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Coronary CT Angiogram
From Irshad Khan, New Delhi, India
I have taken last week CT Angiogram and its findings are worrisome. The main impressions are:
Calcium score: 18, Soft plaques seen in proximal LAD and D1 segment.
LEFT CORONARY ARTERY
LM - Normal
LAD - (Prox/Middle/Distal)- Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing.
Diagonals----
D1 ----- Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing.
Obtuse Marginal Branches
OM1 --- Normal
OM 2 --- Large OM2 artery seen with distal branching. Proximal vessel reveal focal luminal narrowing with approx 60-65 % stenosis.
Please advise me what course of treatment is advisable.
I have taken last week CT Angiogram and its findings are worrisome. The main impressions are:
Calcium score: 18, Soft plaques seen in proximal LAD and D1 segment.
LEFT CORONARY ARTERY
LM - Normal
LAD - (Prox/Middle/Distal)- Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing.
Diagonals----
D1 ----- Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing.
Obtuse Marginal Branches
OM1 --- Normal
OM 2 --- Large OM2 artery seen with distal branching. Proximal vessel reveal focal luminal narrowing with approx 60-65 % stenosis.
Please advise me what course of treatment is advisable.
I think I explained this in another post.
Let's say you have a large blockage in your LAD near the top. You have a large blockage in your RCA halfway down. You have a small blockage in your Left Circumflex(anywhere in the vessel). Now, let's say that you have opened many collaterals, and have absolutely no symptoms. As you say, you could leave things alone, just use medication. Medication simply hides symptoms and doesn't make any physical changes to your problem. Now, it's important to picture the blood flowing around your coronary arteries. The blood has to come from somewhere to be fed to all areas of the heart muscle. If your LAD isn't receiving enough blood through its natural route (the left main stem), then it must be receiving blood from collaterals. Those collaterals will fed from another Artery on your heart, perhaps the Left circumflex. You now rely on the Left circumflex for TWO reasons. ONE, to feed all the heart tissue that the LCX would normally be feeding. TWO, to supply blood across to the LAD to help that vessel feed the heart muscle it's responsible for. So, IF the blockage in the LCX grows sufficiently, then you will suddenly have lots of problems because a) the tissue fed from the LCX will start to die, and b) the LAD will no longer be receiving an additional supply through collaterals and so more tissue will start to die. This will be a huge impact.
So to simply say "I have blockages but I feel fine because I have collaterals", is not reason enough to avoid intervention. You need to know WHERE the collaterals are being fed from, which vessel, AND what is the condition of that vessel. You also have to decide if you want your heart to rely on just ONE vessel to keep everything running, with no backup.
I was in this situation in 2007. My LCX was the only vessel keeping me alive. It was feeding the heart muscle it normally would, plus it was the FULL supply now for my LAD through collaterals. It was known by myself and Cardiologists that if I formed a clot in the LCX, then my life would be over because the left side of my heart would have no oxygen at all. This is why I pushed and pushed Cardiologists to open up and stent my LAD, even though it was a risky procedure. I now have 2 open feeds to the left side of my heart. The LAD and the LCX. If one blocks, I still have the other.
It's a bit like jumping out of a plane with a parachute and having no safety chute. If the first one fails, you die.
Let's say you have a large blockage in your LAD near the top. You have a large blockage in your RCA halfway down. You have a small blockage in your Left Circumflex(anywhere in the vessel). Now, let's say that you have opened many collaterals, and have absolutely no symptoms. As you say, you could leave things alone, just use medication. Medication simply hides symptoms and doesn't make any physical changes to your problem. Now, it's important to picture the blood flowing around your coronary arteries. The blood has to come from somewhere to be fed to all areas of the heart muscle. If your LAD isn't receiving enough blood through its natural route (the left main stem), then it must be receiving blood from collaterals. Those collaterals will fed from another Artery on your heart, perhaps the Left circumflex. You now rely on the Left circumflex for TWO reasons. ONE, to feed all the heart tissue that the LCX would normally be feeding. TWO, to supply blood across to the LAD to help that vessel feed the heart muscle it's responsible for. So, IF the blockage in the LCX grows sufficiently, then you will suddenly have lots of problems because a) the tissue fed from the LCX will start to die, and b) the LAD will no longer be receiving an additional supply through collaterals and so more tissue will start to die. This will be a huge impact.
