Two Different Successful Angioplasty Methods in Patients with Stenotic Coronary Artery Ectasia
A 72-year-old man presented with exertional chest pain. He was an ex-smoker and had diabetes mellitus. He visited the department of chest surgery for a palpable abdominal mass. The diagnostic work-up showed ascending and abdominal aortic aneurysm, aortic stenosis, and severe discrete concentric stenosis in the mid portion of the right coronary artery (RCA) with mild ectatic change (). Aortic valve replacement (AVR; with a Carpentier-Edwards Perimount Magna 23-mm valve), reduction aortoplasty of the ascending aorta (with the suture plication technique and external wrapping with a 26-mm vascular graft), and coronary artery bypass graft (CABG; left great saphenous vein from aorta to distal RCA) was done. After 6 months, replacement of the abdominal aorta with a Hemashield 20-mm straight graft was done.\nAt 7 months after the last surgery, the patient developed exertional chest pain. Coronary computed tomography (CT) angiography showed two focal sites of significant, eccentric stenosis in the mid RCA and total occlusion of the LGSV to RCA. (). Echocardiography showed acceptable bioprosthetic aortic valve function and no regional wall motion abnormalities.\nCAG through the right femoral artery was performed. The angiographic findings showed moderate tubular concentric stenosis in the proximal RCA and severe discrete concentric stenosis in the mid RCA with ectatic changes. However, blood flow from the LGSV to RCA was not shown, which suggested total occlusion ().\nBecause of the larger size of the stenotic CAE, balloon angioplasty with parallel stenting was considered. However, balloon angioplasty alone without stenting was planned initially because of the possibility of early discontinuation of dual anti-platelet agents because of the chance of additional surgery for underlying valvular heart disease and aortic disease. The patient had previously undergone major cardiac surgery twice before owing to aortic stenosis and aortic aneurysm. Although the prosthetic aortic valve was intact, the aortic aneurysm was repaired through a staged operation and the graft did not entirely cover the aneurysm. Thus, we considered the possibility of future additional operative repair.\nWith a 7F AR2 catheter as a guide (Medtronic Inc., Minneapolis, MN,USA), balloon dilation was done with an Avita 3.0×15-mm balloon (Orbusneich, Wanchai, Hong Kong) and residual stenosis was more than 70%. Further ballooning was done with a Mercury 4.5×20-mm balloon (Abbott Vascular, Illinois, USA) and residual stenosis was less than 30% ().\nThe patient was on the dual antiplatelet agents (aspirin and clopidogrel), a lipid-lowering agent (simvastatin), a calcium channel blocker (diltiazem), and a beta-blocker (carvedilol) after the percutaneous coronary intervention. He was safely discharged without chest pain or any other cardiovascular events. Routine follow-up CAG at 6 months showed no significant restenosis at the previous balloon angioplasty site (). Dual antiplatelet agents were maintained for 2 years because of his history of diabetes and restenosis after CABG.