Discrete Stenosis of the Left Anterior Descending Coronary Artery (LAD)

This is a 50 year old gentleman who had complaints of chest pain on walking for more than 5 minutes, since last two months. He was non-diabetic and non hypertensive. A chronic smoker. Coronary angiography showed a severe discrete Stenosis of the main LAD artery. This was treated very simply by balloon angioplasty and insertion of a single stent. The patient is doing very well 5 years after the procedure.

This elderly gentleman presented with history of unstable angina since 2 weeks. He was initially treated conservatively, but since the chest pain persisted he was taken up for angiography. This revealed a totally occluded LAD artery, with only a stump seen. Since the blockage was presumed to be recent, he was subjected to angioplasty, which was successfully performed with restoration of full flow into the LAD artery.

60 year old lady, diabetic, presented with angina pectoris, with pain in the throat on climbing stairs. ECG revealed ischemic changes in the lateral leads. Coronary angiography demonstrated a subtotal 99% Stenosis of the distal circumflex artery. This was easily treated with angioplasty and use of a single stent.

This patient was admitted to the ICCU with a lateral wall infarct. Inspite of giving thrmbolytic treatment with Urokinase, the patient continued to have chest pain. Patient was transferred for coronary angiography which revealed a severe Stenosis of the proximal circumflex artery. After giving Integrellin, a GP263a drug, the patient was subjected to angioplasty and stenting, leading to the opening up of a very large circumflex and obtuse marginal artery. The patient’s chest pain disappeared immediately after the procedure.

This 48 year old dock worker, a addict to “Gutka”, presented with 6 months history of angina. His stress test was positive for ischemia, and coronary angiography revealed only single vessel disease, with occlusion of the distal RCA. The right coronary artery distal to the block was found to be large on the retrograde filling from the left coronary system. Angioplasty was performed by passing through the total occlusion using a hydrophilic guide wire, performing balloon dilatation, and finally implanting a stent at the site of blockage. This resulted in totally opening up of the previously occluded RCA, this avoiding surgery in this young man.

This middle aged stock broker was admitted with chest pain since 2 days. Coronary angiography revealed severe Stenosis of the proximal right coronary artery with suggestion of a clot present in the lesion. A new type of clot removing catheter, called Driver Catheter, was used to extract the clot from the lesion. This was followed by angioplasty and stenting of the artery. Presence of significant amount of clot in the artery can lead to complications during angioplasty. This can be solved either by giving drubs such as Integrellin into the coronary artery before attempting angioplasty, or removing the clot mechanically with catheters such as the Driver Catheter.

57 year gentleman from East Africa presented with history of extertional chest pain since 2 years. He was a severe diabetic, with impaired kidney function. He was also a chronic smoker, with emphysematous lung disease. Angiography revealed severe discrete Stenosis of the RCA which was tackled by angioplasty and insertion of a single stent.

A 67 year old male, diabetic, bypass surgery 9 years ago, presented with extertional chest pain since one week, ECG revealed changes of anterior wall sub endocardial ischemia.

Coronary angiography revealed a total occlusion of the vein graft to the LAD. Recent history of symptoms suggested a thrombotic occlusion of the graft to the LAD. The total occlusion of the vein graft to the LAD was crossed with a Choice PT guide wire. Following balloon dilatatations, two drug coated stents were implanted, leading to total recanalization with good flow into the LAD artery.

On discharge from hospital 3 days later, the patient was fully mobilized with absence of all symptoms of angina and normalization of the ECG changes.

This case report demonstrates:

1. The importance of early invasive evaluation of a post CABG patient, to detect closure / impending closure of the surgical graft.
2. The feasibility of recanalization of even fully occluded grafts.

A 60 year old man presented within 1 hour of acute heart attack, Anterior wall myocardial infarction was diagnosed on ECG, and he was taken up for emergency angioplasty. Coronary angiography revealed totally blocked LAD artery. A guide wire was used to cross the blockage, and balloon angioplasty was performed. A long medicated stent was then placed in the LAD artery. Patient recovered very well, and was discharged from hospital with no damage to the heart muscle as confirmed by echocardiography.

With facilities currently available in major hospitals in Mumbai and with experienced angioplasty experts, angiography can be performed safely within few hours of heart attack. The advantage is to restore blood flow to the heart muscle, prevent damage, and also to prevent complications of a heart attack such as cardiac arrhythmias.