Peripheral bare-metal stent implantation for a very-late stenosis of an aortic-left main Cabrol graft: a case report

Abstract

Background: The surgical ascending aorta repair according to the Cabrol procedure involves the interposition of a prosthetic conduit between the aortic prosthesis and the native coronary ostia. Previous cases of the Cabrol conduit stenosis have been described, most of which presented as acute coronary syndromes due to thrombotic occlusion of the graft.

Case summary: We present a case of stable exertional angina due to very-late stenosis of the coronary prosthetic conduit, successfully treated with trans-femoral percutaneous angioplasty and off-label implantation of a balloon-expandable bare-metal stent designed for peripheral artery disease. The multimodality imaging approach gave an essential contribution both to the assessment of the lesion and to the procedural planning. Despite the concerns about long-term results, a peripheral bare-metal stent was preferred over a standard coronary drug-eluting stent due to the remarkable dimension of the Cabrol conduit. Three years after the procedure, the patient is free from angina, and coronary computed tomography showed no significative luminal loss of the stent.

Conclusion: Elective angioplasty of a Cabrol graft requires a careful planning through a multimodality stenosis assessment. Conventional coronary stents can be not large enough to ensure adequate apposition to the wide prosthetic conduit and peripheral bare-metal stents may be taken into consideration, at the price of unknown long-term outcomes.

Keywords: Bentall technique; Cabrol graft PCI; Cabrol technique; Case report; Multimodality coronary imaging assessment.

Figure 1

A detail of the aortic computed tomography-angiography exam performed according to the Institutional follow-up program after ascending aortic repair. Even if the quality of the images is suboptimal to allow a reliable coronary evaluation (computed tomography scan was not electrocardiogram-gated), a discrete narrowing at the transition point between the Cabrol graft conduit (red arrow) and the left main stem (yellow arrow) is clearly displayed.

Figure 2

Cath-lab assessment of the Cabrol conduit stenosis. The red arrow shows the prosthetic conduit; the yellow arrow shows the native left main stem. (A, B) Invasive coronary angiography showing a hazy image between the Cabrol conduit and the left main. (C) Functional assessment with fractional flow reserve. (D) Intravascular ultrasound scan, at the site of the conduit narrowing; quality of the intravascular imaging is suboptimal, principally due to the considerable graft diameter.

Figure 3

Multimodality imaging assessment of the Cabrol conduit stenosis after percutaneous angioplasty. The arrow shows the implanted bare-metal stent. (A) Left anterior oblique angiographic projection at the end of the procedure shows the patency of the graft and the intended proximal-distal tapering of the implanted stent. (B) Intravascular ultrasound image of the distal Cabrol conduit shows restoration of vessel patency and good stent expansion; even if the conduit boarders cannot be sharply displayed, a satisfactory stent apposition seems to be obtained. (C–E) Electrocardiogram gated computed tomography-angiography performed 3 years after percutaneous angioplasty: BMS does not show significative luminal loss.