Original Articles Korean Circulation J 1999;29 1 :46-54 좌관상동맥개구부혈관성형술의성적 문건식 김연중 김재성 홍석근 황흥곤 Outcome of Surgical Angioplasty for Isolated Coronary Ost

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1 Original Articles Korean Circulation J 999;9:454 좌관상동맥개구부혈관성형술의성적 문건식 김연중 김재성 홍석근 황흥곤 Outcome of Surgical Angioplasty for Isolated Coronary Ostial Stenosis Keon Sik Moon, MD, Yun Joong Kim, MD, Jae Sung Kim, MD, Suk Keun Hong, MD and Hweung Kon Hwang, MD Department of Internal Medicine, Sejong General Hospital, uchon, Korea ABSTRACT BackgroundAlthough surgical angioplasty for isolated coronary ostial stenosis is assumed as an alternative approach to CABG, the clinical features of isolated coronary ostial stenosis, postoperative complications and followup angiographic results would have not been well studied. MethodsWe retrospectively studied 4 patients femalemale04, mean age.0. yr who underwent surgical angioplasty for isolated coronary ostial stenosis using patch fresh autologous pericardium, saphenous vein during the period of March 9 through ebruary 998. Repeat coronary angiography patients and echocardiography 4 patients were performed. Aortic regurgitation was evaluated semiquantitatively Grade Grade. ResultsThere were deaths after surgical angioplasty. One death was due to acute coronary dissection perioperatively, the second due to low cardiac output syndrome weeks postsurgery, and the third due to traumatic panperitonitis 0 months postprocedure. Angina recurred in 4 patients and the remaning 8 patients were symptomfree. Repeat angiography Mo showed widely patent ostium with excellent runoff except patients distal patch stenosis, ostial restenosis in Takayasu s arteritis. The third symptomatic patient was proven to have coronary spasm by ergonovine test. AR increased in the fourth patient Grade with patent ostium. ConclusionSurgical angioplasty may be feasible and alternative operative method to CABG for isolated coronary ostial stenosis. It should however be noted that postop AR can develop and/or increase. urther investigation is needed to evaluate the clinical significance of the AR. Korean Circulation J 999;9:454 KEY WORDSSurgical angioplasty Coronary artery disease Aortic regurgitation. 서 론 4

(transaortic) 수술접근법으로 활성화된 후 Sullivan 등,7) 8) 9) 으로 나이, 성별, 임상증상, 심전도, 운동부하검사, 심초 0) Dion 등, Bortolotii 등, Dias 등 에 의해, 일부 선택 음파도 및 관상동맥조영술, 협착원인, 술후 경과등의 임 된 환자에서 기존 관상동맥우회술을 대치할 수 있는 효 상적 소견을 검토하였다.

2 (transaortic) 수술접근법으로 활성화된 후 Sullivan 등,7) 8) 9) 으로 나이, 성별, 임상증상, 심전도, 운동부하검사, 심초 0) Dion 등, Bortolotii 등, Dias 등 에 의해, 일부 선택 음파도 및 관상동맥조영술, 협착원인, 술후 경과등의 임 된 환자에서 기존 관상동맥우회술을 대치할 수 있는 효 상적 소견을 검토하였다. 또한 4예의 환자중 예(남 과적인 치료로 보고되고 있다. 그러나 이에 대한 임상 적 특징 및 술후 시행한 추적 관상동맥 조영술등의 결 과에 대한 장기적 보고는 드물어 저자등은 본원에서 시 행한 결과를 국내외의 문헌고찰등과 함께 후향적으로 비 교 검토하였다. 대상 및 방법 9년 월부터 998년 월까지 세종병원에서 좌 관상동맥 개구부협착으로 진단되어 좌관상동맥 혈관성형 술(양측관상동맥 혈관성형술 예 포함)을 실시한 4예 ig.. On coronary angiogram, left coronary ostial stenosis is demonstrated. (남자 4명, 여자 0명, 평균연령.0±.세)를 대상 Table. Clinical charateristics of 4 patients with Isolated LM ostial stenosis Case No Age (yr) Sex EKG TMT Ostial stenosis(%) 4 Symptom duration (Mo) CCS class Angina M S IRBBB (LCA), (RCA) 0 5 S 75 M Q in V (LCA), (RCA) 5 4 M 5 S M S LVH CCS class Canadian cardiovascular society angina classification unstable angina stable angina normal sinus rhythm Nonspecific STT change IRBBB incomplete right bundle branch block TMT treadmill test by Bruce protocol not available positive S suggestive positive LCA left coronary artery RCA right coronary artery 47

