Coronary Stenting in a Patient With Dual Left Anterior Descending Artery

Double left anterior descending coronary artery (LAD) originating from the left main stem and the right coronary artery (type IV dual LAD) is a extremely rare coronary artery anomaly. We report a case of type IV dual LAD in a patient with history of myocardial infarction and worsening effort angina. The proper LAD and both the circumflex (Cx) and the right coronary (RCA) arteries showed multiple severe stenoses. The patient underwent successful percutaneous coronary intervention.     

冠状动脉左主干病变介入治疗

冠状动脉左主干病变的介入治疗具有挑战性。现从冠状动脉左主干的解剖特点、冠状动脉左主干病变的病因形成、左主干病变的诊断、左主干病变的治疗、左主干病变支架术的适应证和禁忌证、器械选择、治疗策略等进行了详细的阐述。对于存在冠脉旁路移植术禁忌证、拒绝外科治疗或经严格选择的左心功能正常的无保护左主干病变的病人,冠脉支架置入术是一种较理想的治疗方法。     

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: Pre- and Postoperative Echocardiography Findings in Three Unusual Cases

Diagnosis of anomalous left coronary artery from the pulmonary artery was prospectively established by color Doppler echocardiography in three patients. In two asymptomatic girls, aged 10 years and 5 years respectively, referred for evaluation of a murmur with normal ECG and chest X ray, two-dimensional and pulsed-Doppler examination showed no intracardiac abnormalities. Color flow mapping detected flow in a dilated right coronary artery and left coronary artery to pulmonary artery shunting. Color guided pulsed-Doppler examination permitted further evaluation of coronary flow. Another child had a dilated cardiomyopathy with an echo-dense anterolateral papillary muscle and mitral insufficiency. Postoperative echoes after subclavian to left coronary artery anastomosis and ligation of the left coronary artery at its origin showed residual high-velocity shunting resulting in reoperation in one case and a moderate supravalvular pulmonic stenosis in another. These findings further emphasize the benefit of color Doppler echocardiography in the pre- and postoperative evaluation of anomalous left coronary artery. (ECHOCARDIOGRAPHY, Volume 8, September 1991)     

Percutaneous transluminal laser guide wire recanalization of chronic subclavian artery occlusion in symptomatic coronary-subclavian steal syndrome.

Treatment of subclavian artery stenosis by percutaneous balloon angioplasty and adjunctive stent placement was shown to be safe and efficacious, but it may be limited in tight stenoses and long occlusions. We describe the case of a patient who experienced progressive angina pectoris associated with signs of cerebrovertebral insufficiency 9 yr after bypass surgery, including left internal mammary artery (LIMA) grafting to the left anterior descending coronary artery. Angiography showed reversed flow through the LIMA graft into the subclavian artery and a 4-cm occlusion beginning at the origin of the left subclavian artery, representing a rare coronary-subclavian steal syndrome. After a conventional approach failed, recanalization was performed successfully using laser guide wire angioplasty with adjunctive stent placement in a combined radial and femoral approach.     

Coronary subclavian steal syndrome after internal mammary artery bypass grafting. A cause of severe postoperative recurrent myocardial ischemia

A 65-year-old underwent a triple bypass: internal artery mammary-descending coronary artery, aorta diagonal-lateral coronary (sequential). Three weeks later he started to have severe angina pectoris with ST depression in anterior EKG leads. A left transradial coronary angiography was performed. The examination showed a total occlusion of the left subclavian artery 2 cm after the aortic arch and a retrograde flow in the internal mammary artery (IMA). Via transfemoral approach, angiography showed the patency of the aorto-veinous sequential graft and a retrograde flow through anastomosis in the left mammary artery. The patient underwent a reimplantation of the IMA on the brachiocephalic artery. One month later the patient is doing well without chest pain. A coronary subclavian steal syndrome should be suspected in case of recurrent ischaemia after IMA bypass, particularly if there is more than 20 mmHg systolic pressure differential between the arms. Left transradial approach achieved diagnostic in case of total left subclavian artery occlusion.     

