Coronary CT Angiogram

[Irshad51]

From Irshad Khan, New Delhi, India

I have taken last week CT Angiogram and its findings are worrisome. The main impressions are:

Calcium score:      18, Soft plaques seen in proximal LAD and D1 segment.

LEFT CORONARY ARTERY

LM   -  Normal

LAD   -  (Prox/Middle/Distal)-  Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing.

Diagonals----  
D1    -----   Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing.

Obtuse Marginal Branches

OM1   --- Normal
OM 2  ---  Large OM2 artery seen with distal branching. Proximal vessel reveal focal luminal narrowing with approx  60-65 % stenosis.

Please advise me what course of treatment is advisable.

[ed34]

My LAD had a very long solid blockage, it was about a quarter the length of the vessel. The problem was finding a cardiologist with enough skills to do the job. A lot of the risk is to do with how confident the cardiologist is and his experience. I had already had a bypass, a triple, which failed after 3 months.

[Alshamari]

Why you had to push doctor to stent your lad and why it was dangerous? Did you mean it needed a bypass instead?

[ed34]

both have advantages/disadvantages but Drug eluting ones seem to suffer less scar tissue which can quickly cause a re-block. There are risks with stents, during the procedure, such as heart attack/stroke but believe me, the risks are tiny. I've had 10 now with no problems.

[nila7459]

Thanks, appreciate your quick response. Any risks with stents? I am reading about two types of stents. Any suggestions as to what will be safer.

[ed34]

The other option would be bypass, but of course, this is still an option further down the road if necessary. Bypass, like stents, carries no guarantee and recovery is long. My three bypass grafts lasted 3 months, they can last weeks or many years, nobody can say. I think the stents are the best initial choice. I also think, from looking at the report, the sooner the better. All three major coronary arteries have severe blockages and so the situation is urgent.

[nila7459]

My father went for Coronary scan and these were the results. He is 68 years old.
TECHNIQUE:
- CT STUDY OF CORONARY ARTERIES WERE PERFORMED ON DUAL SOURCE 64 SLICE SCANNERS.
- CALCIUM SCORE PERFORMED
- 75CC OF NON-IONIC IODINE CONTRAST (350MG/ML) WAS GIVEN INTRAVENOUSLY.
FINDINGS:
Calcium score: 544.7
CORONARY ARTERIES: NORMAL ORIGINS RIGHT DOMINANT CIRCULATION
LMCA There is a calcified plaque with mild narrowing .
LAD : Ostium & proximal segments have calcified_plaques with severe
narrowing. Mid segment is normal. Distal segment has a calcified plaque with mild narrowing.
Dl : Moderate size vessel; Normal
D2 : Moderate size vessel; Normal
LCX : Ostium & proximal segments have calcified plaques with severe
narrowing; Mid and Distal segments are of small caliber diffusely diseased.
OM1 : Large vessel; Ostium & proximal segments have calcified plaque with moderate narrowing.
RCA prox calc mild.mid cad severe distal calc mild
PDA Normal.
PLVB Normal.
AORTA: Root of aorta, ascending aorta and descending aorta are normal in size. No dissection. No aneurysm.

Doctor is suggesting to put stents in 3 places and get admitted immediately. Can anyone confirm if this is the only treatment for this?

[ed34]

"And you said for vulnerable plaque bypass is not the solution"
Well, it would be difficult to decide where to bypass onto, if you can't see the vulnerable plaque beneath the artery lining. If you do opt for bypass, please make sure that the plan is good, because believe me, it is not nice going through all that discomfort for it just to last a very short period of time.

[nagrajjain]

When I find you have so many stents why my doctor did not put a single stent after my angiography and strait way told me about quadruple bypass surgery. My health is ok. Only my age of 71 years was of any problem I do not know. And you said for vulnerable plaque bypass is not the solution. Any way I will be going for third openion as and when time for will be suitable.Thank you all of you.