So to simply say "I have blockages but I feel fine because I have collaterals", is not reason enough to avoid intervention. You need to know WHERE the collaterals are being fed from, which vessel, AND what is the condition of that vessel. You also have to decide if you want your heart to rely on just ONE vessel to keep everything running, with no backup.
I was in this situation in 2007. My LCX was the only vessel keeping me alive. It was feeding the heart muscle it normally would, plus it was the FULL supply now for my LAD through collaterals. It was known by myself and Cardiologists that if I formed a clot in the LCX, then my life would be over because the left side of my heart would have no oxygen at all. This is why I pushed and pushed Cardiologists to open up and stent my LAD, even though it was a risky procedure. I now have 2 open feeds to the left side of my heart. The LAD and the LCX. If one blocks, I still have the other.
It's a bit like jumping out of a plane with a parachute and having no safety chute. If the first one fails, you die.
Because of heart attack my ctherter angiography was done by doctor. I f I have collaterals and no pain then why quadruple bypass. I fail to understand.
I think you need to go back a step though. Why would you have an angiogram if A. there were no symptoms, or b. A stress test etc didn't reveal ischemia?
There would be a good valid reason for investigating with an angiogram. With regards to collaterals, you are correct, some are invisible because they are too fine. BUT, you can generally see in an angiogram if there is collateral feed from somewhere. I can give you such an example from my own history...
In 2007 I had an angiogram which revealed my LAD was totally blocked at the top. Now, I was not dead, so obviously there was blood coming from somewhere. When dye was injected down my Circumflex, it appeared in the LAD, showing it must be cross feeding. The blood was flowing UP my LAD instead of DOWN, another indication. You don't always have to see the collaterals themselves. But, yes, until something better comes along, angiography is the gold standard.
There would be a good valid reason for investigating with an angiogram. With regards to collaterals, you are correct, some are invisible because they are too fine. BUT, you can generally see in an angiogram if there is collateral feed from somewhere. I can give you such an example from my own history...
In 2007 I had an angiogram which revealed my LAD was totally blocked at the top. Now, I was not dead, so obviously there was blood coming from somewhere. When dye was injected down my Circumflex, it appeared in the LAD, showing it must be cross feeding. The blood was flowing UP my LAD instead of DOWN, another indication. You don't always have to see the collaterals themselves. But, yes, until something better comes along, angiography is the gold standard.
It looks that colateral blood circulation developped is not detected by catherter angiography. If that is the case then results will always be doubtful about so called Gold Standard.
Just to add. It is an important factor if the lesion is concentric or eccentric. Different results from Stenting are associated with the two types.
So with a DES, the success rate is 90% or more. Those are very good odds for anyone. Of course, restenosis doesn't mean death. This produces symptoms like those originally felt and in most cases as stated, are treated with another stent, OR, laser. Heart attacks etc during a procedure are rare, and of course can be treated while on the table. The statement "There is a risk with angioplasty that some people ignore and believe a stent(s) is the answer to their cardivascular chronic angina and don't consider the risks of intervention" is not true, ALL people are aware because they are made aware of the risks before treatment, even emergency. Stenting has without a doubt saved millions of lives.
What we have to ask, to see the other side of the coin, is how many people survive if they refuse stents. If someone is having a heart attack or very bad angina, and they refuse stents, what are their chances?
What we have to ask, to see the other side of the coin, is how many people survive if they refuse stents. If someone is having a heart attack or very bad angina, and they refuse stents, what are their chances?
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