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Heart Disease (Expert Forum)
Re: Is Collateral Feed to Blocked LAD Adequate?
This forum is for questions and support regarding heart issues such as: Angina, Angioplasty, Arrhythmia, Bypass Surgery, Cardiomyopathy, Coronary Artery Disease, Defibrillator, Heart Attack, Heart Disease, High Blood Pressure, Mitral Valve Prolapse, Pacemaker, PAD, Stenosis, Stress Tests.
Re: Is Collateral Feed to Blocked LAD Adequate?
by Michael__0__0, Jan 01, 1995 12:00AM
Posted By Michael on June 04, 1998 at 21:53:05:
In Reply to: Re: Is Collateral Feed to Blocked LAD Adequate? posted by CCF Cardio MD-SGM on June 02, 1998 at 14:47:14:
I am a 50 year old male who experienced left arm angina during exercise. Positive echo stress test resulted in a catherization. Results of catherization were a 100% blocked but well collateralized Left Anterior Descending Artery (LAD) and a 85% blockage of the Obtuse Marginal Branch. Doing a PTCA on the OM is not a problem (98% success estimate) to open it up. Not so with the LAD, which has a 1" blockage, estimated success for PTCA of LAD artery is 25%. I would like to know how one determines if the collateral feed to the LAD is sufficient for that artery, with drug therapy, or should action (MIDCAB or CABG) be taken to address the blockage for the long run. Please be kind enough to answer this question. You have the best Forum by far of any I have seen. Thank you.
: Dear Michael,
In deciding on the best recommendation to treat your coronary artery disease, several factors must be considered, including your symptoms (angina with exercise), the overall and the regional pumping function of the left ventricle, and the results of the stress test your underwent. In your case, it is not clear whether the OM branch or the occluded and collateralized LAD is responsible for your symptoms. This is important because the LAD territory, despite being collateralized, may not be functioning. It may well have suffered a heart attack in the past, and its ability to regain any function following a bypass or percutaneous intervention (stent, angioplasty) is in question.
So, the question becomes: "what to do with the occluded and collateralized LAD". One reasonable approach to this problem is to use one of various tests to look for ischemia or viability in the LAD territory. This would indicate that revascularization (whether surgical or percutaneous) may well lead to improvement in ventricular function and overall prognosis. However, dead, non viable heart muscle in the LAD territory would not likely need to be bypassed, and the risks of a complicated percutaneous intervention to this vessel would need to be weighed against the limited benefits of opening it up.
Thus, I recommend that you discuss with your cardiologist whether the LAD territory demonstrates Ischemia (reduced blood flow with exercise) or has suffered damage and is Viable. Either of these conditions would suggest that revascularization is indicated (again, surgical vs. percutaneous revascularization depends on your preferences and the recommendations of the surgeon and interventional cardiologist involved). The OM branch can be treated with angioplasty if no intervention to the LAD is required. Otherwise the OM can be bypassed during surgery.
I hope I have helped to clarify this issue. If you would like an evaluation at the Cleveland Clinic Foundation, kindly call 1-800 CCF CARE for an appointment with Dr. Topol or Dr. Ellis at Desk F25. Information in the Heart Forum is for general purposes. Specific diagnoses and therapies can only be provided by your physician.
Dear CCF CARDIO MD:
As I stated before, this Forum is the best I have seen with respect to addressing questions and providing intelligent answers. I must ask a few folowup questions based on the plan of attack I have developed with my cardiologist. The plan is to do a PTCA of the OM, and his partner, who performs the PTCA (and who I have heard good things about), wants to probe the LAD to see if the blockage can be breached. I have heard this is risky because the collaterals could suddenly close up if the LAD is opened. My cardiologist is also telling me, upon my concern that the collaterals could clog with the LAD left as is, that they do not. I find this hard to believe and am hearing opposing views on this (since they are arteries, they are subject to clogging).
If the opening up of the OM clears the exercise related angina, and if the PTCA with stent keeps the OM open after three months, is it a reasonable approach to leave the LAD as is, since I grew my own collaterals?
