of the article. SH; final approval of the article.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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