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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 12-18

Mid-term results of one-stop endovascular aortic repair/percutaneous coronary intervention hybrid procedure for patients with aortic and coronary artery diseases


1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
2 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing; Department of Vascular Surgery, The 2nd Xiangya Hospital of Central South University, Changsha, Hunan, China

Date of Submission09-Nov-2020
Date of Decision09-Dec-2020
Date of Acceptance12-Dec-2020
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Chang Shu
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037; Department of Vascular Surgery, The 2nd Xiangya Hospital of Central South University, Changsha, Hunan 410011
China
Dr. Yida Tang
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT-D-20-00010

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  Abstract 


BACKGROUND: This study aimed to report our experience of endovascular aortic repair (EVAR) combined with percutaneous coronary intervention (PCI) for “one-stop” treatment of aortic and coronary artery diseases.
SUBJECTS AND METHODS: From January 2016 to December 2017, 17 patients (average age: 69.0, range: 44–86) with abdominal aortic aneurysms (n = 9), penetrating aortic ulcers (n = 6), and type B aortic dissection (n = 2), also combined with severe coronary artery disease, underwent “one-stop” EVAR/PCI hybrid procedure in Fuwai Hospital and were analyzed retrospectively.
RESULTS: The technical success rate was 100%. 11 cases received abdominal EVARs, 5 cases underwent thoracic EVARs, and 1 case had just aortic angiography. For the coronary lesions, 10 cases received coronary stent implantations, with an average stent number of 1.8 (1–3); one case underwent only balloon dilatation, and 6 cases merely had coronary angiography. There was no in-hospital death. Postoperative complications included subcutaneous ecchymosis in 4 cases; One suffered from pseudo-aneurysm at the puncture point of the left brachial artery, which was repaired surgically. Two had mild type II endoleak after abdominal EVAR. One patient was lost 12 months later and 16 patients were followed up for 28.6 (12–39) months. 3 deaths, with the cause of cancer in 2 and unknown in 1, and 2 readmissions were recorded. All other patients reported disappearance or significant reduction of previous symptoms. Both type II endoleak disappeared in 12 months.
CONCLUSIONS: The “one-stop” EVAR/PCI hybrid procedure is a safe and feasible option for the treatment of aortic and coronary artery disease.

Keywords: “One-stop,” endovascular aortic repair, hybrid, percutaneous coronary intervention


How to cite this article:
Luo M, Fang K, Ye S, Yang M, Fan B, Xue Y, Zhao J, Chen Z, Zhang H, Lv B, Tang Y, Shu C. Mid-term results of one-stop endovascular aortic repair/percutaneous coronary intervention hybrid procedure for patients with aortic and coronary artery diseases. Vasc Invest Ther 2021;4:12-8

How to cite this URL:
Luo M, Fang K, Ye S, Yang M, Fan B, Xue Y, Zhao J, Chen Z, Zhang H, Lv B, Tang Y, Shu C. Mid-term results of one-stop endovascular aortic repair/percutaneous coronary intervention hybrid procedure for patients with aortic and coronary artery diseases. Vasc Invest Ther [serial online] 2021 [cited 2021 Jun 16];4:12-8. Available from: https://www.vitonline.org/text.asp?2021/4/1/12/311340




  Introduction Top


With the increase of life expectancy and the aging of the population, hypertension, hyperlipidemia, and diabetes are becoming increasingly common. Atherosclerosis, which has become one of the most common and highly prevalent pathologies, can lead to aneurysm, arterial ulcers, arterial stenosis, occlusions, and many other lesions. As systemic atherosclerosis is often synchronized, the condition is often associated with various diseases, including coronary artery disease, aortic aneurysm, aortic ulcer, lower extremity arterial stenosis, carotid and visceral artery stenosis, etc.[1],[2] In cases of aortic diseases with severe coronary artery disease both requiring interventional treatment, two therapeutic strategies regarding the timing of the coronary procedure and aortic repair can be considered: staged or simultaneous procedures. However, the ideal treatment for this condition remains controversial.[3]

At present, there are some case reports combining endovascular aortic repair (EVAR) and percutaneous coronary intervention (PCI) in a staged style.[4] However, there is no report utilizing “one-stop” implementation of thoracic/abdominal EVAR and PCI in English literature till now. Mainly based on the preliminary clinical practice of Fuwai Hospital, National Center for Cardiovascular Diseases, China, this study investigated the safety, effectiveness, specific technical details, and complications of this “one-stop” EVAR/PCI hybrid procedure for the first time.


  Subjects and Methods Top


Subjects

We retrospectively analyzed the clinical data of 17 patients with aortic atherosclerotic disease combined with coronary artery disease who received “one-stop” EVAR and PCI in Fuwai Hospital from January 2016 to February 2017. The male: female ratio was 15:2, and the average age was 69.0 (44–86) years. The patients were all admitted due to aortic diseases, including abdominal aortic aneurysms in 9, penetrating aortic ulcers in 6, type B aortic dissection in 2, and were scheduled to receive thoracic or abdominal EVAR treatment. In addition, after detailed medical history was collected, we found that 15 patients in this group had symptoms suspected for angina pectoris before, and the other 2 patients had systemic atherosclerosis including aortic pathologies, lower extremity arterial stenosis, carotid, and vertebral artery stenosis, and smoking history of more than 30 years. Accordingly, preoperative computed tomography angiography (CTA) examination for coronary artery was suggested to them, and finally revealed severe coronary calcification and stenosis, so coronary angiography was then strongly recommended; when necessary, PCI treatment was also conducted. The basic data of this group of patients are provided in [Table 1].
Table 1: Baseline characteristics and procedural findings of patients

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Perioperative management and “one-stop” endovascular aortic repair/percutaneous coronary intervention hybrid procedure

Preoperative preparation: We conducted comprehensive inspections to reach a clear diagnosis and developed the “one-stop” intervention regimen. We recommended that the patients take aspirin 100 mg + clopidogrel 75 mg daily starting from 3 to 5 days before the “one-stop” EVAR/PCI hybrid procedure or to take aspirin 100 mg + clopidogrel 300 mg as a single administration 1 day before the procedure. In the late phase of our project, patients over 75 years of age were recommended to take the former approach, that is, taking aspirin 100 mg + clopidogrel 75 mg daily starting from 3 to 5 days before surgery, to avoid taking the maximum dose in one administration.

“One-stop” EVAR/PCI hybrid procedure: For all patients in this group, general anesthesia was chosen to avoid patients' excessive nervousness and possible angina. Vascular surgeons first made small inguinal incisions to expose the femoral artery and then performed the thoracic or abdominal EVAR procedure through the femoral artery approach (a routing technical operation was conducted). For abdominal aortic lesions, bifurcated and straight stent-grafts can be chosen according to the shape and range of the pathologies; for the thoracic lesions, an endograft was used routinely to cover the ulcer or the first entry of the dissection, and chimney technique was also carried out in case of coverage of the left subclavian artery. After the above procedure, the femoral artery was sutured; the brachial artery puncture point was pressed well. Thereafter, the femoral artery was punctured again by interventional cardiologists under direct view to conduct coronary angiography and to clarify the conditions of any coronary lesions. Once interventional indications were confirmed, coronary angioplasty or coronary stent implantation was performed. After the whole procedure was completed, the layers of the groin incision were sutured.

Postoperative treatment: The inguinal incisions were pressed with sandbags for 6–12 h, with close observation of wound bleeding, ecchymosis range, lower extremity skin temperature, dorsalis pedis artery pulse, and other signs. We also monitored myocardial enzymes, routine blood test results, and blood biochemical test results. According to the principle of PCI postoperative treatment, we recommended dual antiplatelet therapy for the 1st year, including aspirin 100 mg, once daily + clopidogrel 75 mg, once daily, followed by aspirin 100 mg, once daily for lifetime. Antihypertension, antihyperlipidemic, and other medical treatments were implemented if necessary.