3 결 좌관상동맥개구부협착의빈도 연령분포및성별 임상증상 과 Table. Clinical feature of 4 patients Men Women Number 4 0 Age years Angina Stable 4 Unstable Duration of Symptom.8...5* CCS class Class 9 Class 0 Class 0 *Excluded 5 cases case No.,4,0,, 이학적소견및심전도 위험인자 운동부하검사 Table. Risk factors of 4 patients Men n4 Women n0 Smoking 4 amily history 0 Hypertension 7 Hyperlipidemia 0 Diabetes 0 Radiation therapy 0 revious infarction 0 No risk factor 0 Table 4. Treadmill exercise test Men n4 Women n0 ositive 0 8 Warmingup phase Stage 5 Stage 0 Stage Stage IV 0 Suggestive positive Negative 0 0 Not available 0 Korean Circulation J 999;9:454

고 음성인 경우는 없었다(Table 4). 심초음파도 술전 시행한 심초음파도에서 예에서는 경미한 좌심 실 기능부전소견을 보였고 또다른 예에서는 대동맥판 막 폐쇄부전증(Grade 예, Grade Ⅱ 예)를 보였으 며 나머지 0예에서는 정상소견이었다. 술후에 경미한 좌 심실기능부전을 가진 예는 정상으로 되었고 나머지 예는 변화 없었다.

4 고 음성인 경우는 없었다(Table 4). 심초음파도 술전 시행한 심초음파도에서 예에서는 경미한 좌심 실 기능부전소견을 보였고 또다른 예에서는 대동맥판 막 폐쇄부전증(Grade 예, Grade Ⅱ 예)를 보였으 며 나머지 0예에서는 정상소견이었다. 술후에 경미한 좌 심실기능부전을 가진 예는 정상으로 되었고 나머지 예는 변화 없었다. 대동맥판막 폐쇄부전증이 8예(Grade 예, Grade Ⅱ 예)에서 수술후 새로 발생하였고, 기 존 Grade Ⅱ인 예는 Grade Ⅲ로 증가하였고 나머지 ig.. ostoperative followup angiogram shows widely patent ostium with excellent runoff. Table 5. Operation and result Date of op AR Case No Cause / Left ostioplasty+ CABG SV 5 / Asymptomatic 0 Mo 8 / Left ostioplasty A / 94 Asymptomatic 98 Mo 0 / Left ostioplasty A Expired 4 7 / 9 Left ostioplasty A 8 / 9 Ⅱ Asymptomatic 87 Mo 5 ibrinomyxoid 7 / 9 Left ostioplasty A / 94 Ⅱ Ⅲ Asymptomatic and expired Op name atch Recath Restenosis ollowup reop ostop Mo, 9 / Left ostioplasty A Asymptomatic Mo 7 / 94 Left ostioplasty A Asymptomatic 5 Mo 8 / 95 Left ostioplasty+ CABG A / 97 Asymptomatic 45 Mo 9 / 95 Bilateral ostioplasty SV Expired 5 / 95 Left ostioplasty A 5 / 9 + Successful TCA at months for recurrent LCO stenosis 8 / 95 Left ostioplasty A Asymptomatic 8 Mo / 95 Left ostioplasty A Asymptomatic 5 Mo A / / 9 Left ostioplasty+ CABG Asymptomatic Mo 5 Takayasus arteritis / 97 Left ostioplasty+ CABG A Restenosis at 7 months steroid medication Asymptomatic 0 Mo / 97 Left ostioplasty+ CABG A Asymptomatic 0 Mo 7 / 97 Left ostioplasty A Asymptomatic Mo 8 7 / 97 Left ostioplasty+ CABG A Asymptomatic 5 Mo 9 8 / 97 Left ostioplasty A Asymptomatic 4 Mo 0 / 97 Left ostioplasty+cabg A Asymptomatic Mo / 97 Left ostioplasty+vvi A Asymptomatic 0 Mo / 98 Left ostioplasty A Asymptomatic 9 Mo / 98 Left ostioplasty A 5 / 98 Asymptomatic 7 Mo 4 / 98 Left ostioplasty A 7 / 98 Recurrent chest pain at month ergonovine test( ) 4 / 97 Bilateral ostioplasty A 8 / 97 + Ⅱ =athrosclerosis CABG=coronary artery bypass graft, LIMA to LAD bypass VVI=permanent pacemaker VVI type TCA=percutaneous transluminal coronary angioplasty SV=saphenous vein A=autologous pericardium =not available LCO=left coronary ostium 49

