blocked LAD

A CT angiogram revealed 70-90% blockage on my left anterior artey (LAD) .
I am a 50 year old man , insulin dependent  diabetic, CABG (2 vessels, RCA and circumflex) performed 8 years ago. The grafts are clean according to the CT angiogram. I have impaired LV ejection fraction with different methods (echo, cath, CT angiogram) giving a range of 30-43% . I am fitted with ICD. 8 years ago stenting  prior to CABG failed within weeks. I am active, go to the gym and in full time job.

Given the above history, what are the options for me ?
Thanks

[ed34]

The occlusion built up in your LAD is quite severe. I am wondering which vessels they used for grafting? did they use one or both arteries from the chest (Lima/Rima) or just one of these? How many veins were used from your legs?
It would also be of interest to know where in the LAD that your occlusion has formed. Is it near the top, mid section or distal.
Given that you show no symptoms with exercise, the cardiologist may opt to continue trying to maintain your health with medication but under the circumstances, and your age, I would have  thought that he would recommend intervention treatment through surgery. You have diabetes which gives a greater risk of stents failing, through restenosis, but did you have Drug Eluting Stents fitted 8 years ago? or just the Bare Metal Stents? Maybe DES will give a slighly better chance of success.
If you have an Artery left in your chest which they can use (Rima/Lima) then they may suggest having another bypass. Veins seem to last in your body when grafted, not everyone has that luxury and so they will probably use a spare artery (if available) and a vein or two. To save you all the discomfort, you may wish to pursue the Stent option again. Your Cardiologist may decide to do nothing, but if the occlusion has grown to 90% in just 8 years, then I would be a bit concerned in leaving it.

[kenkeith]

You certainly have an unfavorable history for CAD.  It is my understanding from a forum member who has had many stents that by-pass surgery is not a very good option for a diabetic, and open heart surgery with an EF below 50% may also be a factor.  Why is your EF below normal?  Have you had a heart attack, or is there heart muscle disease?  What are your symptoms if any?  Why did the previous stents fail?

[anandbharti]

Hello ed34 and Kenkeith,

Thank you for your input and suggestions.
On my previous bypass, venal grafts were used so I do have the mammary arteries which can be used for a new bypass.
My ejection fraction is low because I have had two previous MI. As I said in my previous posts, the LVEF valuues have varied over the years and with echo, stress cath and CT angiogram from 20-43%  CT angiogram last week gave 43%. One thing I find on my reports over the last eight years is hypokinesis of LV.
My cardiologist thinks EF is reasonably OK but the LAD does need fixing. She thinks DES should work this time around. Last time they probably used "plain" stents and the arteries got blocked in the same place within 8 weeks and resulted in a big MI (according to my cardiologist)
As I said before, I am in a full time employment, drive 100 miles every day. Go for long walks 5 miles on a beach every week & go to the gym four times a week.

[kenkeith]

Hypokenisis (impaired heart muscle contractions) often indicates a prior MI that damaged heart cells,  and that would lower your EF, but 43% is not limiting especially if one's system has compensated well as your life style indicates.  DES has a better record than bms for not having restenosis, but there is a slight higher risk of clots that doctor's like to medicate against (plavix and aspirin) for about a year.  

You may want to go with DES, and harvest mammary vessles in the future if needed.

[ed34]

That's certainly the route I would take, unless the cardiologist gives a very good reason not to. It is likely you will have more luck with DES which will not give the same problem of growing scar tissue through them, causing a blockage. There is also the fast recovery time with Stents compared to bypass surgery and certainly a lot less discomfort.