Total occlusion of the left main and proximal right coronary artery: Case report and review of the literature

Chronic total left main coronary artery occlusion at angiography is very rare, and there are only four cases reported with concomitant total right coronary artery occlusion. We describe a case of total left main and proximal right coronary artery occlusion and review the clinical and angiographic characteristics of this condition which represents the most severe form of coronary artery disease compatible with life. © 1996 Wiley-Liss, Inc.     

Vital recognition of complete occlusion of the left main coronary artery]

Left main coronary artery occlusion is found in about 0.05% of all coronary arteriograms. In this case report left main occlusion was associated with a dominant right coronary artery and good collaterals to the circumflex and left anterior descending coronary arteries, which seems to be essential for survival in this lesion. Our case belongs to the minority of patients who have survived a myocardial infarction in the presence of left main occlusion.     

Chronic effort-induced angina as presentation of a totally occluded left main coronary artery: a case report and review

In this report, the case of a 40-year-old patient with chronic total occlusion of the left main coronary artery is discussed. Total occlusion of the left main coronary artery is a rare finding at coronary angiography. When present, patients most often have extensive collateral circulation from the right coronary artery. The mainstay of treatment is surgical with coronary artery bypass grafting.     

Minor ST-segment deviations followed by tall T waves in precordial leads caused by acute left main coronary artery occlusion:A case report

A 53-year-old male with chest pain complicated with cardiogenic shock was presented to the emergency department. The electrocardiogram showed features of acute myocardial infarction due to left main coronary artery occlusion,and minor ST-segment deviations followed by tall T waves in precordial leads with concomitant left anterior fascicular block. Emergency coronary angiogram revealed left main coronary artery complete occlusion without collateral circulation. Percutaneous intervention of the left main coronary artery was then carried out. The ECG features of a left main occlusion were discussed with this case report.[S Chin J Cardiol 2019;20(3):197-200]     

Left main coronary artery occlusion

Patients with complete occlusion of the left main coronary artery are candidates for massive myocardial infarction and sudden death and are thought to have a uniformly poor prognosis. Complete occlusion of the left main coronary artery was identified in 2 male patients among 2,546 patients undergoing cardiac catheterization over a period of 14.5 years in our institution. Both patients had angina pectoris. Left ventricular end-diastolic pressure was markedly elevated in one, and the ejection fraction was moderately to markedly reduced in both. Significant collateral flow to the left coronary system from the right coronary artery was present in both patients. Our study supports previous reports that left main coronary artery occlusion is rarely encountered during cardiac catheterization.     

Transluminal percutaneous coronary angioplasty of the left coronary artery]

This paper describes our preliminary experience with left main coronary angioplasty in 8 patients (9 procedures). In 6 patients the left main coronary artery was "protected" either by previous by-pass surgery (4 patients) or by collateral vessels from the right coronary artery (2 patients). Three patients had a total occlusion of the left main coronary artery and 2 of them had a recent or acute myocardial infarction and the coronary angiogram suggested a thrombotic occlusion of the infarct-related artery. Three patients were not considered surgical candidates and an additional patient, who was in cardiogenic shock, required an emergency coronary angioplasty as "rescue" procedure. A successful dilatation was achieved in 6 patients (including a patient with successful deployment of a Palmaz-Schatz stent) but, unfortunately, one them eventually died 7 days later from a femoral sepsis related to the procedure. However in the 2 remaining patients--with a total occlusion of the left main coronary artery in relation with a myocardial infarction--the dilatation procedures were unsuccessful. One patient underwent a successful repeat coronary angioplasty for restenosis of left main coronary artery. Our preliminary experience confirms previous reports suggesting the value of coronary angioplasty in patients with left main coronary artery disease providing a careful selection of possible candidates is performed prior to the procedure.     

Left main coronary artery atresia diagnosed by multidetector computed tomography

Left main coronary artery atresia is an extremely rare disease. Differential diagnosis of left main coronary artery atresia from atherosclerotic occlusion of left main coronary artery is difficult even if performing invasive coronary angiography. We present a case of a 48-year-old male with left main coronary artery atresia. Echocardiography showed left ventricular dysfunction. Invasive coronary angiography showed absence of left main coronary artery. A multidetector computed tomography showed a string-like structure at the site of left main coronary artery. A diagnosis of left main coronary artery atresia was made, and he underwent coronary artery bypass grafting. At the operation, a thin and not-sclerotic left main coronary artery was observed. Echocardiography, performed after the surgery, showed normalization of the left ventricular systolic function. Multidetector computed tomography might be a useful method to diagnose left main coronary artery atresia.     