5 관상동맥조영술소견 수술방법및협착원인 임상경과 고안 Korean Circulation J 999;9:454

6 Table. Review of the literature of surgery for bilateral coronary ostial stenosis Case Reference Year Age/Sex Cause Operation Outcome ollowup Beck et al 95 0 Syphilictic aortitis Endartectomy Not available Saphenous vein CABG atent grafts at 8 Hutter et al Not specified to LAD and RCA months LIMA occlusion at Saphenous vein CABG Thompson et al 98 4 Not specified weekssuccessful to RCALIMA to LAD reoperation Saphenous vein CABG Asymptomatic and patent 4 Tanaka et al 9 7 Takayasu s aortitis to LMCA and RCA grafts at 8 months 5 Eng et al 99 Not specified Triple CABG Not available Eng et al 99 M Not specified 7 Dion et al 99 8 erosis? 8 rierson et al 99 M Not specified Saphenous vein patch angioplasty of RCA LCO dilatation with RCO and LCO ostioplasty with fresh autologous pericardial patches Saphenous vein CABG to LCX and RCA RIMA TO LAD Not available atent ostia at 0 months Aymptomatic at Months 9 Van Doorn et al 994 5M Not specified LCO and RCO dilatation* atent ostia at years 0 Bortolotti et al Aortitis Bilateral ostioplasty with tanned autologous pericardium *Surgical technique not specified LADleft anterior descending arteryrcaright coronary arterylimaleft internal mammary artery LMCAleft main coronary arterylcoleft coronary ostiumrcoright coronary ostium LCXleft circumflex arteryrimaright internal mammary artery atent ostia at year Aymptomatic at years 5