Left Atrial Myxoma Causing Coronary Steal: An Atypical Cause of Angina

Cardiac myxomas are rare primary cardiac tumors that usually present with dyspnea or manifestations of systemic embolization. Coronary steal is a rare phenomenon of unbalanced blood flow that is seen primarily in patients who have undergone coronary artery bypass grafting and have subclavian artery stenosis.We report the case of a 72-year-old woman who presented with fatigue, weakness, and exertional chest heaviness and had abnormal results on a cardiac stress test. The results of coronary angiography showed no obstructive coronary artery disease but revealed a large intracardiac left atrial mass that was supplied by 2 anomalous coronary arteries. The patient underwent successful ligation of the anomalous coronary arteries and resection of the mass, which was histologically an atrial myxoma. The patient''s symptoms resolved, and results of a repeat cardiac stress test were normal.To our knowledge, this is the first report of a highly vascularized atrial myxoma that caused coronary steal with objective evidence of ischemia, and with subsequent resolution after resection of the mass and ligation of the anomalous coronary arteries.     

Stenting of Unprotected Left Main Coronary Artery Stenoses: Immediate and Late Outcomes

Objectives. We examined the immediate and long-term outcomes after stenting of unprotected left main coronary artery (LMCA) stenoses in patients with normal left ventricular (LV) function.Background. Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area.Methods. Forty-two consecutive patients with unprotected LMCA stenoses and normal LV function were treated with stents. The post-stent antithrombotic regimens were aspirin and ticlopidine; 14 patients also received warfarin. Patients were followed very closely with monthly telephone interviews and follow-up angiography at 6 months.Results. The procedural success rate was 100%, with no episodes of subacute thrombosis regardless of anticoagulation regimen. Six-month follow-up angiography was performed in 32 of 34 eligible patients. Angiographic restenosis occurred in seven patients (22%, 95% confidence interval 7% to 37%); five patients subsequently underwent elective coronary artery bypass graft surgery (CABG), and two patients were treated with rotational atherectomy plus adjunct balloon angioplasty. The only death occurred 2 days after elective CABG for treatment of in-stent restenosis. The other patients (without angiographic follow-up) remain asymptomatic.Conclusions. Stenting of unprotected LMCA stenoses may be a safe and effective alternative to CABG in carefully selected patients with normal LV function. Further studies in larger patient populations are needed to assess late outcome.     

Coronary ischemia due to subclavian stenosis after arterial revascularization

We describe a case of coronary-subclavian steal in a 60-year-old man who presented with progressive ischemia 16 years after coronary artery bypass with in-situ bilateral internal thoracic artery grafts. Angiography revealed completely patent arterial grafts, but subtotal stenosis of the left subclavian artery. On reoperation, a vein graft was used to connect the aorta to the left internal thoracic artery which was proximally disrupted. No coronary ischemia was found postoperatively.     

Coronary surgery in patients with porcelain aorta.

Four patients with unstable angina due to left main or three-vessel disease scheduled for coronary artery bypass grafting were found intra-operatively to have porcelain ascending aorta, defined as massive calcification of the ascending aorta from the aortic valve to the transverse arch, precluding ascending aorta cannulation or clamping. A no-touch operative technique was applied using the two internal mammary arteries in three cases, with complementary Y-grafting when necessary. Three cases underwent off-pump myocardial revascularization. The fourth case was revascularized with pump-assisted beating heart and proximal saphenous graft anastomosis with an automatic connector. There was no mortality or neurologic morbidity and all patients were discharged home before post-operative day 8.     

Coronary subclavian steal syndrome: treatment by stenting of the left subclavian artery

A 48-year-old Turkish male presented with worsening angina and a painful left hand eight years after coronary artery bypass surgery. Coronary angiography showed extensive coronary atherosclerosis with patent vein grafts to his diagonal branch and right coronary arteries. There was a severe narrowing lesion in the left subclavian artery before the origin of the left internal mammary artery (LIMA), which appeared patent. Percutaneous subclavian angioplasty and stent implantation to the left subclavian artery stenosis restored normal flow to the left hand and the LIMA with abolition of his ischemic hand symptom and marked improvement of his angina.     

