Collapsed Blood vessel in Heart

52 yo male with history of non-hodgkins lymphoma, whole body irradiation, bone marrow transplant 5 years ago-cancer free now, and diabetic.  Has had 8 stents put in his heart in the last 3 months-2 heart caths, 2 angioplasts.  3 days at home after last heart cath( 2 more stents placed)he was rushed to hospital-blood vessel/branch in his heart collapsed went into shock-had trouble stabalizing-was critical.  Next day was put in ICU & evaluated for heart surgery and told there was no point in doing surgery-because his arteries are a 3rd of the size they should be because of chemo/radiationand that fact coupled with the diabetes-he wasn't going to live long. :(  Apparently he scars (scar tissue)badly-and has after the heart caths. Called for a second opinion- dr is researching/evaluating possibility of using beta radiation to help with the scar tissue to help open up his blood vessels. (He has no previously history of heart probs)

My question:  What questions should we be asking? My understanding is that stents are generally a temporary fix. Realistically what kind of hope is there?  Hearing something like that from a surgeon is obviously not encouraging.  What could have caused the blood vessel to collapse?  What are they odds of it happening again? I have a fairly decent knowledge of heart physiology, but the dr's won't talk to me. (They have permission from the patient.)  I am flying out there (the pt is my dad) but want to ask the right questions and be aware of any possible treatments or causes to ask about.    Thanks for any assistance-this is a stressful time.

[CCF-M.D.-KE]

Dear stormy,

Sorry to hear about your father. The description you provide suggests that your father has diabetes, prior radiation therapy for non-Hodgkins lymphoma and coronary artery disease which has required multiple intracoronary stents. Following his recent stent placement he developed shock (cardiogenic) due to reocclusion of the stent 3 days later.

Stents are intended to be a permanent treatment for blockages in the heart arteries and you are describing instent restenosis. Approximately 40% of patients who have stents placed will experience renarrowing within the stent at 6 months. Approximately 50% of these patients will experience symptoms. Therefore around 20% of patients having stents placed will experience symptomatic instent restenosis requiring a repeat procedure.

Most recently your father experienced subacute stent thrombosis, when the most recent stent occluded 3 days after its placement. The incidence of subacute stent thrombosis is approximately 0.9 to 2.5%  of stents placed and the risk factors include older age, hypertension, decreased ventricular function, along with certain characteristics of the blockage and the stent itself. Also, from what you describe he has small vessels making poor targets for bypass surgery, which is probably related to his diabetes and radiation therapy.

The most important question I have is whether or not your father is a surgical candidate or not, people with diabetes tend to do better with surgery. You should consider having your father's doctors review his case with a very experienced surgeon. I would recommend having them call a large university based medical center near by or even calling here (1-800-CCF-CARE) in order to get an experienced second opinion.  They can discuss his case with one of our world renowned heart surgeons here, who may be able to offer an opinion.

If your father is not a surgical candidate beta radiation is a good idea. However, your father may be a candidate for a coated stent (rapamycin). This stent is currently not available in the U.S. but it can be used on a compassionate basis. The doctors may be able to call the FDA and get permission to use it in this case.

Your father's case is very complex, I hope I have been able to help you in your knowledge and  decision making.

Thanks for your question,


CCF-MD-KE

[HealThySelf]

Sorry to here about your father.  It's too bad that he went through all of that suffering and overcame his previous disease only to be put in another life threatening condition by an irresponsible cardiologist.

8 stents are criminal!  There is no way that any person should receive 8 stents.  When a cardiologist sees a situation like that, he should pull out and refer the person for bypass surgery.  If he did nothing the person would have a better chance of recovery.

With the risks of restenosis cited by the CCF doctor, it's a given that at least 2 or 3 of those stents will be closed by restinosis.

Probably your only hope is to take him someplace good and have him re-evaluated for surgery.

Best Wishes