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Prognosis after stent failure
Dear Doctor,

In 2001, just before my 43rd birthday, I was diganosed with congenital stenosis of the left main coronary artery just beyond the bifurcation off the aorta.  I had a 70 to 80% occlusion.  At that time, my doctors recommended  CABG over stenting.  A double graft was performed, LIMA to LMCA and radial artery (harvested from my left arm) from LIMA to circumflex.  I was pain free for about two years, then my symptoms returned.  It was determined that scar tissue within the chest cavity had formed around the LIMA, above the radial to circumflex graft, that was "kinking" the LIMA and decreasing blood flow to both the LMCA and circumflex.  A stent was inserted in an attempt to straighten the kink and improve perfusion.  In the end, over the next few of years, the LIMA was stented several more times (I lost count) because scar tissue formed inside the LIMA at the stent site each time.  My docs say I'm one of those few individuals with a propensity for scar formation.  Finally, in January of 2006, the decision was made to stent the LMCA.  By June 2006, this too had begun to occlude due to scar tissue, and a second stent was placed in the LMCA with a small portion of it extending into the aorta.  At that time, my docs felt another bypass would be too risky because a) I was somewhat anemic, b) I did not want to be placed on a heart-lung bypass machine (my original CABG was done as a "beating heart" surgery), c) I do not want to receive blood transfusions, d) the new grafts would have to be anchored on the aorta itself, e) there is so much scar tissue in my chest now it would make the surgery much more complicated, and f) the risk of developing more scar tissue and ultimate failure of the grafts again is very high.  Now, a little over a year since the last stent was implanted, I am having persistent cp again, radiating into my left arm, at rest or with the slightest exertion - my typical cp pattern.  SL Ntg is somewhat helpful.  Otherwise, my heart is very healthy.  Repeated angiography and Adenosine stress tests have revealed no other narrowed vessels (other than the bypass grafts which have completed occluded) and no infarcted areas.  I have no dysrhythmias,  normal bp, normal cholesterol levels.   My only cardiac meds are plavix and ASA.  My doc would like me to take diltiazem or Norvasc for occasional bouts of vasospastic angina, but I have a poor tolerance of beta blockers and calcium channel blockers and the vasospastic episodes are rare and short-lived, so I have chosen not to use them.

Here are my questions:

1)  I have heard a lot of negative discussion about self-eluting stents (which all of mine are) in recent months.  Is there any relationship of the repeated scar tissue formation at the stent sites to the problems that seem to be coming to light with these stents?

2)  I have no doubt, based on the return of my symptoms, that the latest stent is becoming occluded.  Other than attempting another CABG what other options to I have?

3) What is my prognosis in this situation?  I am under the impression that total restenosis, in my case, will be fatal.  Obviously, loss of the LMCA will result in loss of the LAD which, as far as I know, is catastrophic.  If so, how long do I have?

Thanks!
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9 Answers
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242440 tn?1264523444
Recommend posting this on the doctor forum - as this is the patient to patient forum and you won't get an answer from a doc here.  I hope you are able to get your question in, and wish you the best with your problem.  Take care!
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242440 tn?1264523444
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214864 tn?1229718839
You need help fast it seems. If it is possible, get an appointment at the Cleveland Clinic. It may be possible to stent the left main. Scar tissue may form again, but by that time, new procedures will be available. In 2001, the left main was not stented....Science and research is keeping us alive.

My very best to you and I hope that you get your question to the doctors. Sometimes early in the morning is the best time to try.

Jack
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214864 tn?1229718839
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Thanks pointing me in the right direction!
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Thanks to you too for pointing me to right forum!
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My left main has been stented twice already, Jan 2006 and July 2006.  That's what's becoming occluded now.  Cleveland is a bit far for me and my insurance would not cover my treatment there, but I am getting excellent care from one of the best cardiac institutions in the country, Ochsner Foundation Hospital in New Orleans.  I am totally disabled and, if I survive that long, will be eligible for Medicare in about a year.  Then I might be able to check out another hospital like Cleveland Clinic.  For now, I just wanted a second opinion.  Thanks again.
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214864 tn?1229718839
Yes, I am so sorry that I missed that :(  As I re-read your post, I see you mentioned it at least 2 times...I My mind interpreted left main (LMCA) as one of your grafts....I am obviously not awake yet.

You are totally disabled now. Why the wait on medicare?
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I am otherwise a healthy 56 year old working nurse with restenosis of the LAD twice in the last three years with a DES-I am now working on my 3rd occlusion as of two weeks ago with a 40% occlusion of the 2/3 distal LAD. I  have had heart failure secondary to "stiff left ventricle." They tell me it is all scar tissue, am onb plavix,asa,lasix.prinivil,imdur and zocor.I g uess I am waiting for the boot to drop, my next step is going to be a single vessel bypass.
Good luck to you !




















































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I have to wait on Medicare because my private insurance and it will not cover me to go out of network and we cannot afford the enormous expense.   I posted my questions to the doctor's forum and basically got the same answers  that my own doctors have given me.  I don't think I could get any better care overall at another hospital than I'm getting at Ochsner.  I just wanted to see what another doc had to say.
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I wish you luck with that.  It's a very long road, but the bypass may do the trick for you.  As you read above, I had the bypass first, but I formed scar tissue (adhesions)  around the outside of the grafts that kinked them off.  The grafts remained patent otherwise and had no scar tissue inside them until the docs inserted stents to straighten the kinks.  Now my grafts are completly useless, the LM is closing off and I'm not a good candidate for another bypass.  My advice to you, before having that single bypass is to discuss the possibililty of scar tissue (adhesions) forming outside or around  the graft vessel and what can be done to minimize it.  If you are as prone to producing scar tissue as I am, this is a real concern.  Again, good luck!
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