Interventional Cardiology 101.......Coronaries of Diabetics

 

https://youtu.be/FkT5-ZTEVoc

Normal Left Coronary Artery. 

The central big long vessel, the Left Anterior Descending artery [ LAD ] supply the main "piston" of the heart, the ''main driver or pump" of blood moving out of the heart chambers to all part of body, via the major blood vessel , the Aorta.

The LAD supplies mainly the  anterior segment of the left ventricle. The Left Circumflex branch supply the back portion of the left ventricle. This cine shows normal circulation of both arteries with rich healthy branches.

You imagine your heart as big as your fist, these arteries sit on your heart, astride on the heart, like a 'mat rempik' on his 'motor bike'.

The LAD and the L Circumflex  branch join together to form the Left Main , which got itself inserted to the root of the big vessel the Aorta, receiving highly oxygenated blood just gushing out from the pumping left ventricle. This flow into the LAD and LCirx , which then move on on into the small arterioles and vessel which ramifies into the ventricular muscle wall, to supply oxygen and energy , ATP's, required by the hard working , non stopping muscle fibres of the heart.

When your heart stop pumping , you also STOP!!!

https://youtu.be/rlnfnX91jBQ

Compare that left coronary system with this one angio I did on an obese diabetic pt of mine, who just celebrated his 40th birthday, married, with 4 young children in toe. ..in his Left Anterior Descending artery itself I can see 4 significant lesions to be ballooned and stented. 

The Left Circumflex branch has one narrowing  which need ballooning plus DEB ballooning [ drug eluting balloon ] or small stenting. The view in the extreme left appears crowded because there is late appearance of distal circulation of the right system. It should not be there. The fact it can be seen from this left shots means the Right Coronary Artery is totally occluded....

This young man has severe triple vessel disease, at an early age.

He has had maturity onset diabetes since age 30.

Currently he is in deep 'shit'...he needs revascularization...1st choice would be bypass surgery. Given his relative young age, I have great  reservation about sending a young man for bypass, but it still remain 1st choice from the viewpoint of extent and severity of the blockages in the both the left and the right coronaries.

To me the left side is easily dowable even though I may end up implanting 3 stent there, but his right total occulsion as seen from the left coronary shots poses special difficulty for us 'plumbers'.

1stly, we may not be able to the cross the occlusion with our guidewire, a necessary pre requirement before we can balloon or stent the lesion. The guidewire acts as a 'railway  sleeper and line for the balloon and stent deployment.

Nonteheless, if this young man refuse surgery , I will do him in 2 stages.

1stly the left system. If I am happy, with the result, I may not even attempt to open the right, since it is already well covered by the retrograde flow from the left.

Of course some 'purists' amongst the plumbers would insist on doing the right, whatever the cost, even though there is a high risk of wire perforation of the artery, since the occluded portion in the right appears too long for comfort.

To me the right coronary is already a 'lost cause'.

The young man has had a 'silent' heart attack in the past on the right side...something common in a diabetic...damage to that side has been done...and now he has some blood supply to the right side from the diseased left. If I correct the left, the right side will get better supply., full stop!

Bypass surgery in this young man , though the 1st option, is not even ideal. The LAD would need sequential graft with a LIMA graft, since there are multiple blockages in the LAD.

Like everything, even bypass surgery has  a 'shelf life'.

By 10 to 12 years, some graft may reblock.

Stents and ballooning also have its  problems....restenosis...though it is easily repeatable.

We are looking at shelf life and shelf life.....whatever we do!

This is not an ideal world...the world of a diabetic with coronary problem.

I approach coronaries like playing 'gin rummy'.

To me, CABG is the all important 'JOKER'.

If I can delay using my 'JOKER', I will delay playing it, and by time 1st with balloons and stents.

'Gedebuk gedebak gedebuk gedebak' young diabetic with coronaries problem give special headache to both us 'plumbers as well as to surgeons!

Diabetes with obesity are causing major problem in the young people this millennium further compounded by a relative lifestyle of physical inactivity.

There will be an epidemic of diabetes amongst the younger generation now since the IT, the handphones, and the video games have produce a whole generation of obese, 'couch potatoes' amongst our children.