7 5 요약 연구배경 : 방법 : 결과 : Korean Circulation J 999;9:454

8 결론 : 중심단어 REERENCES ) Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol ) De Mots H, Rosch J, McAnulty JH, Rahimtoola SH. Left main coronary artery disease. Cardiovasc Clin ) De Mots H, Bonchek LI, Rosch J, Anderson R, Starr A, Rahimtoola SH. Left main coronary artery disease. Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization. Am J Cardiol ) Effler DB, Sones M, avaloro R, Graves LK. Coronary endarterectomy with patch graft reconstructionclinilcal experience with 4 cases. Ann Surg ) Sabiston DC, Ebert A, riesinger GC. roximal endarterectomy Arterial reconstruction for coronary occulsion at origin. Arch Surg ) Hitchoock J, Robles de Medina EO, Jambroes G. Angioplasty of the left main coronary for isolated left main coronary artery disease. J Thorac Cardiovasc Surg ) Sullivan J, Murphy D. Surgical repair of stenotic ostial lesions of the left main coronary artery. J Thorac Cardiolvasc Surg ) Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg ) Bortolotti U, Milano A, Balbarini A, Tartarini G, Levantino M, Borzoni G, et al. Surgical angioplasty for isolated coronary ostial stenosis. Tex Heart Inst J ) Dias AR, Jatene MB, Dias RR, Jatene AD. Surgical experience with the enlargement of left coronary ostial stenosis. Cardiovasc Surg 995suppl 89. ) Eng J, Beton DC, Lawson RA, Moussalli H, Nair UR, Rahman AN. Coronary ostial stenosissurgical considerations. Int J Cardiol ) Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol ) rater RW, Jordan A. Syphilitic coronary ostial sclerosis. Ann Thorac Surg ) Chun K, Jones R, Robinowitz M, Davia JE, Lawrence J. Coronary ostial stenosis in Takayasu s arteritis. Chest ) Wilson VE, Bates ER. Subacute bilateral coronary ostial stenoses following cardiac catheterization and TCA. Cathet Cardiovasc Diagn 994. ) Midell AI, DeBoer A, Bermudez G. ostperfusion coronary ostial stenosis Incidence and significance. J Thorac Cardiovasc Surg ) Topaz O, Warner M, Lanter, Soffer A, Burns C, DiSciascio G, et al. Isolated significant left main coronary artery stenosis angioplasty, hemodynamic, and clinical findings in patients. Ann Thorac Surg ) Beck W, Barnard CN, Shrire V. Syphilitic obstruction of coronary ostia successfully treated by endarterectomy. Br Heart J ) Hutter JA, asaoglu I, William BT. The incidence and management of coronary ostial stenosis. J Cardiovasc Surg Torino ) Tanaka K, Mizutani T, Yada I, Yuasa H, Kusagawa M. Aortacoronary bypass grafting for bilateral coronary ostial stenosis caused by Takayasu s aortitis [letter]. J Thorac Cardiovasc Surg ) Dion R, uts J, Abramowiez M. Bilateral surgical ostial angioplasty of the right and left coronary arteries [letter]. J Thorac Cardiovasc Surg 945. ) rierson JH, Duke DJ, Berney BW, Molloy TA, Dimas A. Isolated bilateral ostial coronary artery stenoses. Ann Thorac Surg ) Van Doorn CAM, Nair RU. Direct enlargement of isolated coronary artery ostial stenosis [letter]. J Thorac Cardiovasc Surg ) Briffa N, Clarke S, Kugan G, Coulden G, Wallwork J, Nashef M. Surgical angioplasty of the left main coronary arteryollowup with magnetic resonance imaging. Ann Thorac Surg ) Koh KK, Hwang HK, Kim G, Lee SH, Cho Sk, Kim SS, et al. Isolated left main coronary ostial stenosis in orient 5

9 ial people operative, histopathologic and clinical findings in six patients. J Am Coll Cardiol ) Lee WY, Kim EJ. Surgical angioplasty of left main and proximal left anterior descending coronary artery. Korean J Thorac Cardiovasc Surg ) Yoon CS, Yoo KJ, Lee KJ, Kim DJ, Kang MS. The clinical experiences of patch angioplasty in isolated critical left main coronary artery stenosis. Korean J Thorac Cardiovasc Surg ) Hutter JA, asaoglu I, Williams BT. The incidence and management of coronary ostial stenosis. J Cardiovasc Surg ) Vijayanagar R, Bognolo D, Eckstein. Safety and efficacy of internal mammary artery grafts for left main coronary artery disease. J Cardiovasc Surg ) Hartridge H. Dynamics of the circulation. In Evans CL, Hartridge H, eds. rinciples of Human hysiology, London Churchill Livingstone95. ) Hitchcock J. The return of surgical angioplasty of the left main coronary artery. Int J Cardiol Korean Circulation J 999;9:454

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노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding