Andreou, Andreas Y.

Avraamides, Panayiotis C.

Georgiou, George M.

Elsevier - Publisher Connector 

Archives of Cardiovascular Disease (2011) 104, 423—424
IMAGE
Stenting  for  an  internal  mammary  artery  graft  kink
Stenting  d’un  pontage  artériel  mammaire  interne
Andreas  Y.  Andreou ∗,  George  M.  Georgiou,
Panayiotis  C.  Avraamides
Cardiology  Department,  New  Nicosia  General  Hospital,  Old  Road  Nicosia-Limassol  213,
P.O. Box  2029,  Strovolos,  Nicosia,  Cyprus
Received  23  June  2010;  received  in  revised  form  29  June  2010;  accepted  5  July  2010
Available online  22  February  2011
KEYWORDS
Internal  mammary
artery  graft;
Coronary  graft  kink
MOTS  CLÉS
Pontage  mammaire
interne  ;
Greffon  coronaire
A 60-year-old  male  cigarette  smoker  with  hypertension  and  hyperlipidaemia  underwent
coronary  artery  bypass  surgery  after  hospitalization  for  unstable  angina.  An  in  situ,  pedi-
cled,  left  internal  mammary  artery  (LIMA)  was  grafted  to  the  left  anterior  descending
(LAD)  artery,  and  vein  grafts  were  placed  to  the  right  posterior  descending  and  obtuse
marginal  arteries.  One  month  later,  the  patient  underwent  repeat  angiography  for  severe
angina;  this  revealed  patent  vein  grafts  and  a  signiﬁcant  LIMA  stenosis  at  the  site  of  a  kink
(Fig.  1),  which  was  refractory  to  selective  catheter  injection  of  nitroglycerine.  Because
no  other  possible  culprit  lesion  was  revealed,  we  intervened  directly  with  deployment
of  a  3.0  mm  ×  15  mm  everolimus-eluting  stent  across  the  kink  site.  This  led  to  complete
resolution  of  the  stenosis;  sustained  relief  of  angina  was  conﬁrmed  at  1-year  follow-up.
Kinking  of  an  IMA  graft  is  a  rare  cause  of  signiﬁcant  stenosis  and  recurrent  ischaemia.  It
is  produced  secondary  to  distortion  of  the  geometry  of  the  graft  either  due  to  stretching
of  the  naturally  tortuous  IMA  to  facilitate  grafting  or  looping  of  a  redundant  graft  induced
by  inadvertent  twisting.  Kinking  may  be  intermittent  and  produced  secondary  to  marked
bending  of  a  redundant  graft  induced  by  lung  motion.  Both  pedicled  and  skeletonized
IMAs  develop  kinks  with  similar  frequencies;  however,  the  associated  stenosis  severity  is
signiﬁcantly  higher  in  the  latter,  possibly  due  to  the  small  amount  of  connective  tissue  left
around  the  graft  to  serve  as  a  cushion  that  facilitates  kink  development  at  a  sharper  angle.
Furthermore,  documented  cases  of  spontaneous  resolution  of  such  kinks  have  implicated
local  wall  oedema  and  haematoma  produced  during  harvest  as  possible  causes  of  IMA  graft
kinking.  Perioperative  IMA  spasm  may  simulate  a  kink  and  although  it  may  be  intractable,  its
resolution  after  intraconduit  administration  of  vasodilators  facilitates  their  differentiation.
Abbreviations: IMA, internal mammary artery; LAD, left anterior descending; LIMA, left internal mammary artery.
∗ Corresponding author. Tel.: +357-22603490; fax: +357-22604322.
E-mail address: y.andreas@yahoo.com (A.Y. Andreou).
1875-2136/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.acvd.2010.07.007
424  
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tigure 1. (A) Posteroanterior and (B) right anterior oblique vie
nterior descending (LAD) artery. Note the signiﬁcant stenosis pr
omplete resolution of the stenosis without secondary kink develop
Kink-site  stenosis  usually  resolves  completely  and  only
arely  progresses  to  a  more  severe  lesion.  Thus,  treatment
s  justiﬁed  only  in  the  presence  of  ischaemic  sequelae.  Tho-
acotomy  to  uncoil  and  ﬁx  a  redundant  IMA  graft  along  the
nterior  surface  of  the  right  ventricle  may  be  undertaken.  In
ther  cases,  stenting  of  the  kink  site  may  be  employed,  with
n  anticipated  high  procedural  success  and  good  outcome.
nlike  older-generation,  stiff  stents,  the  ﬂexible  stents  used
C
NA.Y.  Andreou  et  al.
the kinked left internal mammary artery (LIMA) graft to the left
ed at the kink site. (C) Post-stenting LIMA angiogram displaying
.
oday  can  accommodate  the  normal  contour  of  the  vessel
nd  prevent  secondary  kink  development;  however,  rela-
ively  long  stents  may  be  required  for  such  a  purpose.onﬂicts of interest statement
one.


Stenting for an internal mammary artery graft kink 

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Stenting for an internal mammary artery graft kink

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