Tag: CABG

By Humayun Naqvi MD , Interventional Cardiologist
and Salman A. Arain MD (Associate Professor McGovern Medical School at UT Health)

A 56 year old man presented to Dr. Naqvi with angina in 2021. Cath showed multivessel CAD and underwent CABG with LIMA to LAD and vein grafts to OM and Diagonal. The RCA was not bypassed.

He presented in June 2023 with worsening angina despite optimal medical therapy (OMT). Here are angiograms:

LIMA was patent and filled the distal LAD; OM graft was patient suppling a small territory. Diagonal graft was not visualized. RCA which has not been bypassed was occluded.
Patient was started on optimal anti anginal therapy with isosorbide mononitrate, ranolazine, metoprolol, amlodipine, and aspirin. His angina resolved reducing the need for sublingual nitroglycerin. The question was what to do next: The choices were:
Optimize GDMT and pray for the best
Consider EECP (and GDMT)
Viability study +/- judicious PCI
Viability study +/- re-do CABG
LVAD evaluation
Look for experimental therapies, e.g. myocardial laser or stem cell therapy.
Here is our thought process:
The most common symptom in patient with CTOs and significant ischemia is dyspnea (and not chest pain). The reason for the ‘graft failure’ in this patient is a discussion in itself. (They did not fail as you will see). We typically like to determine viability, ischemic distribution, and burden before embarking upon complex PCI. Here the strong possibility of balanced ischemia and the angina despite a hefty anti anginal regimen, made us choose PCI first. The plan was to perform a PET after ‘unbalancing’ the ischemia…

There is significant ischemia in the RCA territory. We decided to work on his native coronaries and ended up with stents in the ramus and LCX. POBA in the LAD. I like to use a technique called JSBT or JSKBT – jailed semi-inflated (kissing) balloon technique. This is the absolute best way to preserve side branches. 👌🏼Here are the final images:

You can see that the diagonal graft fills retrogradely and was therefore open. Also there is a blush in the distal RCA territory signifying later remodeling or vessels and collaterals.
Patient is followed by Dr. Naqvi and as of December 2023 seems to be doing well with significantly less effort angina and return to a decent lifestyle.

Essay edited from WhatsApp messages by AHK. December 9 2023.

QUESTIONS:
Some questions raised by the readers: ” ood technical case. May I ask the question, if angina resolved with medical therapy with less use of NTG, what was the wisdom for extensive stenting at that point?” Second: ” Thanks for the share. From a percutaneous perspective, the SVG to OM was widely patent and most of the ischemia was inferior. So what was the rationale of doing LM into LCX PCI before RCA? Wasn’t RCA PCI alone indicated/enough?” I advised entering the questions in in the blog itself which has place for discussion so it could be answered there.
ANSWERS:
Dr. Naqvi: The angina did not completely resolve. He was needing to take 2-3 pills of nitroglycerin on top of all the medical therapy, extremely fatigued, and the episodes of angina 2-3 times a week was anxiety provoking for him leading to an ER visit as well. That’s why he was referred for PCI.
I saw him yesterday in the clinic for follow up and he was almost in tears thanking us. He said he hasn’t felt like this in years and has so much more energy. He is back at work, active, and doing more physical work. Worked in his garage the whole day without a problem.

Dr. Salman Arain:
Good questions. Here are the answers and a comment:
Most patients with a CTO and significant ischemia (>15% or more) do not have angina. They have exertional dyspnea and fatigue which can be lifestyle limiting.

1. The stress test was after the LM PCI. Also, most guidelines and experts favor treating the donor arteries (and any non CTO lesions) before addressing the occlusion. There were left to right collaterals and we were under the impression that a graft to a major diagonal had gone down.

Now for the comment. CTO PCI is done for quality of life not survival. There is some data from Lance Gould using PET that the degree to which ischemia can be reversed has an impact on mortality. But we haven’t been able to connect this mortality benefit to CTO PCI.

But there is more to life than just longevity. Fixing a major CTO (like this one) can have a major impact on QOL. And reduce the number of medications needed. Of course, it doesn’t replace the need for essential GDMT.

I tell my colleagues that CTO PCI is a bit like doing knee surgery for someone with bad joint disease. Does it prolong life? Not at all. But you don’t have to rely on crutches any more, and you become more mobile. Of course, you still need to lose weight, go through rehab etc. Obviously, this is a biased perspective, but it is supported by my experience of treating CTOs of the past five years. Patients can and do feel a major difference. I almost always do some type of functional test so that the pre-treatment probability of benefit is high.

BTW, here the purpose of the PCI was also to finish the job that CABG had started – complete revascularization. Interestingly, many of my patients are post CABG.