Statistical analysis

SPSS 17.0 statistical software (IBM Corporation, Somers, NY, USA) was used for statistical processing. The data in the results are expressed as the mean ± standard deviation (X ± s), and the statistical method used was the t-test. P < 0.05 indicated that the difference was statistically significant.


  Results Top


Perioperative period

For the aortic pathologies, 11 cases received abdominal EVAR procedure, including 9 cases underwent bifurcated stent-graft implantation into the aorta and both iliac arteries and the other 2 underwent straight stent grafts in the abdominal aorta; and 5 cases had thoracic EVAR procedure, including 2 cases underwent chimney technique-mediated left subclavian artery reconstruction simultaneously through left brachial artery puncture. The last one patient, a 74-year-old woman, just had aortic angiography and did not have repair procedure because the whole aorta enlarged severely.

For the coronary intervention treatment, 10 cases were treated with coronary stent implantation, with an average stent number of 1.8 (1–3); 1 case was treated with only balloon dilatation, and 6 cases just had coronary angiography without any intervention because it showed no indication for stenting in 5, and coronary artery bypass grafting (CABG) was recommended in 1 because of severe multivessel lesions.

The technical success rate of “one-stop” EVAR/PCI hybrid procedure was 100%, and there were no hospital deaths or major cardiovascular events. Postoperative complications included 4 cases that had large areas of subcutaneous ecchymosis in the vicinity of the groin incision, of which 1 case had subcutaneous hematoma in the incision and was infused with 2 U of erythrocytes for decreased hemoglobin levels. One case of penetrating aortic arch ulcer had pseudo-aneurysm at the left brachial artery puncture point after chimney for left subclavian artery rescue and received pseudo-aneurysm resection + brachial artery repair. Two had mild type II endoleak after abdominal EVAR without any additional treatment. The detail information is shown in [Table 1].

Follow-up

One patient was lost to follow up 12 months later. This patient returned to the hospital 12 months after the procedure with a good status, but thereafter, he did not come again and cannot be reached by telephone neither.

The other 16 patients were followed up for a period of 28.6 (12–39) months through outpatient service or telephone review. During the follow-up, 3 deaths were recorded, 2 of which died of terminal cancer 29 and 24 months after the procedure, and the last 1 with an unknown reason, suspicious of a sudden cerebral event 14 months postoperatively. The survival curve is shown in [Figure 1]. Besides, there were 2 aortic or coronary-related readmissions. One patient who suffered from abdominal aortic aneurysm with severe calcification and stenosis of the iliac and femoral artery underwent abdominal EVAR and coronary angiography simultaneously had re-intervention for iliac stent graft occlusion 3 months after the previous procedure. The other patient who underwent only aortic and coronary angiography without any stenting because of enlargement of the whole aorta lacking of enough proximal and distal landing zone, and mild or moderate stenosis of the circumflex artery which need not intervention, suffered from acute myocardial infarction 16 months postoperatively, treated by medical treatment and recovered well. 5 other patients had nonaortic-noncoronary readmissions because of pulmonary or digestive system diseases.
Figure 1: Kaplan–Meier estimates of overall survival

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The clinical symptoms of all the other patients had either disappeared or were significantly alleviated; their quality of life was improved. All patients who returned to our hospital for reexamination underwent computed tomography examination to observe the conditions of their aortic and coronary stents. Both type II endoleak disappeared in 12 months.


