Is this a case of treating with medicines OR a bypass grafting is needed in my case.

[mskukreja]

Hi,
  I am a 70 yr old female who has two stents done some 9 yrs back. I did another routine angiogram and here are the results:
Can you suggest what should I be doing? Is this a case of treating with medicines OR a bypass grafting is needed in my case. Please advice.
Procedure Coronary Angiography Results:
1. Minor irregularity in the distant Left Main
2. Minor irregularity in Ostial LAD. The patient had PTCA done to LAD 9yrs back and received 2 overlapping Cypher stents. Intimal hyperplasio at the overlapped site of stents causing around 50% eccentric stenosis. TIMI III flow in the distal LAD which is a large artery
3. 80% short segment eccentric stenosis of the ostial circumflex. Minor non-obstructive plaques in the mid circumflex
4. Dominant RCA which continues as PDA. 30-40% eccentric plaque in proximal RCA
5. Normal LIMA
6. Normal renals
7. Normal LV on 2D echo

[ed34]

Oh and I'm pleased that the Cardiologist changed his opinion with the nuclear scan (Thallium). It will prove very useful in your situation.

[ed34]

Glad to be of help. I've been through a lot and made mistakes along the way which you can warn others about. My big concern with your case is that even though the blockage has reached 80%, there are no obvious symptoms. I am of the opinion that you are probably getting crossfeeds into the vessel from somewhere else which will likely improve as the blockage worsens. I have a total blockage in the ostial of my LAD and this doesn't matter because the vessel gets its feed from somewhere else, thanks to nature. I had it bypassed, stented and yet it still refused to stay open. After so much intervention I am in the same position I was in back in 2007. If I could go back in time, I would have none of the intervention and let nature handle it.

[mskukreja]

Thanks Ed. Your answers were very helpful and the doc said the same as you informed me. This gives me comfort to know that there are knowledgeble folks like you helping in this good cause.

[ed34]

Sounds good. You just need to ensure that if any symptoms present themselves such as shortness or breath, chest pains, throat discomfort, dizziness etc then get to the hospital. Your body will let you know if the blockage is becoming too much.

[mskukreja]

Thanks Ed and everyone. The doctor's verdict is out. No surgery but asked to do a follow up Stress Thalium next year and increased the dosage of lipitor.

[Brenda_2011]

This is a major surgery (my husband had it 2 months ago) and if this would be me I would get a second opinion if you can. You should also ask the cardiologist and surgeon to explain why they believe a bypass is the answer, and ask them to review the associated risks for each procedure.

[ed34]

Not as desirable? I do like the optimism with some Cardiologists. I had a Cardiologist who said stenting was the wrong decision, I needed bypass. I was told it would last the rest of my life. I had a triple bypass and it lasted 3 months and shut down. I then had 10 stents and 5 of those have closed. There is no way to tell what the result will be or how long it will last. I'm just being honest with you. I met patients who saw their bypass fail after just 2 weeks. I've met others who have seen it last 10+ years so far. 2 of my stents have been open now since 2007 and are doing great still. The other 3 are around 1-2 years old. This is my point, nobody can predict outcomes. If I were in your position I would probably be doing the same thing. I would have the less invasive first and see how it lasts. It could last many years, or follow the fate of many ostial stents and block within weeks/months with scar tissue and plaque. Just be alert and listen to your body after treatment. Make sure you go to the hospital if you feel something isn't quite right. When blockages form, they are progressive and not instant, so you will get warnings when they reach 90-99%. I would also ask one more thing of your cardiologist. Drug eluting stents are meant to inhibit scar tissue from growing. If you imagine a mesh tube expanded, there are a lot of gaps which don't touch your artery wall. This is where the drug is not delivered and scar tissue can grow quickly. Ask the Cardiologist if using a Drug eluting balloon will give better results before the stent is applied. This balloon will deliver the drug to ALL the artery wall and then the stent could be installed. This was used for years across Europe with good success but the FDA waited a couple of years before accepting it, to see the results. I do believe they accepted it a couple of years ago.