[ed34]

" If the demand by the heart cells for oxygen exceeds the capacity of the blood to supply it, then the heart undergoes ischemia and muscle cells can start to die"

And the worrying thing is that this can happen in a very short space of time. For example, if a pocket of vulnerable plaque erupts, this can float down the blood vessel and block it in a narrower section. The area where the plaque erupted from will form a blood clot so repairs can take place. The trouble is, platelets are not intelligent and don't realise when an artery is damaged all the way through the wall, leaking. They are simply signalled that the artery is damaged and automatically they block it, not realising it will kill you if there is no leak.
Some people have ischemia and feel no discomfort or symptoms, and so will likely suffer tissue death because no intervention is received. On the other end of the scale, people are in agony with pain.
Of course, if a pocket of vulnerable plaque is stented, it cannot erupt. The compression of the stent prevents this.

[ed34]

The blood inside the heart is not what gives oxygen to heart muscle. Blood is pumped out of the left ventricle, through the Aortic valve and into the Aorta (largest artery). Hanging off of this huge artery are the small coronary arteries which run along the outside of the heart. This is what feeds the heart muscle.

[curmudgen]

Heart muscle dies due to ischemia - the lack of oxygen to the heart cells -  not necessarily due to lack of blood, which of course, is the way it happens in most cases.  If the demand by the heart cells for oxygen exceeds the capacity of the blood to supply it, then the heart undergoes ischemia and muscle cells can start to die.  

[nagrajjain]

My doctor did not tell me anything more about colaterals. If you remember I have raised one philosophical question that how heart muscles die for lack of blood when heart itself is full of blood. Are there any other ways? I may recommend you change of doctor or second openion.

[ed34]

I saw my Cardiologist yesterday morning for a checkup and he showed me my angiogram from March, when I had MI. He showed me where they put the 2 stents (which I knew anyway) and then pointed out another blockage which they had missed.
I explained that I feel better now than I have for years, but his professional opinion is that this blockage will have already grown and will continue to grow. He wants to do an angiogram and if it's fairly large, he wants to stent it.
Do I believe him when he says the blockage will have grown and will continue to? yes. My history has proved this many times so I don't doubt it. Will I have the angiography? yes. I want to keep my Circumflex clear in case any of the many stents in my LAD block. That way I will have a good source to form collaterals if and when the time comes.
I know there is a tiny risk associated with angiography, but I will take a bet with anyone that I will be here typing soon after the procedure :)

[ed34]

Hi
Wow, is the first word which I think of. It really is hard to imagine two things here. First that you have no symptoms, even with medication AND how are your collaterals getting enough flow? Your left circumflex is severely blocked at the beginning (80% min), your LAD is severely blocked at the beginning (90%), your RCA is severely blocked at the beginning (90%). So how are you getting enough flow from anywhere to keep the collaterals open?

I know we see things differently, with different opinions, but if this was my heart I would be having a bypass. The minimum bypass I would have is to get a feed into the left circumflex because this is likely to be the vessel doing all the work through collateral feeds. Personally, I believe that if this vessel becomes more blocked, collaterals will start to close down, removing feeds to the RCA and LAD.
Has your Cardiologist told you which vessel is feeding your collaterals?

Again I have to say WOW, I think you are doing amazingly well.

[nagrajjain]

In continuation - I doubted the results of the test and therefore decided to go for the same test again by some other doctor and after about two to three years. Other tests are of no much use to me. at present I am very much ok on medicines only for about an year. i would like to know your advice. thank you.

[nagrajjain]

your August 11 ,2011,10.16 AM post - You have perfectly understood my case. That is exactly I am doing now. No further test is of any purpose. I wonder how following blockages are shown on angiogram.
Left anterior descending artery -The proximal LAD has a 90% long segmentlesion followed by a 80% short segment lesion.The mid LAD has a 60% long segment lesion. D1 and D2 are diseased.
Left circumflex artery - The ostial LCx has a 80% excentric lesion.
Right coronary artery - The proximal RCA has a 90% short segment lesion followed by a 90% long segment lesion in its mid segment. the distal RCA is diseased.
Coclusion - Three vessle coronary artery disease.

