I'm a 72 year old non-smoking male, BMI 24.5, fairly well conditioned. I was diagnosed with CAD about 1999 and subsequently had to have over the years eight stents, a pacemaker, and two years ago had double bypass surgery. About three months ago I started to become tired with exercise and breathless. A stress test suggested new blockages, and I was shocked to learn two weeks ago the following, per the procedure notes following an Angiogram: "Complete thrombotic occlusion of both bypass grafts. Severely diseased right coronary vessel, not readily amenable to percutaneous coronary intervention."
I've been told to withdraw from exercise and normal physical activities and stay at rest until next week when I'll be re-evaluated. My question is what would cause my grafts to become blocked with blood clots so soon? What would cause the blood clots? Is developing collateral arteries my best hope going forward?
It seems that you have made some good choices by being a non-smoker, keeping your BMI in the healthy weight range, and being ‘fairly well conditioned’, so I can understand your shock and likely disappointment upon hearing that despite all of this good work - your grafts are blocked. I am however somewhat heartened that your specialist has taken your change in exercise tolerance seriously, investigated appropriately, and is now considering the best course of action. Your cardiologist is the best person to answer your questions within the context of your full medical history. The following is some general information that you may find helpful.
A number of factors determine how long bypass grafts will remain open or ‘patent’. Other medical conditions are important, particularly any conditions associated with a tendency towards forming blood clots. A positive family history of blood clots can be relevant in this setting. Patients with multiple cardiovascular risk factors (including positive family history, diabetes, kidney disease, high cholesterol, and high blood pressure) are also at higher risk of recurrent disease in their bypass grafts. Adherence with medications such as aspirin is also important.
The next set of factors relate to the grafts themselves. It is worth discussing with your cardiologist and/or cardiac surgeon whether there were any difficulties or complications at the time of your bypass surgery? Grafts can be either arterial (from a vessel inside the chest called the internal mammary, or alternatively the radial artery) or venous (usually harvested from the legs). There are many factors that determine which option is best for each patient. If arterial grafts are an option these are often preferred due to their better long-term patency (some of the original studies are from the Cleveland Clinic: i.e. Loop FD The New England Journal of Medicine 1986).
Early bypass graft loss can indicate that there was competitive flow via the native coronaries. This occurs more commonly in patients with mild to moderate native coronary disease. Blood flow via the native coronaries ‘competes’ with flow via the bypass grafts. Clotting can occur in this situation. Given your history of multiple stents it seems less likely that you had only mild to moderate residual disease in your native vessels but this is something you could re-visit with your cardiologist.
Collateral arteries are certainly helpful in providing alternative sources of blood flow in the setting of coronary narrowings or blockages. Your cardiologist should be able to tell you whether you already have collateral arteries. Other factors that will impact on your future heart health are: the presence of any significant rhythm disturbances, the presence of reduced left ventricular function (low ‘ejection fraction’), and any other significant medical conditions (especially diabetes and kidney disease).
Be sure to write a list of your 5 top questions for your cardiologist.
One bypass graft was accomplished with the mammary artery, and the second was done using leg vein. I'm told that I have collateral arteries, but poorly formed. I'm blessed by the fact that my EF is rated pretty high for someone in my heart health state, about 44%. I am diabetic, but lost a great deal of weight once heart issues occurred and control diabetes with diet now. However, as a young man, I was the exact opposite of what a good example would be for someone trying to be heart healthy, and suspect I'm paying the price. Thanks so much, I shall ask the questions when I meet with my Cardiologist and Surgeon next week.
I'm happy to hear that you're on the right track now with looking after your health. Keep up the good work and don't focus too much on past mistakes. The only past mistakes that you should spend time thinking about are those that teach you how to do better in the future.
I did meet with my doctor, and did ask key questions. I did avoid the past, tried to ask questions going forward, and was answered with increased drug doses of Imdur and Ranexa, plus I was given to the care of the Cardiac Rehab nurses.
I asked about how well I'm developing collateral arteries, and got a very discouraging response, almost nil. Given the fact that I'm active, have exercised for ten years, it's not expected I will develop them. He suggested I continue to exercise, take the increased drugs, and also suggested I reduce stress by resigning from some volunteer leadership roles, which I have done. When they downloaded my pacer hx and compared it to my calendar, heart issues seemed to coincide with stressful events, so was prescribed to resign from my work/volunteer roles. I'm following directions. Thanks so much for your response.
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