Dual Left Anterior Descending Artery Arising From Left Circumflex Artery With an Intramyocardial Coronary Aneurysm

Dual left anterior descending (LAD) artery is a rare anomaly conventionally classified into 4 types. We present a case of dual LAD artery in which the long LAD artery has arisen from the left circumflex (LCx) artery, a condition not previously included in the 4 defined types. Moreover, the long LAD artery specified here is associated with an intramyocardial coronary aneurysm. To our best knowledge, it is the first time such a coronary artery anomaly has been reported. This case suggests the important role of coronary computed tomography angiography (CTTA) for diagnosis and therapeutic planning for such an anomaly.     

Coronary subclavian steal syndrome

Coronary subclavian steal syndrome arises when a stenosis of the subclavian artery results in reduced antegrade or retrograde flow in an internal mammary artery with resultant coronary ischemia.……     

A very unusual origin of left subclavian artery

The left internal mammary artery, a branch of the left subclavian artery, is the most commonly used arterial graft during coronary artery bypass grafting. Although extremely rare, an abnormal origin of left subclavian artery may lead to a difficult coronary angiography procedure or result in a catastrophic complication if iatrogenically occluded during a stent-graft repair of thoracic aneurysm. We present a case of an unusual anomalous origin of the left subclavian artery, which was discovered during a diagnostic coronary angiography.     

Classification and Atherosclerosis Distribution in Patients with Left Main Coronary Disease

Objective: The purpose of this investigation was to characterize clinical variables and angiographic distribution of coronary atherosclerosis to classify patients with de novo left main (LM) disease in a real-world population presenting for coronary angiography.
Background: Limited quantitative and angiographic published data exist that provide detailed quantitative information to classify potential target population for elective LM percutaneous coronary intervention (PCI) and guide development of dedicated LM PCI platforms.
Methods: Medical history and clinical presentation were prospectively collected on 177 consecutive patients with LM stenosis ≥50% by coronary angiography. Blinded quantitative coronary angiography (QCA) was performed on all LM stenoses to classify LM-A (ostial), LM-B (nonostial, non-bifurcation), and LM-C (bifurcation involvement). QCA was performed on the left anterior descending (LAD), left circumflex (LCx), and right coronary arteries (RCA) and branches (≥2.5 mm) to identify lesions with ≥60% stenosis or occlusion.
Results: No differences in baseline clinical history or presentation discriminated the distribution patterns of LM stenosis. QCA revealed 66% of LM stenoses were LM-C. Mean LM reference vessel diameter was 4.65 mm and average lesion length was 11.12 mm. Around 88.7% of patients had at least one lesion ≥60% in a major epicardial artery and 32.2% of patients had RCA chronic total occlusion. Right-to-left coronary collateralization was only identified in patients with obstructive stenosis in the LAD or LCx in addition to the LM stenosis.
Conclusion: Dedicated LM stent platforms may need to be developed to accommodate larger vessel size and bifurcation distributions. A majority of patients with LM stenosis will require adjunctive epicardial vessel PCI to achieve complete anatomic revascularization.     

Traumatic ostial stenosis of internal mammary coronary graft

Because of the extensive use of arterial conduits for coronary surgery there is a growing interest in percutaneous intervention in these conduits. This kind of intervention presents a challenge for the interventional cardiologist owing to the anatomic and functional characteristics of this graft. In most cases significant internal mammary artery disease occurs at the distal anastomosis. Ostial stenoses are rare and their pathology uncertain. The authors report a case of an ostial graft lesion, most probably caused by repetitive ostial engagement of the left internal mammary artery in combination with atherosclerosis in the subclavian artery affecting the internal mammary artery. (Int J Cardiovasc Intervent 2004; 1: 43–44)     

Coronary-subclavian steal syndrome presenting with chest pain and syncope

The present case is a 68-year-old patient with complaints of chest pain and syncopal attacks during physical activity of the left arm, for the last six months. He had a coronary artery bypass graft operation 10 years ago. Angiographic examination demonstrated total occlusion of the subclavian artery. The subclavian artery was stealing blood from the left anterior descending artery via the left internal mammary artery and from the brain via the left vertebral artery, leading to the diagnosis of subclavian artery steal syndrome; a rare cause of coronary and cerebral ischaemia.     

