Treatment for occluded LIMA graft

[runnertom]

I had bypass surgery for a bifurcation lesion 4 1/2 years ago at age 54. The mammary artery was used to graft the LAD and a saphenous vein used for the diagonal. Since the surgery, my risk factors have been under good control. Never smoked, blood pressure low normal except during exercise (taking beta blocker for that), LDL/HDL of 80/60 until recent change to Vytorin reduced LDL/HDL to 62/76. Trigylcerides 60.
A recent 64 slice CT scan for surveilance purposes found that the LIMA graft was essentially occluded with a patent vein graft.  The original cath showed the LAD lesion was not all that bad in the first place, which is probably the reason the LIMA has closed down. The literature indicates that when this happens, later surgical options are severely limited. However, there are reports that LIMA grafts such as mine may be recruited later if flow through the native vessel closes off.
Questions: As for exercise, for maintaining whatever flow is left in the graft, would fairly intense exercise such as interval training be preferable to longer bouts of more moderate activity?
As for the LAD lesion which is apparently fairly heavily calcified, would it be possible to get reversal of the narrowing if I maintained the good lipid profile?
I am afraid of drug eluting stents with my heavy exercise due to the possibility of late thrombosis. Would a bare metal stent or maybe angioplasty without a stent be good options? My cardio isn't sure what to do.

[CCF-M.D.-CA]

There is evidence that even more aggressive risk factor modification diminished atheroma burden as measured by IVUS: this was accomplished with an LDL of 60 with the drug Crestor. This was a novel finding not found with other lipid lowering drugs, and may translate into clinical benefit but we don't have that data as of yet.
You are probably correct about the LIMA: it was probably a surgical error to bypass a non severely stenotic lesion because that condiut will likely not be re-usable. I would favor a moderate amount of exercise but avoid things that involve prolongued physical activity (marathons and triathlons.) In addition I would be on the watchout for any symptoms such as chest pain, palpitations, which would limit the amount of exercise performed.
There is no evidence that you need any intervention to either the LIMA or native LAD unless you have symptoms (ches pressure or pain, severe shortness of breath with exercise, swelling of legs). Even then, the only benefit obtained is resolution of symptoms and not life saving (that is unless you have what is known as an ACS.) So be careful about receiving stents simply because you LIMA is now occluded.

[chrisr]

Surprising that the LIMA graft has occluded since I have always heard that  they last much longer than the vein bypasses. From my own experience you have to be extremely careful if you are thinking about stenting the LAD via the LIMA. In trying to stent a distal LAD lesion via the LIMA from 1st CABG stenters at Miami Baptist severely dissected my LIMA and said there was virtually nothing they could do. Of   course this almost completely shut down the LAD with serious ischemia to the left heart. Thanks to the very good and skilfull cardios at CCF I was able to do a 2nd CABG replacing the LIMA with the RIMA and bypassing all the previous stent work. This eliminated all previous stent medications, felt much better and according to a recent CT scan all bypases are patent after almost 2 years. Good luck and hope  all goes well with you.

[runnertom]

Chris,
Thanks for your comments. I would hope that my situation doesn't come to repeat CABG or even angioplasty. My concern is that my LIMA has been "used up" to no benefit and my LAD still has the original lesion. If that lesion follows the normal course, it will eventually become more severe and require intervention. It may be stentable, but the that option was considered to be a poor one at the time of my CABG.
My "ace in the hole" is good collateral circulation that developed either because of the LAD restriction or my long term heavy exercise. I am certainly hoping that the low HDL I have achieved results in reversal of the existing blockage.

[Healthyself2]

Hey Tom,

We've been around for a while.  You certainly don't fit the profile of someone with CAD.  I suspect that your plaque was a response to some type of stress injury to the artery.

I do fit the profile.  Had family history, risk factors, and a lifelone horrible lipid profile.

When they told me 8 years ago, after my M.I., that I needed bypass surgery and then 6 1/2 half years ago, after their second unsuccessful attempt at angioplasty, that they would give me a 40% chance of death within 5 years without bypass surgery, I'm glad that I didn't drink the Koolaid.

After many years of maintaining a perfect lipid and BP profile with a multi-drug cocktail, and exercising moderately, my disease seems to be in total remission.

I'm a believer in the longer duration lower intensity exercise for building collaterals and strengthening the heart.  I walk every day, and hike for a couple hours uphill frequently.  Of course now I live between three volcanoes, so there is plenty of opportunity to walk uphill.

Don't take a stent - they are forever.  This widespread stenting of young people is criminal in my opinion.  The dissolvable ones might be ok, but they are a few years away.

--Bill

[runnertom]

Bill,
   The fact that I don't fit the normal cardiac profile has certainly not escaped my notice. However, I found enough "marginal" risk factors I do have to accept the fact that I do have cardiovascular disease and move on from there. Denial won't solve anything. For a while, I was blaming my blockage on an incident I had while back in a triathalon. Someone turned in front of me biking at 30 mpg and I went over the bars landing flat on my back. I had pain between my shoulder blades for weeks and I thought my heart may have inpacted my rib cage hard enought to damage the cardiac arteries. Maybe so, maybe not.
   I found that my homocysteine was quite high. As mentioned in my post, I find that I have exercise induced hypertension with bp hitting 230/110 at my limit. A recent case study in one of the journals documents a marathoner with similar risk factors as mine with exercise induced hypertension that has extensive CAD after 30 years of doing 3 marathons per year. I have also some occupational chlorine exposure that recent evidence says may be responsible for lipid peroxidation that leads to CAD.
   Now, I am retiring and will have ample time to do whatever exercise I wish for as long as I wish. It could be walking at a pulse rate of 80, hours of cycling with a pulse of 130+, or running with pulse over 150. I doubt that anyone really knows which is preferable.

[manny 1966]

I am 40 yrs old, and had triple bypass this past march. The last two months I have increased my work outs and have started to walk two miles three times a week.
Shortly after surgery I I guess post surgery pain, ie pain that would radiate from the left part of neck, arm and some chest. Especially during long walks in the super market or now while walking. For a short period of time the pains had stopped. I saw ny Cardio about  two months ago and did not thing was wrong.Then it restarted in the last two weeks. I called my Cardio and set me up for a nuclear stress test.My doc said I failed, suppossely the botton left front of the heart is not getting enough blood/ oxygen. I think I am saying it concerning the bottom front. He wants to go in for a angiograph. I will meet with him and discuss my options, such as artherectomy, but I don't know which of the three procedures are appropriate. My Thoraci surgen who performed the bypass thinks from reading the report that is no stenosis but, the new artery could have closed up.
My question is is it fesable or appropriate to ask my docs to be a little more aggressive such as the Arterectomy and clear my previos blockages. My original blockages are 99 percent blocked in the lower let ventricle, and 60 percent on top and 40 percent on the bottom upper left ventricle that leads in the left main ventricle where it intersects. They call it the Widow maker.
I will have the cath but I want to increase my blood flow as much as I can.
Is it realistic for the Cardio or Thorasic surgeon to perform this with some successful results?

[peeshaw]

A related discussion, Saphenous Veins was started.