  Discussion Top


Nowadays, atherosclerotic disease has become a common clinical disease throughout the world;[5] it is particularly common in regions with higher living standards, such as developed countries or first-tier cities in China. Years of clinical practice at Fuwai Hospital, National Center for Cardiovascular Diseases, China, have suggested that these patients have systemic arteriosclerosis and that the same patient often carries several lesions, such as multiple arterial stenosis, occlusion, ulcer, and aneurysms. Therefore, we recommend examinations of the coronary artery disease for elderly patients with nonemergent aortic aneurysms or aortic ulcers, since the cardiac event is a common cause of morbidity and mortality following treatment of aortic pathologies, and additionally, coronary artery disease is known to be the leading cause of early and late mortality following aortic aneurysm surgeries.[6] The indication of preoperative CTA for coronary artery may include the following status: (1) patients with symptoms suspected for angina pectoris before; (2) patients with high-risk factors of coronary disease over the age of 50 or with systemic atherosclerosis including aortic pathologies, lower extremity artery stenosis, carotid, vertebral or vertebral artery stenosis.

These examinations are very helpful for attaining a comprehensive understanding of the patient's condition and an objective assessment of perioperative risks and for developing sound surgical procedures to avoid perioperative complications due to missed diagnosis. Similarly, for patients with coronary artery disease who underwent PCI or CABG, further assessment of the aortic lesions should be conducted when necessary. Particularly when associated aortic lesions, such as thoracic penetrating aortic ulcers, are accidentally identified when conducting coronary CTA to clarify coronary diseases, it is mandatory to conduct a comprehensive aortic CTA examination for the whole aorta. The adequate preoperative examination helps to avoid missed diagnosis and to reduce the risk of iatrogenic aortic injury. In addition, for patients with stenosis of the carotid artery, lower extremity arteries, and other peripheral arteries, preoperative assessment of the existence of coronary arterial and aortic lesions also helps the clinicians to fully grasp the patient's condition. If coexisting lesions are found, concurrent or sequential treatment can be applied when necessary, thus reducing surgical complications and the re-hospitalization rate and improving long-term event-free survival. As CTA examination carries side effects sometimes, such as contrast agent toxicity and radiation, the interval between two CTA examinations must be at least 24 h according to our experience. Adequate drinking of water on the day of CTA examination can facilitate contrast agent excretion through urine, and this and other measures can help to reduce the side effects of CTA. In addition, color Doppler ultrasound should be used as the first choice for primary screening (such as screening of the carotid artery and lower extremity arteries) to reduce the use of CTA when feasible.

Traditionally, for patients who have the need for intervention of both coronary artery disease and aortic disease (aortic aneurysm/aortic ulcer, etc.), doctors from the majority of hospitals adopt the approach of sequential treatment of endovascular aortic repair and PCI/CABG, and patients are sequentially admitted to two different departments and receive separate treatment for aortic and coronary artery diseases. The advantage of this traditional staged approach is that each procedure only deals with one lesion, the operation and anesthesia time is shorter, and each operation uses low amounts of contrast agents and may have a lower operative risk. However, there are also disadvantages. 1. There are risks during the waiting period between the two sequential procedures. For example, after endovascular aortic repair, temporarily untreated coronary artery disease may lead to perioperative and early postoperative myocardial infarction.[7] If coronary artery disease is treated first, antiplatelet therapy after coronary procedures may increase the risk of rupture in aortic diseases.[3] 2 patients are sequentially admitted into two different wards, receive two administrations of anesthesia, two operations, and two perioperative treatments, and may have a longer hospital stay. The above factors will lead to increased costs of time and total hospital costs and increased consumption of medical resources.[4],[5]

