Spasm of LIMA during Stent Placement

[chrisr]

Spasm of LIMA bypass graft during stent placement in distal LAD.

I am a 61 yr old male with 3x CABG, AVR and aortic repair 5 yrs ago. Six weeks ago I had a 90% lesion in the RCA bypass graft successfully stented. After recent chest discomfort and nausea, one week ago at a different hospital I had an IVUS guided PTCA and stenting of a LAD artery distal to the anastomosis of the LIMA. According to the post-procedure report, assessing the distal lesion was difficult due to the ‘tortuosity’ of the LIMA. After removal of the IVUS a 2.5 x 16 Taxus drug-eluting stent was implanted into the distal LAD. After stent deployment, no flow in the main LAD was noted even after multiple doses of nitroglycerine and Nipride. A 2.5 balloon was advanced to the no-flow site, inflated several times without flow improvement. A 2.5 x 10-mm high pressure balloon was then advanced to stent site implant and high-pressure balloon inflation done at 16 atm. Balloon was removed and further angiography done without any success in flow improvement in the mid portion of the LIMA. Because of the possibility of wire-induced vasospasm ot he LIMA, the wire was removed and further injection performed with still no improvement of distal flow. Wire advancement was attempted but the risk of wire perforation was considered and so no further attempt made. I was then left on Nitro drip for about 2 days during which time I had considerable left chest pain which I had never experienced before. I am still left with chest discomfort and nausea.How serious is this and what if anything can be done now? Thanks, Chris R

[Cleveland Clinic]

Chris,

Sorry to hear of your events.

Causing damage to the arteries you are working on is one of the major risk of percutaneous interventional procedures. This damage can result from tearing, perforating or causing the arteries to spasm during the procedure. You had the closure of your LAD which is the main artery of the heart during your procedure, which may have resulted in a frank heart attack and some permanent damage. Sometimes, on nitroglycerine arteries that spasm will open back up.

I generally would be interested in if you had injury from the procedure which would be manifest by elevations in your cardiac enzymes or damage to your pumping chamber which could be assessed by an echocardiogram. With your continued symptoms, I would also be interested in whether there is something that could still be done in terms of stents and balloons to alleviate your symptoms. This could be assessed noninvasively with stress imaging or by another catheterization.

I would also want to make sure you are on a good antianginal medical regimen.

good luck

[chrisr]

Sorry to add a comment but I was unaware of the length of post.I wanted to end by also asking Will this now be a major problem for the LAD. The full report now says that there is a thrombus in the LIMA with little antegrade flow. CAn anything be done for this also even at CCF?
MY sincere thanks again for allowing all my questions. Chris R

[LacyMary]

I marvel at how you know about your stent/procedure.

I had a stent put in the LAD and RCA without incident except the Fellow in training (which I was not aware some novice was being trained on me) had a heck of a time deploying the Taxus stent.  This is August 2004. All normal cardiac enzymes , pre and post stent/caths.

Then in 12/2004, I had some chest discomfort which I was told, I needed another Cath. (chest discomfort was not heart related)
I told them NO FELLOW to touch me.  They had me knocked out and again they trained some Carido Fellow on me and this time I felt like a truck was on my chest right after the Cath.  They discharged me with these chest pains and I ended up in the ER room, 2 days later, to find that the Troponin levels were elevated. (heart enzyme) The ER doctor said the Troponim had to of been a lot higher two days earlier (after the Cath)as I had to of been injured during the Cath/Stenting yet this is not indicated on my limited cath report. (stent placed for a low pressure reading and not for a blockage)

I have not done well since. The Cath doctor would not talk to me after this incident.  I had asked why no heart enzymes were taken /pre-post cath and he said not necessary.  

Chris, these heart enzymes are very important pre-post cath/stents in my books. An elevation means "something". Please check and see if you had these taken.

I did get a doctor to order an MRI one week later and they did see a small MI in the septal region.  

I also had another incident 2 weeks ago now and the Troponin was elevated again.  (I made sure they did it this time)

If you can get to CC and talk to experts there this will relieve your mind of "what happened".  They are top notch.  Good Luck to you.

[chrisr]

Dear Dr. Firstly, thanks alot for answering my question. Some more comments which you requested.
1.Did have temp. elevations of cardiac enzymes.
2. Did subsequently have successful stenting of a large 1st obtuse marginal branch with no residual stenosis.
3. Thallium stress test showed ischemia in inferolateral territory area of large 1st obtuse marginal branch. LAD has appeared to be onfarcated with no reversible ischemia. Gated cardiac wall motion studies showed akinetic apical infarct zone with inferolateral hypokinesis. Estimated EF 42%.
4. Am on Nitropatch, Lasix20mg, Cardizem120mg, Plavix, Asp81mg, Diovan80mg, GlucotrolXL5mg and finally Coreg3.125mg which I am skeptical to take because of prior reactions to Betablockers.
Any further comments would be graciously appreciated and regret for not giving you the full story on my first attempt.