Total left main coronary artery occlusion in a female patient after AVSD surgical repair in childhood as a cause of non ST elevation myocardial infarction

A case of a 51-year-old woman with symptoms of non-ST-segment elevation acute coronary syndrome and concomitant atrial flutter is presented. Patient underwent atrioventricular septal defect repair in childhood. Coronary angiography showed total occlusion of left main coronary artery and massive collateral network originating from right coronary artery supplying entire left coronary artery. Ablation of atrial flutter had been performed and patient was subsequently submitted to mitral valve replacement, tricuspid valvuloplasty and coronary artery bypass grafting. The potential causes of left main occlusion are in this case discussed.     

Chronic Total Left Main Coronary Artery Occlusion— A Case Report

We report on the clinical and angiographic data of a patient suffering from total chronic occlusion of the left main coronary artery. For many years the patient’s only complaint was of mild stable angina (CCS I). He had a history of a previous acute myocardial infarction 20 years ago, possibly caused by the occlusion of the left main coronary artery. The anatomic and clinical findings of chronic total occlusion of the left main coronary artery during his life are discussed.     

Acute coronary syndrome without ST segment elevation in a 78 year-old woman caused by critical proximal right coronary artery stenosis with concomitant chronic total occlusion of left main coronary artery

Total occlusion of the left main coronary artery is a rare finding at coronary angiography. When present, patients most often have extensive collateral circulation from the right coronary artery. The mainstay of treatment is surgical with coronary artery bypass grafting. We present a case of a 78 year-old woman admitted to our department with two days history of nonspecific, abdominal pain. Her coronarography revealed chronic total occlusion of left main with concomitant critical, proximal right coronary artery stenosis.     

Unusual combination of total occlusion of left main coronary artery and heart failure with pulmonary hemosiderosis: case report

A case of total occlusion of the left main coronary artery, congestive heart failure, and pulmonary hemosiderosis in a 54-year-old man is reported. Cardiac catheterization showed total occlusion of the left main coronary artery, subtotal occlusion of the right coronary artery, severely deranged hemodynamics, and an akinetic left ventricle except for a hypokinetic posterobasal segment. A radionuclide left ventricular performance study revealed an ejection fraction of 0.16 with diffuse biventricular hypokinesis and dilatation. Despite all the risk factors, the patient underwent a total of six saphenous vein grafts without perioperative or immediate postoperative complications.     

The power of collateral circulation: a case of asymptomatic chronic total occlusion of the left main coronary artery

Total occlusion of the left main coronary artery predominantly presents with recurrent angina or myocardial infarction. Long-term survival and myocardial function depends on the well-developed right to left collaterals. We report a case of a 46-year-old man who was referred because of incidental finding of low ejection fraction during work-up for syncope 5 months prior. The patient denied any recurrence or any other symptom after that episode and claimed an unchanged exercise capacity. He had hypertension, hyperlipidemia, and history of 15-pack/year smoking. Except for class II morbid obesity, he had completely normal vital signs, physical examination, and lab tests on admission. The echocardiogram was suggestive of previous anterior wall myocardial infarction and demonstrated a low left ventricle ejection fraction with diffuse hypokinesis of the left ventricle. The patient underwent cardiac catheterization, which revealed total occlusion of the left main coronary artery, dominant right coronary artery with a 95% stenosis in the proximal segment, and collaterals from the right to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the left main coronary artery and severe stenosis of the proximal right coronary artery.     

Mechanical emergency recanalization of the left main coronary artery

Acute occlusion of the left main coronary artery is normally fatal. According to the literature, only a few cases have been treated by intracoronary thrombolysis; the prolonged period of ischemia, however, resulted in severe left ventricular dysfunction and numerous complications. Therefore, effort should be directed to recanalize the left main coronary artery within the shortest possible interval. We followed this approach in a case of acute occlusion of a subtotal stenosis of the left main coronary artery which could be mechanically reopened and dilated within a few minutes. The intervention resulted in immediate reversal of profound cardiogenic shock and complete restoration of normal left ventricular function. At hospital discharge, the patient was asymptomatic with a negative bicycle stress test. Immediate mechanical recanalization and angioplasty appear to be a feasible approach in life-threatening coronary occlusion.     

Survival after myocardial infarction caused by acute left main coronary artery occlusion: case report and review of the literature

We report a 44-year-old white male presenting with an acute anterior myocardial infarction. Cardiac catheterization at 2 weeks postinfarction revealed total occlusion of the left main coronary artery. There was a normal dominant right coronary artery supplying moderate collaterals to the left coronary system. The patient was managed with conservative therapy and was N.Y.H.A. functional class II on followup 2 years later. A review of the literature relative to myocardial infarction caused by acute left main coronary artery occlusion is presented, and unique features of these cases are described.     

