Effect of revascularization of chronic total occlusion on tandem stenoses in a "donor" artery

Abstract

The presence, severity, and extent of ischemia predict the outcome of coronary artery disease. Indeed the extent of myocardial ischemia and viability determines the value of revascularization in coronary stenosis after acute myocardial infarction. In multivessel coronary artery disease, noninvasive methods for the evaluation of ischemia are often inadequate to guide percutaneous coronary intervention. It is a common misperception that revascularization might not benefit a myocardial segment in the chronic total occlusion distribution when that segment is supplied by well-developed collateral vessels, because severe ischemia is unlikely to be present under these circumstances. An 82-year-old man presented with acute coronary syndrome, tandem stenoses in a "donor" artery, and a chronic total occlusion of the right coronary artery. We present a rationale for using fractional flow reserve to determine the existence of ischemia and to aid in deciding the best approach to the treatment of that ischemia.

Keywords: Acute coronary syndrome/therapy; coronary occlusion/therapy; coronary stenosis/diagnosis; decision making; fractional flow reserve, myocardial; myocardial revascularization/methods; percutaneous coronary intervention; stents.

Figures

Fig. 1.

This result of a Persantine Cardiolite® stress test reveals a fixed defect in the inferior wall during stress and rest, which is consistent with infarction.

Fig. 2.

Coronary angiogram (left anterior oblique view with cranial angulation) shows the left main coronary artery with tandem stenoses (indicated by the 2 large arrows), between which are 2 collateral vessels (one continuous, indicated by the small arrows). These collateral vessels served to reconstitute the occluded right posterior descending artery.

Fig. 3.

Coronary angiogram (left anterior oblique view) shows total occlusion of the right coronary artery.

Fig. 4.

Coronary angiogram shows the right coronary artery after the deployment of 3 bare-metal stents.

Fig. 5.

Coronary angiogram (left anterior oblique view with cranial angulation) shows the left main coronary artery with tandem stenoses (2 large arrows), between which are 2 septal branches with obliteration of collateral connections (small arrows).

Fig. 6.

Coronary angiogram (left anterior oblique view with cranial angulation) shows the left coronary artery with stented left main and left anterior descending coronary artery lesions and an Impella® catheter in the left ventricle.