[kenkeith]

Sorry that is not my intention!.  Attempting to help communication.

[kenkeith]

Sorry, I didn't answer your question to me shown on the other post and you do have the advantage of my prior answer... (:  My  answer is NO, why would you even ask, it doesn't make sense to me, so please restate and you may change your question now that you had read my prior post to your other questions or do you still not understand?  I wish I could draw a picture for you or you could draw onbe for me?.You can build on the information from my prior post because it does, in effect,  answer the question if you understand . I just don't know

[kenkeith]

Q:"So, you have a decision. Do you a) stay as you are because you feel good enough on meds with a normal quality of life, or b) have the 70% lesion treated ?

And if they said they could also open the LAD, giving two main feeds back to the left ventricle would you have this done also? so you don't rely on just one vessel?
I'm just wondering what your decision would be if this was your case."
_______
...Reading your posts strongly indicates to me you do not have any understanding with merit of collateral vessel formation.  Your responses appear preachy, some truths/half truths and platitudes of of common knowledge  that cannot be disputed and offer no enlightenment on the subject.  How can someone answer your report as evidence regarding (whether true)  of how convoluted your vessel configuration you say and then  ntermingle that with  assumptions you make that doesn't in my opinion make sense...If you could stay focussed and limit your rhetoric to facts that would help communication.  

It maybe my fault to understand but your posts seem preachy, making generalizations, half truths/ truths, etc. and  rather than just telling,  present some facts that supports your proclamations. You are permitted to quote some authority to avoid any plagiarism inferences and because this forum is a fair user of copyrighted material it is permissable to quote that source as authority and express your opinion and accept or reject my comments.  So go for it!:)  

For some clarification of your posted questions lets start with the above quote of your question  because I don't understand what you are talking about? Doesn't make sense, but now that you have more information from a member you appear top modify.  Please stay away from what happened to you and your condition, what doctors have told you unless you can support with some logic to support the hearsay!  We can discuss logic, but hearsay can't be questioned as you may understand....lets maintan some intellectual integrity so  we can all learn.
Thanks and it may be awhile for an answer, but lets make this an informative exchange of ideas that have merit. Take care,

Ken  

[ed34]

It very often takes more than one test to back up a patients condition. In 2007 I had emergency stenting to my Left Circumflex and it was seen how my LAD was totally blocked, but fed by a few collaterals. My Cardiologist felt 100% sure that I would have suffered heart muscle necrosis. He ordered an echoscan which showed great results and a 70% LVEF. With the size of my LAD and knowing that the collaterals had been closed for a considerable period of time due to the blockage of their source in the LCX, he ordered a nuclear scan. Now keep in mind that I still had a lot of angina even with medication. You would expect the nuclear scan to show that insufficient blood was reaching the left ventricle. The results shocked everyone, they showed that there was no shortage of blood. So, the nuclear scan AND the echo scan showed perfect results and showed my heart was in great shape with no problems. My Cardiologist said "If you hadn't had a heart attack, emergency stenting and we hadn't seen your Arteries with an angiogram, you would have been classed as fit and healthy with no heart problems, due to those results."
So the gold standard Angiogram was the test that revealed my problems in 2007.
Now moving to 2010 after lots of stenting, it was a mystery why angina was still occurring. Angiograms revealed nothing, everything looked open and normal, so a stress echo was ordered. This revealed ischemia to the distal LAD, in the same area as a 2mm artery. After a few months collaterals fed into this area and killed all angina symptoms. So the gold standard this time was the stress echo scan.
This is why I get annoyed when Doctors simply order a EKG. When most people are laying still on a bed, they have no symptoms and the results are normal. Then walking back to the car park they feel the symptoms again, but feel confused because they've just been told it is nothing to do with their heart. Many heart attacks occur without ST changes and so I often wonder why an EKG is taken so seriously and prevents further investigation in many cases. Perhaps it's to save money? Perhaps the Cardiologist genuinely feels an EKG is sufficient?

