Guidelines for surgical indications for children with
coronary artery disease have been developed in Japan.
Indications for pediatric coronary revascularization
are the same for children as for adult cases and include
ischemic signs and symptoms. Unlike adults, however,
children can be asymptomatic until the late term.
Specifically, surgery is indicated if any of the following
four conditions are present: (i) LMCA lesions, (ii)
stenotic lesions of the multiple proximal coronary, (iii)
proximal left anterior descending artery lesion, and
(iv) collateral development.[
4] Although our patient
was asymptomatic, surgery was performed due to the
presence of a severe proximal LMCA lesion.
Coronary artery surgery for children should be
handled differently than that for adults as it involves
some technical difficulties. These include the size of
the coronary arteries, the difficulty of exposure, and
the accessibility of the appropriate graft. Another
problem is the long-term patency of the graft as
children develop rapidly and their ability to lead a
normal life depends on it. In 1966, Cooley et al.[5]
first reported revascularization with an autologous
saphenous vein graft in a baby with an abnormal left
coronary artery. Later, with the use of the internal
mammary artery and its long-term patency and growth
potential, arterial grafts were preferred.[6] The patency
of arterial grafts has been shown to be 3.5 times higher
than that of venous grafts, even in children younger
than three years old. Yatsunami et al.[7] reported that even in the majority of the neonatal population, the coronary artery diameter is greater than 1 mm and the
use of arterial grafts is appropriate.
The surgical technique to be applied in cases
of proximal LMCA stenosis is controversial. The
traditional surgical treatment for isolated LMCA osteal
stenosis is coronary artery bypass grafting (CABG).
Although this approach is effective, CABG can cause
competition and steal phenomena. In addition, in
cases of isolated osteal stenoses, retrograde perfusion
to a large myocardial area is provided only with the
graft.[8] Mavroudis et al.[1] stated that the combination
of LMCA-plasty and CABG can be effective in this
patient group. However, in the follow-up of their
patients, string-sign findings were observed in the
grafts in almost half of the cases. It was reported
that only osteoplasty is sufficient for these patients.
We preferred LMCA osteoplasty instead of CABG
since our patient had a history of FH and would
need to use long-term immunosuppressants after liver
transplantation.
Although surgical osteoplasty was defined for
adult patients by Effler et al.[9] and Sabiston et al.[10]
in 1965, it was not preferred due to high mortality
rates. Hitchcock et al.[11] obtained good results in
1983 with a posterior approach and Dion et al.[12]
with an anterior approach in 1997. Finally, Liska et
al.[13] suggested the transaortic approach, in which the
aorta is transected and anteriorly mobilized to better
visualize the coronary ostium and its distribution
and facilitate patch reconstruction. We also prefer
the transaortic approach during osteoplasty in our
clinic. It allows the lesion to be better visualized,
and it provides convenience while suturing the patch
during repair.
The biggest advantages of surgical angioplasty
in the pediatric population are that it does not
require bypass material and provides antegrade
flow. It has been used in cases of LMCA atresia,
occlusion, and inflammatory arteritis.[14] However,
there are few studies on proximal coronary artery
patch-plasty. Prêtre and Turina[15] reported successful
results in patients with LMCA osteal stenosis after
surgical angioplasty. Successful reconstruction of
both LMCA and RCA osteal stenosis with an
autologous pericardium prepared in a “pantaloon”
shape was also performed in another study.[16] This
technique achieved good results in some selected
cases of atherosclerotic lesions.[17] The success rate is
high for lesions in the proximal half of the isolated noncalcified coronary trunk. However, an increased
risk of thrombosis has been demonstrated for patients
requiring extension of osteoplasty to the LMCA
branches.[18] The use of autologous pericardium
also has risks of fibrotic thickening, contraction,
calcification, and late aneurysm formation due
to exposure to systemic pressure. Its advantages
are that it is flexible, resistant to infection, and
nonimmunogenic.[19] Another material used in
LMCA osteoplasty is the autologous pulmonary
artery. It contains the intima, media, and adventitia
layer. Long-term results of arch constructions with
autologous pulmonary artery patches have been
reported.[20] However, there are no definitive results
about their use in osteoplasty in the literature. Ma et
al.[21] reported positive early-and mid-term outcomes
after LMCA-plasty. Ischemia was not observed
in any of their patients. The pulmonary autograft
had advantages due to material thickness, ease of
manipulation, genetic homogeneity, and potential
for somatic growth. Moreover, there was no risk
of ectasia seen with pericardial patches. The use
of pulmonary artery patches is thought to be more
appropriate in our clinic. Pulmonary artery defects
are also reconstructed with autologous pericardium to
prevent the risk of pulmonary stenosis.
In conclusion, although patients with FH are
asymptomatic, the risk of early atherosclerosis should
not be forgotten. In cases of isolated LMCA osteal
stenoses, osteoplasty may be a good option. The use of
pulmonary autografts may be advantageous.
Patient Consent for Publication: A written informed
consent was obtained from the parent of the patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design, control/
supervision, critical review: B.Z.T.R., A.C.H.; Data
collection, analysis, literature review, writing: B.Z.T.R.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.