Total occlusion of mid LAD

Total occlusion of mid LAD

Coronary angiogram

Coronary angiogram showing mid left anterior descending coronary artery tapering to total occlusion beyond the first diagonal. It is a diffusely diseased LAD. A small diagonal and septal are originating at the region of total occlusion. First diagonal ostium is also significantly diseased. Viability of the distal supply territory has be to demonstrated for deciding on revascularization. Percutaneous revascularization of this LAD is likely to need more than one long drug eluting stent.

Alternate option is a left internal mammary artery to LAD graft. But it will need demonstration of the distal LAD to be of adequate size to be graftable and free of significant disease. As the distal LAD has not been visualized in this shot, a right coronary injection should be taken with long recording to demonstrate any possible retrograde collateral flow into the distal LAD. This will help in deciding the graftability of the distal LAD.

Same angio would also be useful in documenting the length of total occlusion segment which can guide percutaneous intervention. Simultaneous injection from right and left coronary arteries will be useful in guiding the lesion crossing to ensure that the guidewire tip is taking an intra luminal course and not going sub intimal.

If a long shot is taken the distal LAD may be seen filling through homocollaterals originating from same coronary artery.  Long shot in the right coronary artery may reveal retrograde filling of distal LAD through hetero collaterals from RCA.