CABG vs. Stenting vs. Medical Therapy

[sambose]

Hi,

My brother (40) had a recent incident of UA/NSTEMI little over 4 weeks ago. He felt chest compression and went into ER. At the time of discharge, EKG stress test was done and it came +ve for exercise induced ischemia. Then he got his CAG and following are the reports:

TMT Summary:

Time: 10m 24s
Max HR: 167
THR: 153
Peak Ex: 13.5 METS, ST (-) 3.18 aV1
            
CAG Report:
Left Main: normal
LAD:         80-95% long lesion from proximal to mid LAD (this appears to be after D1)
Diagonals: 95% ostial lesion in D1
LCX:          90% diffuse lesion in distal LCx
OM:           small, diffusely diseased
RCA:         Dominant vessel normal
PDA:         normal
LIMA:        Normal

Double vessel disease

Electrocardiography:
LVEF: 61%
LVID(D):  Normal study

Lipids:
Total: 205
HDL:  30
LDL:   99
Triglyceride: 242

He is currently on std. medication regime:
Asprin
Clopidogrel
Beta blocker
Statin

He has been asymptomatic since the first incident. Family has history of heart disease though.

Questions:

a) Does he absolutely need revascularization (CABG/Stent), since LM is normal and both proximal LAD and proximal LCx don't have >70% stenosis? Mid-LAD & D1 have upto 95% blockages.
Can it be controlled with medication & lifestyle changes?

b) One of the cardiologist interventionist has ruled out stenting because the LAD lesion is long. Will stenting be effective assuming we find a interventionist who is willing to put stent(s) in?

c) Will CABG be effective in this situation? Will he need multiple grafts in mid LAD lesion?

Thanks,
Sam

[ed34]

The most important vessels really are the LAD and the Circumflex because these deal with the left side of the heart which does most of the work, feeding oxygen/nutrients to the body. The right side of the heart only pushes blood through the lungs. So, in this report it appears the right side is fine, but the left is somewhat severe.
The LAD is diseased heavily. I would say it is very restricted after the circumflex branch right the way down to the middle section of the vessel. Another blockage (severe) is in the lower end of the circumflex, before the Obtuse Marginal, but this too is diseased.
LVEF is not bad at 61% but this really means nothing at the moment because the main concern is getting more blood to the heart tissue to prevent tissue damage. If any of those occlusion close up, especially the LAD then it is likely that the heart will arrest.
With so much plaque, there is a risk a piece can break free at any time, causing serious life threatening situations.
My LAD was in the very same situation for two years. They tried a triple bypass which failed after just three months and when I went for a second opinion at another hospital, they said they wouldn't have attempted it because there was nowhere good enough to graft to. I searched and searched for 2 years to find a Cardiologist to attempt Stenting my LAD but they all seemed to look at my Angiogram and quiver in a corner. The length of the occlusion isn't the only concern here, the added problem is that it is on a curve, making it very difficult indeed to keep a wire central through the blockage. In the end, my case reached the desk of a man with 30years experience in stenting. He was working in a research college in London and he was willing to attempt the job. This was a big relief to me, but there were complications to overcome.
First, a piece of plaque broke and hinged down with some artery tissue causing a flap, dangling in the artery. He had to stent this to assist healing. He then proceeded to chip away at the blockage which was very calcified. When the blockage is hard, there is no way a wire can be pushed through it. Patiently he removed piece after piece and thank goodness he suddenly reached a soft area and was able to put the wire through. It took
a few attempt to get it through the blockage centrally, and then a tiny drill was passed along to wire and put against the blockage. Operated like a dentist drill with a foot pedal he started the drill which obliterated the plaque into harmless pieces. Fluid jetted from the front of the drill washed away the debris as he progressed. Suddenly the drill broke away the last piece, my LAD swelled up and my ECG immediately gave a better reading. He continued to do all my LAD and used a total of 5 long stents. Then I thought it was all over but the most scary moment was to come. My heart went into fibrillation and no oxygen was reaching my brain, I passed out. This was my heart reacting to all the treatment. They stabilised it with no damage by using drugs and nothing like that has happened since. So, although stenting sounds like a much simpler method, there are many risk factors to consider.
I am not a cardiologist, but if it was my choice given the above report, I would seek a cardiologist willing to stent because bypasses generally need a clean area of artery to graft to. The recovery is much quicker too, and discomfort is zero. I was discharged the following morning with a fully opened LAD.
When bypassing a LAD, they usually use a minimum of two vessels, usually an artery from the chest already connected to the aorta (Lima or Rima) and a vein from arm or leg.
I think it will be difficult to find someone to stent the LAD, but I firmly believe if you can get blood into an artery the way nature intended, you get better long term results.
I think some people on here may argue with my opinion, but when you are told a bypass will give you a normal quality of life and it fails soon after, you have to question whether Cardiologists make the correct decisions.