Salvage coronary artery bypass after failed stent insertion in adult Kawasaki disease

Kawasaki disease is more common in children but can occasionally present in late adulthood as obstructive coronary artery disease, which is a chronic sequela of the condition. Revascularization is often required in these patients. The decision making can be difficult because of presence of concomitant aneurysms. Attempted percutaneous coronary intervention (PCI) of coronary artery lesions in Kawasaki disease in adults can be challenging and fraught with complications and coronary artery bypass grafting (CABG) should be preferred.
We report a case of a 44-year-old patient presenting with obstructive coronary artery lesions where an attempted PCI was associated with complications and a salvage CABG needed to be carried out.
A 44-year-old man presented with acute ST elevation myocardial infarction. He was non-diabetic, non-hypertensive and a nonsmoker but had a clinical diagnosis of Kawasaki disease made in his childhood. Coronary angiography showed an aneurysm involving the left main stem (LMS) and ostio-proximal left anterior descending artery (LAD), followed by a tight lesion of the LAD. The right coronary artery territory was normal (Figures 1 and 2).
PCI was attempted. The LAD was dilated but during insertion the stent (3.5 × 10 mm) got dislodged and was partially deployed in the aneurysmal part of the distal LMS and the proximal LAD. Only a TIMI 3 flow was achieved at this stage in the LAD and the patient was referred for urgent surgical intervention. Because of the partially deployed stent in the aneurysmal LMS it was decided to graft both the LAD and circumflex territories. As the patient was hemodynamically stable, a left internal thoracic artery (LITA)–right internal thoracic artery (RITA) composite graft created in a Y fashion was used. The LITA was anastomosed to the LAD and the RITA to the ramus intermedius and obtuse marginal, sequentially on the beating heart.
The second issue was to address the aneurysmal segment of the LMS with a stent in situ which would be prone to clot formation and distal embolization. The distal end of the aneurysm was snugged and as the heart was beating, it was possible to assess the impact of attempted ligation on the ECG before tying the artery completely. The proximal end of the aneurysm at the LMS-LAD junction could not be ligated as there was an under-deployed stent in situ extending into the LAD.
Thus concerns remained over the...


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