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Coronary artery dissection treatment


  I am a 43 year old woman and just had bypass surgery for a spontaneous coronary artery dissection in the LAD artery. I noticed a posting by another woman in this list who had also had a spontaneous dissection in her right coronary artery. However, it does not sound like she had bypass surgery.
  I know, in my case, the doctors researched the medical literature extensively (although there are so few cases as this is a very rare condition)  and had me wait in the hospital on heparin for a week (this was about three weeks after my heart attack - the first sign of any trouble). They looked for signs of healing but after a second angiogram, saw no evidence of healing.
  They thought they might be able to stent the dissection but, after a third angiogram with an ultrasound  camera, saw the dissection extended into the left main artery, was spiral, and waving about in the artery. After much discussion of pros and cons, they reached a consensus to recommend the bypass.
  Although I have asked all my doctors this question, I still do not feel I have a clear answer.
  My question is:  will the saphenous vein and/or the IMA used for the bypass  "close up" in the future, particularly the vein?  I know this is a common problem when a bypass is done for CAD where the original arteries were blocked. But my arteries showed no sign of any blockage, I have *very* low cholesterol (122 or so), and plan to follow a strict lowfat diet.  Does such a graft "close up" only because of CAD, or can it simply wear out over time?
  Is it possible that my vein will last a lifetime?
  I know some patients with such dissections have simply been followed medically and did not have surgery. I know every case is different but often wonder if surgery was the right decision.
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Dear Bobbie:
As you mention, not very much is known about spontaneous coronary artery dissection.  Whether surgery is required is always a difficult decision.  In your case, though, surgery sounded like the most reasonable approach.  If a dissection flap extended into the left main artery, and if this were to close off, the result could have been fatal.  Based on what you have written, I would have recommended bypass surgery and I think it was the right decision.
Arterial bypass grafts can last for decades.  Vein grafts tend not to last this long, even under the best of circumstances.  They tend to get clogged up with cholesterol deposits, as well as clots.  It is wise to adhere to a low fat and low cholesterol diet as you are planning.  Most cardiologists would also recommend an aspirin daily.  You should also continue to be followed periodically by a cardiologist, even if you are feeling well.  No one can honestly say how long your vein graft might last - it could last a lifetime.  Even if it closes off slowly, your body might form its own new blood channels.  In addition, the patency of the vein graft may not be essential - your own native arteries might heal.  
If you wish to be evaluated here at the Cleveland Clinic, please call 1-800-CCF-CARE for an appointment with a cardiologist at desk F25.  Information provided in the Heart Forum is for general purposes only.  Specific diagnoses and therapies can only be provided by your doctor.





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