[Irshad51]

If you have not already taken, I suggest, you may consider to go for a Thallium test that would give images of blood flow in coronary arteries and even collaterals. Cath angio cannot provide any idea of these.
If you exercise and climb stairs w/o any pain/symptoms, I do not think you have ischemia (angina). So where is the need for a by-pass? One should go for a cath angio if there are symptoms and it would help in detecting blockage that could be dealt with stent/s or in worst case scenario by pass. Cath angio is a diagnostic tool and is more accurate than CT angio. In a CT angio dye is injected in a vein and after mixing it goes to arteries that affects clarity. secondly, as my Dr. told me, percentage narrwoing does not convey much sense in a CT angio.  

[ed34]

"In my case it is vulnerable plaque as told by doctor"

I assume from your posts, that on arrival at the hospital, your symptoms diminished with anticoagulant medication? You was very fortunate that the erupted vulnerable plaque didn't cause a blockage that required emergency intervention. It sounds like a blood clot formed at the location of the eruption, but you passed the vulnerable plaque through.
I don't think angiograms are the best solution for detecting vulnerable plaques, unless the vessel wall is bulged into the lumen. Vulnerable plaque sits behind the artery lining, and an angiogram only basically sees where blood is flowing. A calcium scan would also not be very accurate because this will only detect calcified plaque, which vulnerable plaque is not. Your plaque is mainly the soft fatty type. I think perhaps a CT or MRI may detect it, but not sure because it would really have to be evident by bulging as a clue. You say they suggested a bypass, but bypass WHAT exactly? If you can't see the vulnerable plaque, how would you know where to graft? and this wouldn't make it less of a risk of eruption anyway. The only way to reduce the risk of eruption is to cover it with something like  stent. I think your best option by far would perhaps to follow a very strict diet, raise your HDL and get LDL right down in the hope your body can remove a lot of the plaque on its own. If you continue to have high LDL levels, then it's likely the vulnerable plaque will just continue to get fed and grow. What do you think?

[nagrajjain]

None of the doctors suggested me to go for stress test till now. Why I do not understand. In my exercise plan I climb seven stories daily twice without any indication of chaste pain. I am normal in all my daily activities.Even sexual activity. When i asked to the doctor if I should go for any tests he said you are perfectly ok on examination and I do not need any test report for your treatment. I go daily for sweeming too. I feel your health indicates how the test reports will be. It will be better not depend on test reports only. Many times they may be misleading.This is my experience I wanted to share with every body.Thank you all.

[ed34]

"That is why to open an occluded vessel redistributes blood flow through the newly open occlusion and that puts pressure on other vulnerable segments of the cariovascular system and possilbly shut down the collateral flow and not that not effectively open the closed vessels"

Well, nothing is really 100% understood. For example, I have collaterals feeding the distal LAD, just a small section due to a blockage which is in a vessel too small to stent. The vessel is around 2mm. The collaterals are fed from the distal LCX. When I had my LAD opened, many collaterals closed, but not those feeding the distal section. However, in my recent MI, the lower section of the LCX was virtually shut off and those collaterals did then close up, making me feel even worse. When stented, after about 3 days, those collaterals re-opened again and everything returned to normal.
I am seeing my cardiologist next monday to discuss having a drug eluting balloon, to open the distal LAD. My very first attack in 2007 was particularly bad and life threatening because my LAD had apparently been totally blocked for years, but there was collateral feed from the LCX. Now this vessel was blocked 99% and blood flow was too low for collateral feeds to the LAD. It was basically a double whammy.
I agree it's common to have lesions form at bifurcations, especially LAD/LCX and Mid RCA.
I know Plavix is related to preventing clotting, which is why I said "turbulence in a stent can cause clots in that stent though, which is why plavix is so important"