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in an Asymptomatic Adult

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly with a mortality of 90% in the first year of life, if not surgically corrected. Adult presentation of the anomalous origin of the left coronary artery from the pulmonary artery syndrome is extremely rare but may occur if a well‐developed collateral circulation from right coronary artery is present. We present the case of a 22‐year‐old asymptomatic female with anomalous origin of the left coronary artery from the pulmonary artery.     

Disseminated multiple ostial stenoses in a young woman presenting as unstable angina

A previously healthy 40-year-old woman presented as unstable angina. She had a family history of stroke as the only cardiovascular risk factor. Her blood pressure on admission was 150/90 mmHg. Laboratory study showed absolutely all negative markers of inflammation, autoimmune disorders, or atherosclerosis. Coronary angiography revealed subtotal ostial stenosis of the right coronary artery (RCA). Additionally, total occlusion of the ostium of the right subclavian artery and severe discrete ostial stenoses of left subclavian, celiac, superior mesenteric, both renal arteries were demonstrated on multidetector computed tomographic and magnetic resonance angiographies. She underwent stent implantation at the culprit lesion of RCA, and the left subclavian and both renal arteries. The fluorine-18-fluorodeoxyglucose positron-emission tomography-computed tomography showed slightly increased glucose metabolism at the proximal left subclavian artery. She is doing very well for 10 months during taking antiplatelet agents only.     

Coronary hemodynamics and subendocardial perfusion distal to stenoses

We compared distal coronary hemodynamics and regional myocardial perfusion in anesthetized dogs in the presence of a single or two coronary artery stenoses in series. After application of either a single or two stenoses on the left anterior descending coronary artery, regional myocardial blood flow was measured with radioactive microspheres. Moderate degrees of single-vessel stenosis (no change in resting coronary blood flow but reduction in reactive hyperemic response of 70%) resulted in no significant change in regional myocardial perfusion at rest despite a pressure drop across the stenosis of 24 +/- 3 mm Hg. When two such stenoses were applied in series, there was a 91% decrease in reactive hyperemia, a significant reduction in resting diastolic coronary blood flow and a 51 +/- 7 mm Hg pressure drop across the two stenoses. Alone, each stenosis produced no change in regional myocardial perfusion; however, together the two stenoses resulted in a significant decrease in subendocardial blood flow and a redistribution of transmural perfusion within the ischemic zone favoring the subepicardium (endo/epi from 0.95 +/- 0.03 to 0.72 +/- 0.03). The results indicate that whereas resting subendocardial perfusion is not significantly affected by moderate degrees of a single coronary artery stenosis, multiple stenoses of the same severity may dramatically reduce subendocardial perfusion.     

Severe Left Main Coronary Artery Stenosis with Abnormal Branching Pattern in a Patient with Mild Supravalvar Aortic Stenosis and Williams‐Beuren Syndrome

Williams–Beuren syndrome (WBS) is a multisystem genetic disorder comprising of craniofacial, developmental, and cardiac malformations. The most common cardiac defects found are supravalvar aortic stenosis and peripheral pulmonary stenosis. However, WBS should be regarded as a general arteriopathy consisting of stenoses of medium‐ and large‐sized arteries including the coronary arteries. Cardiac manifestations are often the initial reason for referral and careful cardiovascular assessment is important as coronary artery involvement confers a significant anesthetic risk and may be associated with ischemia and resultant ventricular dysfunction. Here we review the literature and describe a 2‐year‐old boy with evolving clinical features of WBS. He presented to our pediatric cardiology department for a routine assessment of peripheral pulmonary branch stenosis. A 12‐lead electrocardiogram showed changes consistent with left ventricular ischemia and a two‐dimensional echocardiogram showed reduced left ventricular function and mild supravalvar aortic stenosis. Subsequent cardiac catheterization diagnosed severe left main coronary artery stenosis. Deteriorating ventricular function secondary to acute ischemia postcatheterization required intensive care treatment from which the patient did not recover. This case report highlights the necessity of careful cardiology assessment without delay in patients with a suspicion of WBS. Isolated coronary stenosis though rare in WBS should be considered in the presence of ischemia or reduced ventricular function. Larger case series are needed to further characterize the correlation between WBS and acute coronary events.