[chrisr]

Thanks for your encouraging words. The whole incident of the Taxus stent-induced spasm in my LIMA bypass was also kept away from me for several days until I insisted to know the seriousness of what really had happened including a heart attack. A second stent was then implanted 2 weeks later into another branch of the LAD to try to offset what had happened with the first but it seems irreparable damage has already been done to the LIMA with a thrombus formation. I live in the Virgin Islands and this work was done at Baptist hospital in Miami so its very difficult even to stay in touch with the doctors there. I still have chest discomfort, nausea (which could be a stent side effect) and cannot do much without fatigue and palpitations. From my research on the internet it appears that working through the LIMA is quite risky but I was never informed about this and feel more like a guinea pig now. Where was your work done? Do you know of any good contacts at CCF? I am really frustrated and do not know where to turn to. Any comments form anyone else with a similar situation would be highly appreciated.
Chris

[Cleveland Clinic]

Chris,

It is difficult to provide too much more information without seeing all of your information personally. Yes there is possibly more that can be done.  The Cleveland Clinic has a web consult available that might be able to help you on the web page. Otherwise, any of the interventional cardiologist at the clinic would be available for an appointment in a timely fashion.

good luck

[tickertock]

If I were you I'd pack my bags for Cleveland Clinic and get the best evaluation possible, no pun intended, just my opinion.Best wishes.

[LacyMary]

Chris, I am in Texas. My hubby wants me to go to Cleveland Clinic also but I sure hate going alone.  Scary for women travelling alone.  I have a young one even though I am in my fifties.

I am now in A-Fib and just started tonight a new med.  I feel this is all the result of the second cath and an injustice done to one of my coronary arteries while the fellow was being trained.  I did not need this cath/stent.  So sad.  

One of the doctors I consulted after the fact...talks regulary with a Dr. Eric Topol there at Cleveland Clinic. You might want to see about him as I heard he was very good but not sure he would be the doctor for us in our situations.  

I now have developed something called Dynamic LVOT obstruction due to Systolic Anterior Motion.  Have no idea what this means but they were keeping this also from me until.......one of the Fellows mentioned this to me the other day.  Have to go and and see what all this means.  Sorry for venting.  I wish I never  had the second Cath.  My problems started then.

Chris, vent all you want.  We all are entitled. Maybe..I will see you at CC.  I wish you nothing but the very best for your heart.  God Bless You.

[chrisr]

Thanks to both of you for words of encouragement. My condition does appear more serious than I thought. I will try for an appt at CHC as soon as possible. Any suggestions for well known interventional cardiologists will be most welcomed. CAn anyone also recommend lodging facilities at CHC? Lacy I hope that you can also get there although I am much further away than you are. Will keep in touch. Thanks again.

[Momto3]

Sorry to hear about your health problems.  The CCF has a lot of fabulous physicians who should be able to provide you with a second opinion.  Two interventional cardios that I have personal knowledge of are Dr. Tuzcu and Dr. Irving Franco.  A good friend of mine has been treated for many years by Dr. T. and my son saw Dr. Franco a couple of years ago.  I am told that both doctors are friendly and quite knowledgeable.  Personally, I have seen Dr. Shiota and Dr. Thalmilarisan for TEE and follow up...very, very nice physicians....very thorough and kind.  I have also seen Dr. Michael Lauer for assessment of a regurgitant valve.  Although he has quite the reputation (good) in the world of cardiology, he may not be the right one for your situation.  You may also try calling the clinic and asking for a referral based on your individual situation and availability.  I'm sure you will find them most helpful.  Lastly, there is a website available through the clinic where you have your records sent and they will give you an "e-opinion."  I think it's around $600, and some have found it quite helpful.  The best of luck to you.

There are hotels right near the clinic and also in surrounding communities.  Check out their website for lots of valuable information for visiting patients.

Connie

[LacyMary]

Thanks for the well wishes also.  Chris, go into Google Search and type in Eric Topol, M.D.  There is a lot of information on this doctor at CC.  Very Impressive and he is an Interventional Cardiologist among other attributes. If he cannot help...HE WILL KNOW where to stir you.

No wonder the heart doctor I consulted with 3-4 months ago (in Texas)stays in tune with Dr. Topol.  I am going to e-mail the consultant doctor in Texas about my latest happeneings and possibly going to CC also.  The very best to you.

[chrisr]

I have seen Dr. Topol's credentials and he seems fantastic and the rifgt person for my complication. I am now trying to get an appt with him and already sent up my records. Have you also contacted him directly? I would appreciate knowing your progress in trying to get an appt with DR. Topol. If you don't mind my communicating directly my email is:***@****.
Thanks again, Chris