Percutaneous stenting of chronic total occlusion of unprotected left main coronary artery

Chronic total occlusion of the left main coronary artery is very rare. We report a case in which a totally occluded, unprotected distal left main coronary artery was successfully revascularized percutaneously, establishing normal flow in the left main, left anterior descending and left circumflex coronary arteries.     

Total occlusion of the left main coronary artery. A clinical, hemodynamic and angiographic profile

Although left main coronary artery stenosis has been extensively revicwed, total occlusion of the left main coronary artery has received scant attention. Six patients were diagnosed at cardiac catheterization as having total occlusion of the left main coronary artery over a period of seven years at two institutions. They ranged in age from 32 to 72 years, and all had symptoms ranging from NYHA Class 1-IV at initial presentation. One patient died three days after coronary artery bypass graft surgery. Of the remaining five, two treated medically are alive four and 40 months after catheterization, and three treated with coronary artery bypass graft surgery are alive three, 66 and 68 months after catheterization. Electrocardiogram showed prior myocardial infarction in three patients, stress tests were positive in three of four patients, and hyperlipidemia was present in the five tested. In the three patients without prior myocardial infarction, left ventricular function was preserved (ejection fractions = 0.52, 0.55 and 0.64; left ventricular end-diastolic pressures = 6, 9 and 14 mm Hg). Injection of the right coronary artery in this group revealed extensive collaterals filling the left coronary artery. The three patients with prior myocardial infarction had impaired left ventricular function (ejection fractions = 0.18, 0.30 and 0.33; left ventricular end diastolic pressures = 26, 35 and 35 mm Hg) and sparse intercoronary collaterals. Patients with total occlusion of the left main coronary artery have a varying clinical presentation and may have prolonged survival. In patients with good collaterals, left ventricular function may be preserved.     

Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases

Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease.     

Embolic coronary artery occlusion in percutaneous transfemoral coronary arteriography

A review is presented of 139 selective coronary artery studies during a 25 month period in which 1,112 coronary artery injections were performed using the percutaneous transfemoral artery approach as described by Judkins in 1967.² Six patients (four per cent) developed acute occlusion of the left coronary artery or one of its branches during the procedure, and two of these died with occlusion of the left main coronary artery shortly thereafter.It is felt that since in all cases of this series and most of those of others, embolic occlusion within the left coronary artery system occurred, the complication is related to the thrombogenic properties of the left coronary catheter or to the procedure in which introduction of the second catheter is required.     

Surgical revascularization for acute total occlusion of left main coronary artery

We report our experience with emergency surgical revascularization in 3 patients who were in cardiogenic shock as a result of acute total occlusion of the left main coronary artery. Because they were in profound shock, 2 patients required mechanical support with extracorporeal membrane oxygenation before the operation. Another patient was given moderate inotropic support and treated with an intraaortic balloon pump before surgery, because he had a dominant right coronary artery with extensive collateral circulation to the left coronary artery. All 3 patients underwent surgical revascularization within 20 hours of acute occlusion. Two patients survived, although 1 of them required extracorporeal membrane oxygenation support for 5 days postoperatively. The 3rd patient, despite successful weaning from extracorporeal membrane oxygenation immediately after coronary revascularization, died of hypoxic encephalopathy due to prolonged preoperative resuscitation. Immediate surgical revascularization was an effective treatment in our 3 patients who were in cardiogenic shock due to acute total occlusion of the left main coronary artery. Such factors as abundant collateral vessels from the right coronary artery to the left coronary artery, complete surgical revascularization within 20 hours of acute occlusion, and mechanical circulatory support were deemed important to recovery of left ventricular function. Two of our 3 patients survived.     

Angor with occlusion of the left main coronary artery treated with angioplasty

The occlusion of the left main coronary artery is rare and generally fatal. However, some subjects do survive. The two conditions necessary for survival appear to be the existence of a dominant right coronary artery and above all a rapidly functional left-right collaterality. The time lapse between occlusion and the introduction of an efficient collateral system is fundamental to patient survival. If the time lapse is too long, there is a risk of myocardial infarction, often complicated by cardiogenic shock, with a poor prognosis even after deocclusion. In this study, the case is reported of a patient with left main coronary artery occlusion presenting as unstable angor without an increase in enzymatic levels, and with a totally functional left-right collaterality. Deocclusion angioplasty was successfully performed. Finally, the short- and medium-term results of left main coronary artery angioplasty have been discussed.