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Heart Disease (Expert Forum)
Treatment for occluded LIMA graft
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Treatment for occluded LIMA graft
by runnertom, Jul 01, 2007 12:00AM
I had bypass surgery for a bifurcation lesion 4 1/2 years ago at age 54. The mammary artery was used to graft the LAD and a saphenous vein used for the diagonal. Since the surgery, my risk factors have been under good control. Never smoked, blood pressure low normal except during exercise (taking beta blocker for that), LDL/HDL of 80/60 until recent change to Vytorin reduced LDL/HDL to 62/76. Trigylcerides 60.
A recent 64 slice CT scan for surveilance purposes found that the LIMA graft was essentially occluded with a patent vein graft. The original cath showed the LAD lesion was not all that bad in the first place, which is probably the reason the LIMA has closed down. The literature indicates that when this happens, later surgical options are severely limited. However, there are reports that LIMA grafts such as mine may be recruited later if flow through the native vessel closes off.
Questions: As for exercise, for maintaining whatever flow is left in the graft, would fairly intense exercise such as interval training be preferable to longer bouts of more moderate activity?
As for the LAD lesion which is apparently fairly heavily calcified, would it be possible to get reversal of the narrowing if I maintained the good lipid profile?
I am afraid of drug eluting stents with my heavy exercise due to the possibility of late thrombosis. Would a bare metal stent or maybe angioplasty without a stent be good options? My cardio isn't sure what to do.
A recent 64 slice CT scan for surveilance purposes found that the LIMA graft was essentially occluded with a patent vein graft. The original cath showed the LAD lesion was not all that bad in the first place, which is probably the reason the LIMA has closed down. The literature indicates that when this happens, later surgical options are severely limited. However, there are reports that LIMA grafts such as mine may be recruited later if flow through the native vessel closes off.
Questions: As for exercise, for maintaining whatever flow is left in the graft, would fairly intense exercise such as interval training be preferable to longer bouts of more moderate activity?
As for the LAD lesion which is apparently fairly heavily calcified, would it be possible to get reversal of the narrowing if I maintained the good lipid profile?
I am afraid of drug eluting stents with my heavy exercise due to the possibility of late thrombosis. Would a bare metal stent or maybe angioplasty without a stent be good options? My cardio isn't sure what to do.
Doctor's Answer
by CCF-M.D.-CA, Jul 01, 2007 12:00AM
There is evidence that even more aggressive risk factor modification diminished atheroma burden as measured by IVUS: this was accomplished with an LDL of 60 with the drug Crestor. This was a novel finding not found with other lipid lowering drugs, and may translate into clinical benefit but we don't have that data as of yet.
You are probably correct about the LIMA: it was probably a surgical error to bypass a non severely stenotic lesion because that condiut will likely not be re-usable. I would favor a moderate amount of exercise but avoid things that involve prolongued physical activity (marathons and triathlons.) In addition I would be on the watchout for any symptoms such as chest pain, palpitations, which would limit the amount of exercise performed.
There is no evidence that you need any intervention to either the LIMA or native LAD unless you have symptoms (ches pressure or pain, severe shortness of breath with exercise, swelling of legs). Even then, the only benefit obtained is resolution of symptoms and not life saving (that is unless you have what is known as an ACS.) So be careful about receiving stents simply because you LIMA is now occluded.
You are probably correct about the LIMA: it was probably a surgical error to bypass a non severely stenotic lesion because that condiut will likely not be re-usable. I would favor a moderate amount of exercise but avoid things that involve prolongued physical activity (marathons and triathlons.) In addition I would be on the watchout for any symptoms such as chest pain, palpitations, which would limit the amount of exercise performed.
There is no evidence that you need any intervention to either the LIMA or native LAD unless you have symptoms (ches pressure or pain, severe shortness of breath with exercise, swelling of legs). Even then, the only benefit obtained is resolution of symptoms and not life saving (that is unless you have what is known as an ACS.) So be careful about receiving stents simply because you LIMA is now occluded.
Thanks for your comments. I would hope that my situation doesn't come to repeat CABG or even angioplasty. My concern is that my LIMA has been "used up" to no benefit and my LAD still has the original lesion. If that lesion follows the normal course, it will eventually become more severe and require intervention. It may be stentable, but the that option was considered to be a poor one at the time of my CABG.
My "ace in the hole" is good collateral circulation that developed either because of the LAD restriction or my long term heavy exercise. I am certainly hoping that the low HDL I have achieved results in reversal of the existing blockage.
We've been around for a while. You certainly don't fit the profile of someone with CAD. I suspect that your plaque was a response to some type of stress injury to the artery.
I do fit the profile. Had family history, risk factors, and a lifelone horrible lipid profile.
When they told me 8 years ago, after my M.I., that I needed bypass surgery and then 6 1/2 half years ago, after their second unsuccessful attempt at angioplasty, that they would give me a 40% chance of death within 5 years without bypass surgery, I'm glad that I didn't drink the Koolaid.
After many years of maintaining a perfect lipid and BP profile with a multi-drug cocktail, and exercising moderately, my disease seems to be in total remission.
I'm a believer in the longer duration lower intensity exercise for building collaterals and strengthening the heart. I walk every day, and hike for a couple hours uphill frequently. Of course now I live between three volcanoes, so there is plenty of opportunity to walk uphill.
Don't take a stent - they are forever. This widespread stenting of young people is criminal in my opinion. The dissolvable ones might be ok, but they are a few years away.
--Bill
The fact that I don't fit the normal cardiac profile has certainly not escaped my notice. However, I found enough "marginal" risk factors I do have to accept the fact that I do have cardiovascular disease and move on from there. Denial won't solve anything. For a while, I was blaming my blockage on an incident I had while back in a triathalon. Someone turned in front of me biking at 30 mpg and I went over the bars landing flat on my back. I had pain between my shoulder blades for weeks and I thought my heart may have inpacted my rib cage hard enought to damage the cardiac arteries. Maybe so, maybe not.
I found that my homocysteine was quite high. As mentioned in my post, I find that I have exercise induced hypertension with bp hitting 230/110 at my limit. A recent case study in one of the journals documents a marathoner with similar risk factors as mine with exercise induced hypertension that has extensive CAD after 30 years of doing 3 marathons per year. I have also some occupational chlorine exposure that recent evidence says may be responsible for lipid peroxidation that leads