Please, your opinion on this, since I cannot really find enough information on the adequacy of collaterals (they are visible on the catherization film) to sustain the LAD blockage. On the other hand, if the stented OM closes, I may be put back on the CABG or hybrid MIDCAB track, since I may have to have the OM revascularized and then I would do the LAD also.
Thank You Again,
Michael
In Reply to: Re: Is Collateral Feed to Blocked LAD Adequate? posted by CCF Cardio MD-SGM on June 02, 1998 at 14:47:14:
I am a 50 year old male who experienced left arm angina during exercise. Positive echo stress test resulted in a catherization. Results of catherization were a 100% blocked but well collateralized Left Anterior Descending Artery (LAD) and a 85% blockage of the Obtuse Marginal Branch. Doing a PTCA on the OM is not a problem (98% success estimate) to open it up. Not so with the LAD, which has a 1" blockage, estimated success for PTCA of LAD artery is 25%. I would like to know how one determines if the collateral feed to the LAD is sufficient for that artery, with drug therapy, or should action (MIDCAB or CABG) be taken to address the blockage for the long run. Please be kind enough to answer this question. You have the best Forum by far of any I have seen. Thank you.
: Dear Michael,
In deciding on the best recommendation to treat your coronary artery disease, several factors must be considered, including your symptoms (angina with exercise), the overall and the regional pumping function of the left ventricle, and the results of the stress test your underwent. In your case, it is not clear whether the OM branch or the occluded and collateralized LAD is responsible for your symptoms. This is important because the LAD territory, despite being collateralized, may not be functioning. It may well have suffered a heart attack in the past, and its ability to regain any function following a bypass or percutaneous intervention (stent, angioplasty) is in question.
So, the question becomes: "what to do with the occluded and collateralized LAD". One reasonable approach to this problem is to use one of various tests to look for ischemia or viability in the LAD territory. This would indicate that revascularization (whether surgical or percutaneous) may well lead to improvement in ventricular function and overall prognosis. However, dead, non viable heart muscle in the LAD territory would not likely need to be bypassed, and the risks of a complicated percutaneous intervention to this vessel would need to be weighed against the limited benefits of opening it up.
Thus, I recommend that you discuss with your cardiologist whether the LAD territory demonstrates Ischemia (reduced blood flow with exercise) or has suffered damage and is Viable. Either of these conditions would suggest that revascularization is indicated (again, surgical vs. percutaneous revascularization depends on your preferences and the recommendations of the surgeon and interventional cardiologist involved). The OM branch can be treated with angioplasty if no intervention to the LAD is required. Otherwise the OM can be bypassed during surgery.
I hope I have helped to clarify this issue. If you would like an evaluation at the Cleveland Clinic Foundation, kindly call 1-800 CCF CARE for an appointment with Dr. Topol or Dr. Ellis at Desk F25. Information in the Heart Forum is for general purposes. Specific diagnoses and therapies can only be provided by your physician.
Dear CCF CARDIO MD:
As I stated before, this Forum is the best I have seen with respect to addressing questions and providing intelligent answers. I must ask a few folowup questions based on the plan of attack I have developed with my cardiologist. The plan is to do a PTCA of the OM, and his partner, who performs the PTCA (and who I have heard good things about), wants to probe the LAD to see if the blockage can be breached. I have heard this is risky because the collaterals could suddenly close up if the LAD is opened. My cardiologist is also telling me, upon my concern that the collaterals could clog with the LAD left as is, that they do not. I find this hard to believe and am hearing opposing views on this (since they are arteries, they are subject to clogging).
If the opening up of the OM clears the exercise related angina, and if the PTCA with stent keeps the OM open after three months, is it a reasonable approach to leave the LAD as is, since I grew my own collaterals?
Please, your opinion on this, since I cannot really find enough information on the adequacy of collaterals (they are visible on the catherization film) to sustain the LAD blockage. On the other hand, if the stented OM closes, I may be put back on the CABG or hybrid MIDCAB track, since I may have to have the OM revascularized and then I would do the LAD also.
Thank You Again,
Michael