Queries of the PubMed database reveal that the “one-stop” implementation of EVAR combined with CABG in the treatment of patients with aortic disease associated with coronary artery disease has been reported since 1999, but the number of reports is very limited.[8],[9],[10],[11] However, the simultaneous implementation of EVAR and PCI (”one-stop” EVAR/PCI hybrid procedure) has not been reported to the best of our knowledge. After multidisciplinary discussion, we decided to conduct “one-stop” EVAR/PCI hybrid procedure for this group of patients by a special team formed of experts from the Vascular Surgery Center and Coronary Artery Center of Fuwai Hospital. The advantages of “one-stop” EVAR/PCI hybrid procedure include the following: (1) the risk of the two diseases, aortic and coronary, are attenuated together, avoiding risks during the waiting period between two sequential procedures; (2) psychologically, patients might prefer this approach because they only need to undergo one anesthesia and one operation to treat two diseases; and (3) the overall hospital stay may be shortened, with the consumed medical resources reduced, and the total cost of hospitalization reduced. On the other hand, The disadvantages are as follows: (1) it requires experts from two departments to form a compound technical team, thus demanding relatively high technical standards of the related disciplines and the coordination capacity of the hospital; (2) simultaneous treatment of two diseases increases the short-term use of total amounts of contrast agents, although no related potential risks were identified in this group of patients; and (3) because dual antiplatelet therapy is required after coronary intervention treatment, it is more prone to postoperative bleeding, subcutaneous ecchymosis, local hematoma, or pseudo-aneurysm in the artery puncture point. Severe conditions necessitate the termination of antiplatelet drugs. Our group gained some early experience from the treatment of this group of patients. There were two cases that showed subcutaneous ecchymosis near the groin incision, of which one case was associated with subcutaneous hematoma and received blood transfusion treatment and one case had pseudo-aneurysm at the left brachial artery puncture point and received pseudo-aneurysm resection plus brachial artery repair. These two cases suggest that we have to be extremely cautious and reliable in the postoperative treatment of incisions and puncture hemostatic treatments.

In addition, during endovascular thoracic aortic repair procedure, we should avoid sacrificing the left subclavian artery whenever possible, which can reduce the risk of stroke and left upper extremity ischemia.[12],[13] This measure is especially important for patients with thoracic aortic disease combined with coronary artery disease because these patients may need to receive coronary artery bypass grafting in the future, and the left internal mammary artery (LIMA) which originates from the left subclavian artery is extremely important for coronary artery bypass surgery.[14],[15] Based on this possibility, for the one thoracic penetrating atherosclerotic aortic ulcer case with insufficient endo-grafting landing zone in this group, we still utilized the “chimney” technique to rebuild the left subclavian artery despite the left vertebral artery was not dominating. The “chimney” technique as a minimally invasive technique for the preserving of the supra-aortic vessels has been widely used for years.[16] Otherwise, free LIMA graft or other graft should be chosen as secondary choices, of which long-term patency rate may be lower than regular LIMA graft.

In summary, for aged patients with coronary artery disease or aortic disease and patients with multiple risk factors for atherosclerosis, it may be necessary to conduct preoperative comprehensive screening for systemic arterial diseases. For patients with aortic disease complicated with coronary artery disease, if angiography confirms that both conditions meet the indications of intervention, it is reasonable to conduct a “one-stop” EVAR/PCI hybrid procedure for coronary artery and aortic lesions to avoid the risk of waiting between different stages of procedures, to shorten the total hospital stay, to reduce the consumption of medical resources, and to reduce the total treatment cost. This “one-stop” strategy is also readily accepted well by the patients. In addition, it is possible to take further measures to coordinate experts of the two fields for efficient cooperation during the “hybrid” procedure, to control the total operation time and the amount of contrast agent administered, to focus on the wound, and to achieve complete hemostasis to avoid early hemorrhagic complications. The “one-stop” approach enables the doctors to avoid the respective pros and cons of each separate procedure, fully taking advantage of the “one-stop” endovascular treatment of coronary artery disease and aortic disease. Because postoperative treatment of EVAR and PCI is not mutually exclusive, the postoperative medical treatment regimen is conducted in strict accordance with the principles after PCI.

In addition, before this “one-stop” strategy can be widely approved, a larger scale randomized controlled trial to analyze the perioperative results, long-term results, and the medical economics evaluation is needed.


  Conclusions Top


The “one-stop” EVAR/PCI hybrid procedure is a safe and feasible option for the treatment of aortic and coronary artery disease. Randomized controlled trial and long-term results is needed before widely application of this hybrid procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This work was supported by the Capital Health Research and Development Project (No. 2018-2-4032) & Beijing Municipal Commission of Science and Technology (Z171100000417021).

Conflicts of interest

There are no conflicts of interest.



 
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