[mskukreja]

Thanks for your reply. I met with the doctor today and he said he could place the stents however the result wont be desirable as compared to Bypass.
Nine years back the there was no blockage at Ostial circumflex which is now 80%.
I have asked him to do a Nuclear scan and he doesn't think that this will benefit. Don't understand what to do and hence taking opinions.

I understand while I dont have many blockages but was exploring the option of using the new minimally invase procedure to remove the blockages.

[ed34]

I am a bit confused? You don't have a CTO? The biggest blockage you have is 80%. I thought the system you refer to offers an easier way to transverse to the blockage so a Stent can be deployed? There are usually 3 choices for stenting an ostial lesion. The first is to lay a stent across the main vessel (in your case the LAD) This would start at the left main artery, bridge the circumflex, then go a short distance into the LAD. Another stent is then forced through the mesh of the positioned stent, going into the circumflex. A small amount is left protruding into the first stent, and this is leveled off using a balloon. The second option is very similar, but the circumflex is done first. The third option is the kissing option. One stent is placed from the left artery into the LAD. A second stent is placed from the left artery into the circumflex and then both are allowed to expand. They are side by side. Sometimes however, one stent deforms the other too much so risks are involved. What you now have are two stents side by side, one going straight across into the LAD, the other veers off into the circumflex. Now, not many cardiologists like to stent an ostial blockage, but that's because the procedure is quite technical and time consuming. In your case, the disease is in the circumflex, and statistics show if this is stented, disease will form in the LAD instead. If the LAD is stented, disease will start in the circumflex. However, if careful analysis is done with flow rate and pressure of blood in the areas concerned, this risk can be minimised. If you get the flow rate of blood equal in both vessels, long term prognosis is much improved. This may require adding further stents down either vessel, to increase flow to match the other vessel. For example, some of the irregularities in the circumflex could require stents to increase flow. The 50% occlusion in the LAD where your existing stents are placed may also require widening with another stent inserted inside the existing.
I still think that because you have no symptoms, it would be worth having a nuclear scan. Let me explain why. Angiograms can only see vessels greater than a certain size and many collateral vessels (naturally opening bypass vessels) are too small to be visualised. A nuclear scan involves you being injected with a radioactive isotope which attaches itself to your red cells. You have one scan with your heart at rest and it shows the volume of red cells (oxygen) getting to various areas of heart muscle. You then have a repeat scan with the arteries dilated and the heart working harder. This simulates your ability to deliver oxygen when under exertion. Sometimes the results are quite surprising, showing more than enough oxygen and suggesting the heart is taking care of itself by opening collateral vessels. My left artery (lad) was 100% blocked for years yet I was exercising as normal. A nuclear scan showed that there was a huge network of collaterals from the circumflex and right artery into the LAD. Nature dealt with it. If nature works there is no need for stents and it is the best solution. I've had 10 stents of which 5 have closed up again with scar tissue.

[mskukreja]

Thank you so much. Is there no other way besides the bypass treatment if stents cannot be used? I have no symtoms of chest pain. I have also trying to explore  the BridgePoint chronic total occlusion system for treatment of CTO's, which prevent blood circulation to the heart. It is a new technology FDA approved as an alternative. Any suggestions? The doctor wants the previous angio report done 9 yrs ago to check if the 80% blockage is the same or has increased from before in the new report

[Flycaster305]

What does your doctor think?  I'm not a health professional, but everything seems OK except that 80% Ostial blockage.  Ostial means that the blockage is at juncture of the Circumflex, 80% will get doctor's attention, but Ostial blockages are tough to fix with stents.  I do know doctors hate single bypass surgeries as if you need another in the future, it might be compromised by the first one.  If I were you, I would ask for a full explanation.

[ed34]

The only thing of concern that I can see is an 80% blockage at the top. If they cannot stent this, then the only option is bypass. If you have no symptoms, then I would ask for a nuclear scan to backup the angiogram, to see if any collateral vessels are helping. A nuclear scan is always very useful before jumping ahead with any decisions on bypass.